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Home›The Treatise›Chapters›Chapter 63
Tratado de Cirurgia da Coluna Vertebral
SECTION 8 • Surgical Techniques
Chapter63

INTERLAMINAR ENDOSCOPY IN THE LUMBOSACRAL SPINE

Authors:Marcio Oliveira Penna de Carvalho•Marco Aurelio Moscatelli•Rafael Barreto Silva
Vancouver: Carvalho MOP, Moscatelli MA, Silva RB📖 Pages: 823-838
Full reading of this chapter is available exclusively in the printed edition of the Treatise.
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Sec. 8Surgical Techniques
Cap. 63Clinical Chapter
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Chapter Summary

• Context: The interlaminar endoscopic approach represents the culmination of surgical refinement connecting classic microsurgical landmarks with continuous fluid full-endoscopic visualization. The development of large-channel endoscopes, high-speed motorized burrs, dedicated Kerrison rongeurs, and steerable radiofrequency probes expanded an approach originally conceived for discectomy into advanced bilateral decompression for central and lateral recess stenosis via a unilateral laminotomy (ULBD). Its major value lies in replicating the established decompression goals of open surgery with minimal muscle detachment, reduced blood loss, and direct high-definition visualization. The interlaminar route is particularly suitable for central, paracentral, and axillary disc herniations, downward migrated fragments, central spinal stenosis, lateral recess stenosis, and facet cysts, notably at L5-S1 where the interlaminar window is naturally widest. Achieving excellent outcomes requires precise patient selection, 3D anatomical understanding of the ligamentum flavum and dural borders, controlled bone resection, and strict irrigation management.
• Chapter Objective: Teach the historical, diagnostic, and surgical principles of interlaminar lumbosacral endoscopy. The reader will learn to recognize precise indications and contraindications, integrate MRI, CT, and dynamic radiographs into preoperative planning, select specialized instrumentation, verify criteria for complete neural decompression, and manage complications such as dural tears, epidural hematomas, incomplete decompression, and recurrent herniation.
• Evolution and position among endoscopic techniquesThe chapter reviews the evolution from early percutaneous nucleotomies to modern full-endoscopic interlaminar systems. Dedicated burrs and instruments expanded discectomy to extensive bony and ligamentous decompression. The literature demonstrates favorable perioperative metrics compared to open microsurgery in equivalent indications, while comparisons with the transforaminal approach show that neither is universally superior; choice depends on anatomical level and compressive topography.
• Indications and contraindicationsThe interlaminar corridor is ideally suited for central and paracentral disc herniations (including highly migrated fragments), central canal stenosis, lateral recess stenosis, and symptomatic facet cysts. Severe gross instability, fixed deformities requiring stabilization, and isolated axial discogenic pain are contraindications for isolated decompression. Heavily calcified herniations and severe stenosis require advanced technical maturity.
• Planning and instrumentationMRI defines the neural compromise and soft-tissue stenosis. CT evaluates facet hypertrophy, osteophytes, calcification, and the dimensions of the interlaminar window; dynamic radiographs rule out instability. Figures 63.1 through 63.8 detail specialized endoscopes, working sleeves, diamond burrs, articulating forceps, Kerrisons, dissectors, irrigation pumps, and bipolar radiofrequency systems.
• Technical principlesThe patient is positioned in prone flexed posture to widen the interlaminar window. The approach docks on the inferior border of the cranial lamina. The ligamentum flavum serves as an essential protective shield during the initial drill work. After defining bony margins, flavectomy is performed under direct vision, exposing the thecal sac and traversing root. In disc herniations, nerve root mobilization precedes fragment extraction. Final canal exploration confirms neural pulsation, traversing root mobility, and complete hemostasis.
• Safety and complicationsIncidental durotomy is a major focus. Table 63.1 organizes dural tear patterns and details endoscopic patch repair, clip application, or conversion criteria. Epidural hematoma, incomplete decompression, recurrent herniation, and infection complete the primary risk profile.
• Clinical Application: The choice between interlaminar and posterolateral endoscopic approaches must be established during preoperative planning. For central or subarticular compression, especially at L5-S1 or in patients with high iliac crests, the interlaminar approach provides the most direct and familiar corridor. Window dimensions, calcification degree, and the need for bilateral decompression over-the-top guide the surgical plan. In the early learning curve, surgeons should start with single-level soft paracentral L5-S1 disc herniations before attempting multi-level central stenosis or revision cases. Bony resection must allow safe instrument maneuverability while preserving facet integrity to prevent iatrogenic instability. During surgery, fluid irrigation, venous bleeding, and neural safety are interrelated: continuous low pressure prevents intracranial hypertension, while meticulous radiofrequency coagulation prevents delayed epidural hematoma after irrigation cessation. Figures 63.20 and 63.21 demonstrate focal discectomy and bilateral over-the-top canal decompression.
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Keywords

Preferred DeCS/MeSH Descriptors:
EndoscopyMinimally Invasive Surgical ProceduresLumbar VertebraeIntervertebral Disc DisplacementSpinal StenosisRadiculopathyPostoperative Complications
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Why this chapter matters

In endoscopic surgery, a few millimeters of disorientation can separate an elegant decompression from a catastrophic dural laceration or neural injury. The interlaminar approach offers familiar dorsal anatomical landmarks, but translates them into a 2D magnified screen under continuous fluid pressure within a confined space. Understanding when to enlarge the bony window, how to utilize the ligamentum flavum as a protective shield, and when to convert to open surgery directly determines patient safety and surgical longevity.

“Interlaminar endoscopy combines direct high-definition visualization, effective neural decompression, and minimal tissue disruption, provided the surgeon respects bony anatomy, segmental stability, and technique limitations. Its primary value is offering an optimal corridor for central, paracentral, and lateral recess pathology, with the capability for unilateral laminotomy with bilateral decompression (ULBD) in selected spinal stenosis.”
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Chapter Highlights

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Card 1 — Ligamentum Flavum as a Protective Barrier
Flavum preservation during drilling

During interlaminar bone work, the ligamentum flavum acts as an indispensable shield protecting the thecal sac and traversing root. It should be resected only after adequate cranial and lateral bony windows are established.

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Card 2 — Central and L5-S1 Favor Interlaminar
Topographic corridor selection

Central canal stenosis, paracentral disc herniations, and L5-S1 lesions (shielded by high iliac crests) are most directly and safely addressed through the interlaminar window.

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Card 3 — Inspect Systematically Before Closure
Final canal inspection

Final endoscopic exploration must confirm the absence of residual disc fragments, verified 360-degree neural root mobility, and absolute venous hemostasis with the irrigation pump pressure reduced.

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How to Cite this Chapter (Vancouver Format)

Official bibliographic indexing and citation guidelines
📖 Pages: 823-838Vancouver Style
Authors (Vancouver):Carvalho MOP, Moscatelli MA, Silva RB

Carvalho MOP, Moscatelli MA, Silva RB. Endoscopia interlaminar na coluna lombossacra. In: Pudles E, Defino H, Risso M, editors. Tratado de Cirurgia da Coluna Vertebral (Treatise of Spine Surgery). 1st ed. Rio de Janeiro: Dilivros Editora; 2026. p. 823-838.

ISBN: 978-85-8053-292-0 • 1.ª Edição • Dilivros Editora
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