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Below we compare open post midline or interlaminar surgery and new system SMRUTII surgery? Posterior wall of canal is ligamentum flavum in lower 2/3 of a segment in lumbar spine and IAP lamina is extra ligamentous. It should make us immediately aware that most of bone cutting we do in open surgery is not relevant to target to be rectified. This is shown in detail in 2 videos below one about open surgery for central stenosis and second highlighting my smrutii system basics. [TrUBee is = gore system of tfe + smrutii for stenosis].

Treatment of central canal stenosis is Not foraminoplasty but it is Channelplasty. Below is a video showing differences in f plasty and Ch plasty.

Video Below shows our crystal clear ideas about causes of central canal stenosis on posterolateral walls in form of ligamentum flavum changes. Inside facet edge. This will clarify to u why we must stay away from bone breaking surgery!

https://media.publit.io/file/crystal-clear-S-M-R-U-T-I-I-system-concept.html?player=MISSIONSPINE  or see below

Subpars Medial Reach Upper Transforaminal Intracanal Intervention : S M R U T I I complements TFE gore system.

Patients present to us with low back pain, leg pain or claudication with varying degree of neurological involvement. Claudication commonly indicates stenosis of path of nerves or thecal sac and involvement of arteriovenous system. Lumbar canal stenosis is due to narrowing inside canal as a result of degenerative changes around dural sac. In its front, side and back, 360 degrees all around. 3 structures change in lumbar spine degeneration causing stenosis namely disc in front, facet and its soft tissue cover on ventral face posterolaterally and ligamentum flavum at back. It is INSIDE the canal walls. NO BONE changes are seen after age of skeletal maturity. We have been successfully operating disc and its varied presentations causing pain etc. by gore TFE system using transforaminal access; surgery that is stitch less , under local anesthesia in an awake and aware patient, reaching front and back of the dural sac. Some areas that we were not able to reach easily by TFE now we can and do by smrutii.

Basis is a new awareness of ligamentum flavum anatomy and use of new MRI protocols that completely change our approach to stenosis. We propose to follow ligament from above down and spare the lamina.

I wish we learn thru method, with very precise understanding of anatomy of spine, bony that does not change much and soft tissue that mainly changes as disc, facet ventral face cover and ligamentum flavum. WE SIMPLY DIVIDE ANATOMY AS UPPER ZONE IN CONFINES OF UPPER BODY EG: L4 AT L45, middle zone behind disc at L45 and lower zone that has occupied lower body. We know now that we have 8+1 total 9 symptom generators in degenerative lumbar spine. Middle zone stenosis is central canal stenosis affecting thecal sac. Upper zone affects exiting nerve ENR and DRG dorsal root ganglion. The lower zone has traversing nerve root that is ventrally immobile at entry to root canal or lateral recess. We also study below the 3 zones.

Video on left is for UZ middle is MZ and on right is LZ. They are silent and its mainly showing 3d cross cuts built up from elow upwards. That is UZ is from disc up to lower border of above pedicle. The MZ is built from lower end plate of disc to its uper endplate. Lower zone is built from mid pedicle below to lower discal endplate. It is important to note there is NO posterior midline symptom generator. 

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