Outcomes of percutaneous endoscopic lumbar discectomy via a translaminar approach, especially for soft, highly down-migrated lumbar disc herniation. Int Orthop. 2016;40:1247-1252. [PMID: 27068038 DOI: 10.1007/s00264-016-3177-4]

Unilateral biportal endoscopic discectomy via translaminar approach for highly upward-migrated lumbar disc herniation: a technical note and preliminary treatment outcomes

STUDY DESIGN

A technical note and retrospective case series.

OBJECTIVE

Highly upward-migrated lumbar disc herniation (LDH) is challenging due to its problematic access and incomplete removal. The most used interlaminar approach may cause extensive bony destruction. We developed a novel translaminar approach using the unilateral portal endoscopic (UBE) technique, emphasizing effective neural decompression, and preserving the facet joint's integrity.

METHODS

This retrospective study included six patients receiving UBE translaminar discectomy for highly upward-migrated LDHs from May 2019 to June 2021. The migrated disc was removed through a small keyhole on the lamina of the cranial vertebra. The treatment results were evaluated by operation time, hospital stays, complications, visual analog scale (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) score, and modified MacNab criteria.

RESULTS

The mean pre-operative VAS for back pain (5.0 ± 4.9), VAS for leg pain (9.2 ± 1.0), JOA score (10.7 ± 6.6), and ODI (75.7 ± 25.3) were significantly improved to 0.3 ± 0.5, 1.2 ± 1.5, 27.3 ± 1.8, 5.0 ± 11.3 respectively at the final follow-up. Five patients had excellent, and one patient had good outcomes according to the Modified MacNab criteria. The hospital stay was 2.7 ± 0.5 days. No complication was recorded. The MRI follow-up showed complete disc removal, except for one patient with an asymptomatic residual disc.

CONCLUSIONS

UBE translaminar discectomy is a safe and effective minimally invasive procedure for highly upward-migrated LDH with satisfactory treatment outcomes and nearly 100% facet joint preservation.

The Biomechanics of the Transpedicular Endoscopic Approach

STUDY DESIGN

Biomechanical cadaveric study.

OBJECTIVE

The goal of this study was to analyze the effects of an endoscopic transpedicular approach with different drill diameters (6 and 8 mm) and compare them with the intact native side. In addition, the influence of bone quality on the resistance of the pedicle was investigated.

SUMMARY OF BACKGROUND DATA

Clinical studies have repeatedly highlighted the benefits of endoscopic transpedicular decompression for downmigrated lumbar disc herniations. However, the biomechanical effects on pedicle stability have not been studied up to now.

MATERIALS AND METHODS

Twenty-four vertebras originating from four fresh-frozen cadavers were tested under uniaxial compression load in a ramp-to-failure test: (1) the tunneled pedicle on one side, and (2) the native pedicle on the other side. Twelve lumbar vertebrae were assigned to drill diameter of 6 mm and the other 12 to diameter of 8 mm.

RESULTS

The median ratio of sustained force for the operated side compared with the intact contralateral side is equal to 74% (63-88) for both drill diameters combined. An 8 mm transpedicular approach recorded an axial resistance of 77% (60-88) compared with the intact contralateral side ( P =0.002). A 6 mm approach resulted in an axial resistance of 72% (66-84) compared with the intact opposite side ( P =0.01). No significant difference between the two different drill diameters was recorded ( P =1). For all three subgroups (intact, 8 mm, 6 mm) the Hounsfield units-values and the absolute resistance force showed significant correlations (intact: ρ=0.859; P <0.001; 8 mm: ρ=0.902; P <0.001; 6 mm: ρ=0.835; P <0.001).

CONCLUSION

The transpedicular approach significantly reduces the axial resistance force of the pedicle, which may lead to pedicle fracture. Bone quality correlated positively with the absolute resistance force of the pedicle, whereas the influence of the drill hole diameter plays only a limited role.

Comparison of clinical outcomes between unilateral biportal endoscopic discectomy and percutaneous endoscopic interlaminar discectomy for migrated lumbar disc herniation at lower lumbar spine: a retrospective controlled study

BACKGROUND

Both Unilateral Biportal Endoscopic Discectomy (UBED) and Percutaneous Endoscopic Interlaminar Discectomy (PEID) have resulted in favorable clinical outcomes in the management of LDH. The aim of this study is to comprehensively compare the efficacy of UBED and PEID in treating migrated LDH in the lower lumbar spine, with a specific focus on high-grade migrated LDH.

METHODS

96 patients who underwent UBED (31 cases) and PEID (65 cases) procedures were enrolled in the study. All patients received a minimum follow-up period of 6 months. Clinical outcomes of the patients were assessed with incision length, operation time, total hemoglobin loss, hospital stay, intraoperative fluoroscopy times, visual analogue scale (VAS) for lower back and leg pain, Oswestry disability index (ODI), modified MacNab criteria, complications, area of lamina loss and increased intervertebral height.

RESULTS

The VAS scores for lower back and leg pain and ODI significantly decreased in both groups after the operation. Preoperatively, at 1 day, 1 month, and 6 months after the procedure, the VAS and ODI scores exhibited no significant differences between the two groups. There was no significant difference in terms of modified MacNab criteria, area of lamina loss, and increased intervertebral height. The UBED group had a longer incision length, operation time and postoperative hospital stay, and fewer intraoperative fluoroscopy times than to the PEID group. Complications were noted in both groups throughout the follow-up period, but there was no significant difference in the rate of complications. Moreover, there were no notable differences in clinical outcomes between the two groups in the high-grade migrated LDH.

CONCLUSIONS

Both UBED and PEID could achieve favorable clinical outcomes for treating migrated LDH at the lower lumbar spine. Despite the longer operative time and postoperative hospital stay associated with the UBED group, UBED remains safe and innovative for treating migrated LDH at the lower lumbar spine.

Translaminar Full Endoscopic Technique with Tom Shidi Needles for Highly- and Dorsally-Migrated Lumbar Disc Herniations

BACKGROUND

Thirty years have passed since Kambin's first clinical series of lumbar disc herniations (LDH) treated by arthroscopic microdiscectomy. Despite several advances in this interim, sequestrated LDHs over the dorsal aspect of the dura, and high-grade up- or downward disc migration have been a relative limitation of the transforaminal endoscopic technique. The interlaminar window was the next step to deal with such highly migrated LDHs. Favorable outcomes were obtained in 70-90% of the patients in the long-term, but recurrence rates remained high (approximately 12%), and the approach could be limited by the size of the interlaminar window. Few relevant studies have addressed the role of translaminar full endoscopic technique for migrated LDHs. To describe an innovative modification of the translaminar full endoscopic approach with Tom Shidi needles.

METHODS

This technical modification is presented in a detailed fashion for treating these challenging LDHs and illustrated through a clinical case.

RESULTS

The patient underwent successful translaminar full endoscopic technique with complete pain resolution postoperatively. The postprocedural course was uneventful. A follow-up imaging showed no evidence of residual LDHs fragments.

CONCLUSIONS

Translaminar full endoscopic technique with Tom Shidi needles is a promising modification of the previously presented interlaminar and translaminar endoscopic routes in the treatment of migrated LDHs to fasten surgical procedures and increase the safety of spinal canal manipulation.

Research Trends of Percutaneous Endoscopic Lumbar Discectomy in the Treatment of Lumbar Disc Herniation Over the Past Decade: A Bibliometric Analysis

Objective

This study aimed to explore the research trends of percutaneous endoscopic lumbar discectomy in treating lumbar disc herniation using bibliometrics over the past ten years.

Methods

Relevant publications on the clinical application of percutaneous endoscopic lumbar discectomy in lumbar disc herniation were searched in the Web of Science Core Collection. Subsequently, the characteristics of all these articles were collected. Visualizing data of annual publications, journals, cited journals, authors, cited authors, countries, institutions, keywords, and cited references was performed by using CiteSpace (6.1.R6).

Results

A total of 642 publications were extracted between 2013 and 2022. The number of publications peaked in the year 2020. The most prolific journal was World Neurosurgery (81), and Spine (597) as the cited journal was the most popular one. China (393) was the most prolific country, followed by South Korea (100). The institution with the most productivity was Tongji University (35). Yue Zhou (20) was the most prolific author, and Sebastian Ruetten (310) was the most cited author. The keyword "interlaminar" was top of research developments with the highest citation burst (8.69). "Lumbar disc herniation", "surgical technique", and "complication" were popular keywords. The surgical procedures and complications of percutaneous endoscopic lumbar discectomy have been the hot topics of recent research.

Conclusion

This study summarized the current situation and development trends of percutaneous endoscopic lumbar discectomy clinical research in the form of visualization, and these findings may help researchers explore new directions in the future.

Biomechanical limitations of partial pediculectomy in endoscopic spine surgery

BACKGROUND CONTEXT

Transforaminal endoscopic decompression is an emerging minimally invasive surgical technique in spine surgery. The biomechanical effects and limitations of resections associated with this technique are scarce.

PURPOSE

The objective of this study was to analyze the effects of three different extents of reduction at the craniomedial pedicle (10%, 25%, and 50%) and to compare them with the intact native side. In addition, the influence of bone quality on the resistance of the pedicle after reduction was investigated.

STUDY DESIGN

Biomechanical cadaveric study.

METHODS

Thirty lumbar vertebrae originating from six fresh frozen cadavers were tested under uniaxial compression load in a ramp-to-failure test: (1) the reduced pedicle on one side, and (2) the native pedicle on the other side. Of the 30 lumbar vertebrae, ten were assigned to each reduction group (10%, 25%, and 50%).

RESULTS

On the intact side, the median axial compression force to failure was 593 N (442.4-785.8). A reduction of the pedicle by 10% of the cross-sectional area resulted in a decrease of the axial load resistance by 4% to 66% compared to the intact opposite side (p=.046). The median compression force to failure was 381.89 N (range: 336-662.1). A reduction by 25% resulted in a decrease of 7% to 71% (p=.001). The median compression force to failure was 333 N (265.1-397.3). A reduction by 50% resulted in a decrease of 39% to 90% (p<.001). The median compression force to failure was 200.9 N (192.3-283.9). At 10% pedicle reduction, the Hounsfield units (HU) value and the absolute force required to generate a pedicle fracture showed significant correlations (ρ=.872; p=.001). At 25%, a positive correlation between the two variables could still be identified (ρ=.603; p=.065). At 50%, no correlation was found (ρ=-.122; p=.738).

CONCLUSION

Resection of the inner, upper part of the pedicle significantly reduces the axial resistance force of the pedicle until a fracture occurs.

CLINICAL SIGNIFICANCE

The extent of pedicle reduction itself plays only a limited role: once the cortical bone in the pedicle region is compromised, significant loss of resistance to loading must be anticipated.

Biomechanics of Transforaminal Endoscopic Approaches

STUDY DESIGN

Biomechanical cadaveric study.

OBJECTIVE

The aim of this study was to compare the effect of transforaminal endoscopic approaches with open decompression procedures.

SUMMARY OF BACKGROUND DATA

Clinical studies have repeatedly highlighted the benefits of endoscopic decompression, however, the biomechanical effects of endoscopic approaches (with and without injury to the disk) have not been studied up to now.

MATERIALS AND METHODS

Twelve spinal segments originating from four fresh-frozen cadavers were biomechanically tested in a load-controlled endoscopic transforaminal approach study. Segmental range of motion (ROM) after endoscopic approach was compared with segmental ROM after (1) microsurgical decompression with unilateral laminotomy and (2) midline decompression with bilateral laminotomy. In the intact state and after decompression, the segments were loaded in flexion-extension (FE), lateral shear (LS), lateral bending (LB), anterior shear (AS), and axial rotation (AR).

RESULTS

Vertebral segment ROM was comparable between the two endoscopic transforaminal approaches. However, there was a-statistically nonsignificant-trend for a larger ROM after accessing via the inside-out technique: FE: +3% versus +7%, P =0.484; LS: +1% versus +12%, P =0.18; LB: +0.6% versus +9%, P =0.18; AS: +2% versus +11%, P =0.31; AR: -4% versus +5%, P =0.18. No significant difference in vertebral segment ROM was seen between the transforaminal endoscopic approaches and open unilateral decompression. Vertebral segment ROM was significantly smaller with the transforaminal endoscopic approaches compared with midline decompression for almost all loading scenarios: FE: +4% versus +17%, P =0.005; AS: +6% versus 21%, P =0.007; AR: 0% versus +24%, P =0.002.

CONCLUSION

The transforaminal endoscopic intracanal technique preserves the native ROM of lumbar vertebral segments and shows a trend toward relative biomechanical superiority over the inside-out technique and open decompression procedures.

Transforaminal endoscopic lumbar discectomy with targeted puncture and foraminotomy for very highly migrated disc herniation: A technique note with case series

Background

Transforaminal endoscopic lumbar discectomy (TELD) has been widely used for lumbar disc herniation. However, in some challenging cases such as very highly migrated disc herniation (VHMDH), traditional TELD is difficult to access the pathology.

Methods

From January 2016 to December 2019, 63 patients with single-level VHMDH underwent TELD using targeted puncture and foraminotomy techniques were included. All patients were followed up for 26.5 months on average (range, 24–48 months). Operative time, length of hospital stay, visual analog scale (VAS) score, Oswestry Disability Index (ODI), modified MacNab criteria and surgical complications were evaluated.

Results

The operative time was 40–120 min (56.8 on average). The length of hospitalization was 2.5 days (range, 2–4 d). VAS score decreased significantly from 5.5 ± 1.3 preoperatively to 1.9 ± 1.30 (p < 0.001) 1 day postoperatively, and to 0.9 ± 0.8 (p < 0.001) at the final follow-up. ODI score improved significantly from 23.5 ± 3.2 preoperatively to 13.4 ± 3.0 (p < 0.001) 1 day postoperatively; and 3.1 ± 1.2 (p < 0.001) at the final follow-up. According to the modified MacNab criteria, 40 patients (63.5%) showed excellent results, 20 patients (31.7%) were rated as good, 2 patients (3.2%) were rated as fine, and 1 patient (1.6%) was rated as bad at the final follow-up. No residual fragments, nerve root or cauda equina injury was shown in this series. One recurrent case was resolved by open surgery.

Conclusions

With modified targeted puncture and foraminotomy techniques, VHMDH can be accessed safely and effectively, and satisfactory clinical outcomes can be obtained for these patients.

Trans-Tubular Translaminar Microscopic-Assisted Nucleotomy for Lumbar Disc Herniations in the Hidden Zone

STUDY DESIGN

A prospective cohort study in a high-flow spine center in Germany.

OBJECTIVES

This study aimed to evaluate clinical outcomes and complications of the trans-tubular translaminar microscopic-assisted percutaneous nucleotomy in cases of cranially migrated lumbar disc herniations (LDH).

METHODS

Between January 2013 and January 2018, 66 consecutive patients with cranio-laterally migrated LDH were operated upon. The following outcome measures were evaluated: (1) Visual Analog Scale (VAS) for leg and back pain; (2) Oswestry Disability Index (ODI) and Macnab´s criteria. All patients were operated upon with trans-tubular Translaminar Microscopic-assisted Percutaneous Nucleotomy (TL-MAPN). Perioperative radiographic and clinical evaluations were reported. The mean follow-up period was 32 months.

RESULTS

The mean age was 59 years. L4/L5 was the commonest affected level (27 patients). The mean preoperative VAS for leg pain was 6.44 (±2.06), improved to 0,35 (±0.59) postoperatively. Dural injury occurred in 1 patient, treated with dural patch. Improved neurological function was reported in 41/44 Patients (neurological improvement rate of 93%) at the final follow up. There was a significant improvement in the mean ODI values, from 50.19 ± 4.92 preoperatively to 10.14 ± 2.22 postoperatively (P < 0.001). Sixty four out of 66 patients (96%) showed an excellent or good functional outcome according to Macnab´s criteria. No recurrent herniations were observed.

CONCLUSION

The translaminar approach is a viable minimal invasive technique for cranially migrated LDH. The preservation of the flavum ligament is one of the main advantages of this technique. It is an effective, safe and reproducible minimally invasive surgical alternative in treatment of cranially migrated LDHs.

Earlier or heavier spinal loading is more likely to lead to recurrent lumbar disc herniation after percutaneous endoscopic lumbar discectomy

PURPOSE

To evaluate the clinical features of and risk factors for recurrent lumbar disc herniation (rLDH) after percutaneous endoscopic lumbar discectomy (PELD) in our clinical practice.

METHODS

A total of 942 consecutive patients who underwent single-level PELD from January 2013 to August 2019 were included. Patients were divided into the recurrence group and the nonrecurrence group. Patient characteristics, radiographic parameters and surgical variables were compared between the two groups. Univariate analysis and multiple logistic regression analysis were adopted to determine the risk factors for recurrence after PELD.

RESULTS

The prevalence of rLDH was 6.05%. Age, sex, tobacco use, duration of low back pain, body mass index (BMI), occupational lifting, herniated disc type, facet joint degeneration, operation time and time to ambulation were significantly different between the two groups. Univariate analysis showed that age (P < 0.001), sex (P = 0.019), BMI (P = 0.001), current smoking (P < 0.001), occupational lifting (P < 0.001), facet joint degeneration (P = 0.001), operation time (P = 0.002), and time to ambulation (P < 0.001) could be significantly associated with the incidence of rLDH after PELD. Multivariate analysis suggested that an older age (P < 0.001), the male sex (P = 0.017), a high BMI (P < 0.001), heavy work (P = 0.003), grade II facet joint degeneration (P < 0.001) and early ambulation (P < 0.001) were significantly related to rLDH after PELD.

CONCLUSIONS

An older age, the male sex, a higher BMI, heavy work, grade II facet joint degeneration, and early ambulation are independent significant risk factors for rLDH after PELD. Great importance should be attached to these risk factors to prevent rLDH. We suggest that patients control their weight, avoid heavy work, ambulate at an appropriate time, and perform strengthening rehabilitation exercises to reduce the incidence of rLDH.

[Unilateral biportal endoscopic discectomy for high-grade migrated lumbar disc herniation]

Objective

To investigate the effectiveness of the unilateral biportal endoscopy (UBE) technique in the treatment of high-grade migrated lumbar disc herniation (LDH).

Methods

Between January 2020 and February 2021, 23 cases of high-grade migrated LDH were treated with discectomy via UBE. There were 14 males and 9 females, with a mean age of 48.7 years (range, 32-76 years). All patients had low back and leg pain. The disease duration ranged from 2 months to 7 years (median, 13 months). Lesion segments were L 3, 4 in 2 cases, L 4, 5 in 15 cases, and L 5, S 1 in 6 cases. The operation time, intraoperative blood loss, the time when the patients started to move off the floor, and postoperative complications were recorded. The effectiveness was evaluated using the visual analogue scale (VAS) score, the modified Oswestry disability index (ODI), and the modified MacNab criteria.

Results

All operations were completed successfully, and no complication such as dural tear, epidural hematoma, nerve injury, or vascular injury occurred. The operation time ranged from 53 to 96 minutes, with an average of 71.0 minutes. The intraoperative blood loss ranged from 32 to 56 mL, with an average of 39.3 mL. All patients were removed the drainage tube and wore a lumbar brace to move off the floor around 1 to 2 days after operation. All patients were followed up 3-12 months after operation, with an average of 5.7 months. The VAS scores of low back pain and leg pain and the modified ODI at all postoperative time points were lower than those before operation, and the differences were significant ( P<0.05). The differences were significant ( P<0.05) when comparing the above indexes between the time points after operation. At last follow-up, the effectiveness was evaluated according to the modified MacNab criteria, and 17 cases were excellent, 4 cases were good, and 2 cases were fair, with an excellent and good rate of 91.3%. There was no recurrence of LDH during follow-up.

Conclusion

Discectomy via UBE is an effective method for the treatment of high-grade migrated LDH because of its flexibility, clear view, and wide range of intraoperative exploration, which can effectively reduce the risk of residual nucleus pulposus after operation.

Targeted fully endoscopic visualized laminar trepanning approach under local anaesthesia for resection of highly migrated lumbar disc herniation

PURPOSE

To introduce a new fully endoscopic visualized laminar trepanning approach with a periendoscopic trephine under local anesthesia for resection of highly migrated lumbar disc herniation (LDH) and report the clinical outcomes of one year follow-up.

METHODS

Twenty-one patients with highly migrated LDH who underwent percutaneous endoscopic lumbar discectomy via the laminar trepanning approach from June 2019 to August 2020 were retrospectively reviewed. Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms-Pain Interference (PI) and Physical Function (PF) were selected as outcome measures. The operating duration and complication were documented.

RESULTS

The average age of the 21 patients (15 males, 6 females) was 37.8 ± 6.0 years (29-52 years). Disc migration originated from L4/5 in 19 patients, L5/S1 in two patients. The mean operative duration was 54.1 ± 9.0 minutes (42-79 min). All patients were followed up to 12 months after the operation. PROMIS PI T-scores decreased significantly from pre-operatively mean 68.6 ± 2.4 to 54.4 ± 1.9 (P < 0.001) and 47.1 ± 4.3 (P < 0.001) at six weeks and 12 months, respectively. PROMIS PF T-scores improved significantly from pre-operatively mean 26.7 ± 4.7 to 44.3 ± 4.2(P < 0.001) and 58.4 ± 4.0 (P < 0.001) at six weeks and 12 months, respectively. No complications and disc herniation recurrences occurred.

CONCLUSION

The targeted full endoscopic laminar trepanning under local anesthesia with a visualized periendoscopic trephine offers a safe, efficient and cost-effective option for the resection of highly migrated LDH.

PAIN INTENSITY AND FUNCTIONAL STATUS 30 DAYS AFTER SURGERY: DIFFERENCE BETWEEN TRANSFORAMINAL AND INTERLAMINAR PERCUTANEOUS ENDOSCOPICLUMBAR DISCECTOMIES

ABSTRACT Objective: To compare the differences between transforaminal and interlaminar endoscopic approaches in terms of pain intensity and functionality 30 days after the surgical procedure. Methods: A retrospective cohort study, with patients treated by percutaneous interlaminar or transforaminal endoscopic discectomy at the Spine Service of the ISCMPA, in southern Brazil. Data were collected from the patients’ electronic medical records by two independent physicians. The clinical outcomes of pain intensity and lumbar functionality were evaluated, respectively, using the visual analogue scale and the Oswestry Disability Index. Results: Thirty-six patients were included in the study, with a mean age of 50.8 ± 15.3 years, 19 (52.8%) of whom were males. As for the clinical outcomes for both transforaminal and interlaminar percutaneous endoscopic approaches, we observed a statistically significant reduction in pain intensity (mean difference of 3.5 points, p < 0.001) and a statistically significant improvement in functionality (mean difference of 33.2 points, p < 0.001) when we compared the pre- and 30-day postoperative periods, with no significant differences in terms of approaches. The type of technical approach also differed in relation to the patients’ age, the location, type, and migration of the herniated disc, and the patient’s time in the operating room. Conclusion: There was a similar effect on pain reduction and restoration of lumbar functions, 30 days after percutaneous endoscopic discectomy, in both technical approaches, with no significant differences between them. Level of Evidence III; Retrospective comparative study.

Outcomes of epidural steroids following percutaneous transforaminal endoscopic discectomy: a meta-analysis and systematic review

Background

Percutaneous transforaminal endoscopic discectomy (PTED) has been widely used in the treatment of lumbar degenerative diseases. Epidural injection of steroids can reduce the incidence and duration of postoperative pain in a short period of time. Although steroids are widely believed to reduce the effect of surgical trauma, the observation indicators are not uniform, especially the long-term effects, so the problem remains controversial. Therefore, the purpose of this paper was to evaluate the efficacy of epidural steroids following PTED.

Methods

We searched PubMed, Embase, and the Cochrane Database from 1980 to June 2021 to identify randomized and non-randomized controlled trials comparing epidural steroids and saline alone following PTED. The primary outcomes included postoperative pain at least 6 months as assessed using a visual analogue scale (VAS) and the Oswestry Disability Index (ODI). The secondary outcomes included length of hospital stay and the time of return to work.

Results

A total of 451 patients were included in three randomized and two non-randomized controlled trials. The primary outcomes, including VAS and ODI scores, did not differ significantly between epidural steroids following PTED and saline alone. There were no significant intergroup differences in length of hospital stay. Epidural steroids were shown to be superior in terms of the time to return to work (P < 0.001).

Conclusions

Intraoperative epidural steroids did not provide significant benefits, leg pain control, improvement in ODI scores, and length of stay in the hospital, but it can enable the patient to return to work faster.

Surgical Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion for Highly Migrated Lumbar Disc Herniation

Objective

To describe minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for highly migrated lumbar disc herniation (LDH) and assess its clinical outcomes.

Patients and Methods

This research retrospectively assessed 25 patients who were diagnosed with one-segmental highly migrated LDH and underwent MIS-TLIF in Peking University First Hospital from June 2015 to September 2019. Demographic data, perioperative parameters, complications, recurrence, and surgical outcomes were assessed.

Results

Twelve males and 13 females, with a mean age of 56.68 years old, were involved and the follow-up period was at least one year. The mean operation time was 222.16 minutes, the mean intraoperative hemorrhage was 250.00 mL, and the mean post-operative hospitalization was 5.76 days. The improvements in visual analog scale (VAS) and Oswestry disability index (ODI) were statistically significant. In addition, based on the MacNab criteria, 22 patients (88.0%) acquired satisfactory (good or excellent) results. One patient underwent post-operative epidural hematoma and recovered after evacuation of the hematoma. No recurrence was found.

Conclusion

MIS-TLIF is safe and effective and it can provide satisfactory clinical outcomes for highly migrated LDH.

Endoscopic and Microscopic Interlaminar Discectomy for the Treatment of Far-Migrated Lumbar Disc Herniation: A Retrospective Study with a 24-Month Follow-Up

Purpose

Percutaneous endoscopic lumbar discectomy for the treatment of far-migrated lumbar disc herniation (LDH) is clinically challenging. The aim of this study was to compare the efficacy and safety of interlaminar endoscopic lumbar discectomy (IELD) and interlaminar microscopic lumbar discectomy (IMLD) for the treatment of far-migrated LDH.

Materials and Methods

We retrospectively analyzed 50 consecutive cases of far-migrated LDH treated by IELD or IMLD. Clinical data and outcomes were assessed before the operation and 1 day and 3, 12, and 24 months after the surgery using the visual analog scale (VAS) and Oswestry disability index (ODI). Modified MacNab criteria were used to evaluate patient satisfaction at the 24-month follow-up.

Results

A significant reduction in leg pain and improvement in ODI (P<0.01) were observed in both groups after surgery. Lower back pain (LBP) was reduced at 24 months postsurgery in the IELD group (P<0.05) but not in the IMLD group (P>0.05). There were significant intergroup differences in VAS LBP score at 1 day and 24 months postsurgery (p=0.01 and 0.02, respectively) and in ODI at 24 months (p=0.03). The rate of excellent or good outcome was 90.32% with IELD and 78.95% with IMLD (p=0.55). Hospital stay and time to ambulation were shorter in the IELD group than in the IMLD group, but the former had a longer operative time (p<0.01). Low and comparable complication rates were reported in the IELD (16.13%) and IMLD (10.53%) groups (p=0.70).

Conclusion

Both IELD and IMLD achieve favorable clinical results in the treatment of far-migrated LDH, with only minor complications. Compared to IMLD, LBP was significantly reduced with IELD presumably because it involved less trauma.

Percutaneous Endoscopic Lumbar Discectomy via Transforaminal Approach Combined with Interlaminar Approach for L4/5 and L5/S1 Two-Level Disc Herniation

Objective

The purpose of the present study was to discuss a new surgical strategy that combines percutaneous endoscopic transforaminal discectomy (PETD) with percutaneous endoscopic interlaminar discectomy (PEID) for L4/5 and L5/S1 two‐level disc herniation.

Methods

This was a retrospective study. A total of 19 patients with L4/5 and L5/S1 two‐level lumbar disc herniation (LDH) who underwent percutaneous endoscopic lumbar discectomy (PELD) in our hospital from January 2015 to June 2016 were retrospectively examined. The average age of these 19 patients was 42.21 ± 14.88 years old, including 12 men and 7 women. One experienced surgeon who had carried out more than 3000 lumbar surgeries performed PELD for these patients. During the PELD surgery, the transforaminal approach was adopted for L4/5 level disc herniation and the interlaminar approach was adopted for L5/S1 level disc herniation. The demographic data, operation time (min), fluoroscopy times, hospital stay (days), and complications were recorded and analyzed. The visual analogue scale (VAS), Oswestry disability index (ODI) scores, and the modified MacNab criteria were used to evaluate the surgical outcomes. MRI was conducted to evaluate the radiographic improvement.

Results

All patients underwent PELD via the transforaminal approach combined with the interlaminar approach successfully and achieved satisfactory efficacy. The follow‐up points were 3, 12, and 18 months. The average hospital stay (days) and the average follow up (months) were 3.32 ± 0.98 and 18.63 ± 3.84, respectively. The operation time and fluoroscopy times were 85.79 ± 12.90 min and 39.05 ± 4.59 times, respectively. The fluoroscopy times (frequency) for L4/5 and L5/S1 were 26.95 ± 6.41 and 12.11 ± 3.49 (t = 7.00, P < 0.05). Furthermore, there was no significant difference for fluoroscopy times between male and female patients (t = 0.89, P = 0.99). The preoperative back pain (VAS‐Back) and the last follow‐up VAS‐Back were 5.58 ± 2.01 and 2.37 ± 1.01, respectively (t = 7.14, P < 0.05). The preoperative leg pain (VAS‐Leg) and the last follow‐up VAS‐Leg were 7.00 ± 1.56 and 1.63 ± 1.01, respectively (t = 20.97, P < 0.05). There were significant differences between preoperative VAS‐Back and the last follow‐up VAS‐Back in men (t = 4.61, P < 0.05) and women (t = 6.57, P < 0.05). In addition, there was significant differences between preoperative VAS‐Leg and the last follow‐up VAS‐Leg in men (t = 13.48, P < 0.05) and women (t = 26.87, P < 0.05). There were significant differences between preoperative ODI scores (44.84 ± 10.82%) and the last follow‐up ODI scores (11.12 ± 5.80%) (t = 10.92, P < 0.05). Preoperative ODI scores and the last follow‐up ODI scores were significantly different for men (t = 8.80, P < 0.05) and women (t = 6.63, P < 0.05). All patients received significant pain relief and functional improvement after the surgery. Except for two cases of postoperative dysesthesia and one dural tear, no severe complications occurred. The dysesthesia symptoms of these two patients disappeared within 1 week with the application of dexamethasone and neurotrophic drugs and the dural tear case also recovered well as the dural laceration was small. No poor results were reported and 89.47% of patients achieved excellent or good recovery.

Conclusion

Percutaneous endoscopic lumbar discectomy via the transforaminal approach combined with the interlaminar approach under epidural anesthesia can treat L4/5 and L5/S1 two‐level disc herniation safely and effectively.

Chinese Association for the Study of Pain: Expert consensus on diagnosis and treatment for lumbar disc herniation

Lumbar disc herniation is a common disease in the clinical context and does great harm to either the physical or mental health of patients suffering from this disease. Many guidelines and consensus for the diagnosis and treatment of lumbar disc herniation have been published domestically and internationally. According to the expert consensus, clinicians could adopt tailored and personalized diagnosis and treatment management strategies for lumbar disc herniation patients.

Functional outcomes of full-endoscopic spine surgery for high-grade migrated lumbar disc herniation: a prospective registry-based cohort study with more than 5 years of follow-up

BACKGROUND

Full-endoscopic lumbar discectomy (FELD) is an alternative to posterior open surgery to treat a high-grade migrated herniated disc. However, because of the complexity of the surgery, success is dependent on the surgeon's skill. Therefore, patients are frequently treated using open discectomy. Anatomical constraints and technical difficulties can lead to the incomplete removal of high-grade migrated discs.

METHODS

We retrospectively reviewed patients who had undergone FELD performed by a single surgeon between January 2010 and January 2014 from a prospective spine registry in an institute. Perioperative records and data of the Oswestry Disability Index, visual analog scale scores (preoperatively and 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and 5 years after the operation), and MacNab criteria were collected.

RESULTS

Of 58 patients with a follow-up duration of > 5 years, (41 and 17 patients had undergone transforaminal endoscopic lumbar discectomy [TELD] and interlaminar endoscopic lumbar discectomy [IELD], respectively), the satisfaction rate was 87.8% (five unsatisfactory cases) for TELD and 100% for IELD. The overall percentage of patients with good to excellent results according to modified MacNab criteria was 91.3% (53/58 patients). Two patients had residual discs. Two patients needed an open discectomy due to recurrent disc herniation. One IELD patient received spinal fusion surgery due to segmental instability after 5 years.

CONCLUSION

FELD has a high success rate for the management of high-grade migrated herniated discs. In patients with high-grade disc migration from L1 to L5, TELD is effective and safe. However, for L4-L5 and L5-S1 high-grade upward and downward disc migration, IELD is the favorable option and provides high patient satisfaction.

Epidural steroids following percutaneous endoscopic interlaminar discectomy: A protocol for systematic review and meta-analysis

BACKGROUND

Percutaneous endoscopic interlaminar discectomy (PEID) has been widely used in the treatment of lumbar disc herniation and spinal stenosis, epidural steroids following PEID in an effort to reduce the incidence and duration of postoperative pain. Although steroids are widely thought to reduce the effect of surgical trauma, the observation index is not uniform, so the issue is still controversial. Therefore, the purpose of this paper is to systematically evaluate the efficacy and safety of local epidural steroids application following PEID.

METHODS

We will search the following databases from their inception to August 2020, PubMed, Embase, Medline, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature Database, Web of Science, Wan Fang Database, Cochrane Library. The search strategy includes the MeSH terms. Meta-analysis will be performed using Rev Man V.5.3.5 statistical software.

RESULTS

This study will provide a high-quality synthesis to evaluate the efficacy and safety of local epidural steroids following PEID.

CONCLUSION

This systematic review will provide evidence to judge whether local epidural steroids application following PEID is an effective and safe intervention for patients. It will provide reliable evidence for its extensive application.

REGISTRATION NUMBER

INPLASY2020100085.

Suprapedicular Retrocorporeal Technique of Transforaminal Full-Endoscopic Lumbar Discectomy for Highly Downward-Migrated Disc Herniation

OBJECTIVE

Anatomical barriers (e.g., pedicles, narrow foramina) can hinder direct access to, and removal of, disc fragments that have migrated far downward. Using transforaminal full-endoscopic lumbar discectomy (FELD), we devised a modified technique, the suprapedicular retrocorporeal approach, for herniations in which the disc has migrated to the axilla of the traversing nerve roots. In the present report, we have described our preliminary results.

METHODS

Soft, highly downward-migrated disc herniation was treated with transforaminal FELD through the suprapedicular retrocorporeal approach in 22 patients from June 2017 to May 2019. The clinical outcomes were evaluated, including the preoperative and postoperative visual analog scale scores for the back and leg, Oswestry disability index, and MacNab criteria for surgical success.

RESULTS

The affected discs were at L4-L5 in 14 patients, L3-L4 in 6 patients, and L5-S1 in 2 patients. In each case, the affected disc was successfully removed using the suprapedicular retrocorporeal approach. The mean follow-up was 18.1 ± 5.7 months. The mean visual analog scale scores for back and leg pain improved significantly (P < 0.05 for both). The mean Oswestry disability index had decreased from 62.5 ± 14.2 preoperatively to 10.5 ± 5.9 postoperatively (P < 0.05). Using the MacNab criteria, 13 patients reported excellent outcomes and 9, good outcomes. No complications or recurrence developed during follow-up.

CONCLUSIONS

The suprapedicular retrocorporeal technique is a feasible and effective surgical option in transforaminal FELD for the treatment of herniation in which the disc has migrated to the axilla of the traversing nerve roots.

Modified Interlaminar Endoscopic Lumbar Discectomy for Highly Upmigrated Disc Herniation: A Proctorship Description of the Technique via Translaminar Route

Lumbar disc herniation (LDH) comprises one of the most common causes of low back pain. 35%–72% of LDH is associated with disc fragment migration. The migration of the disc fragments can be high-grade up, low-grade up, high-grade down, and low-grade down. Spine surgeons deal with unique challenges during surgical management of migrated discs. Operational challenges with open surgery include extensive lamina excision, pars excision, and potential for iatrogenic instability without fixation. In contrast, rigid instruments and poor visualization are the challenges with transforaminal endoscopic spine surgery (ESS). Hence interlaminar approach with ESS is an excellent choice with these migrated LDH. The creation of a translaminar crater in the cranial lamina without dealing with the interlaminar window or ligamentum flavum could be an excellent option to deal with these herniations face front. The lamina is the only anatomical barrier between the endoscope and the migrated disc fragment. Hence with a translaminar approach, unnecessary flavectomy can be avoided. In this technical report and video, we demonstrate the surgical technique of performing the translaminar ESS for highly upmigrated LDH with the preservation of optimal natural anatomy.

Contralateral Keyhole Biportal Endoscopic Surgery for Ruptured Lumbar Herniated Disc: A Technical Feasibility and Early Clinical Outcomes

OBJECTIVE

Spinal endoscopic surgery is increasingly adapted as a minimal invasive technique, however, significant facet joint violation may be developed after ipsilateral laminectomy. The aim of this study is to introduce surgical technique of contralateral keyhole biportal endoscopic surgery (CKES) for ruptured lumbar disc and report it is early surgical outcomes with facet joint violation.

METHODS

Between January to December 2019, 27 patients with ruptured lumbar disc were underwent CKES. Simple radiographs were obtained to investigate development of iatrogenic instability or spondylolisthesis. Magnetic resonance imaging scan was checked about 8 hours after surgery to evaluate successful removal of ruptured disc and existence of facet joint violation. Clinical outcomes were assessed by modified MacNab criteria, visual analogue scale (VAS) scores of back and radicular pain.

RESULTS

The mean age of the patients was 62.8 ± 12.48 years. The average operative time and mean follow-up period were 57.1 ± 21.36 minutes and 8.1 ± 3.78 months, respectively. Compared to preoperative scores, the VAS scores of back and radicular pain were significantly improved. Modified MacNab outcome grade was good to excellent in 96.3% (26 out of 27 patients) of patients. The reduction rate of facet joint plane was about 4.9% after contralateral approach.

CONCLUSION

CKES may be considered as an excellent surgical option to treat ruptured lumbar disc without the development of iatrogenic instability. Low rate of facet joint reduction, good visualization of lateral recess, and identification of accurate midline of central spinal canal are advantages of the procedure.

Percutaneous Endoscopic Lumbar Discectomy (PELD) via a Transforaminal and Interlaminar Combined Approach for Very Highly Migrated Lumbar Disc Herniation (LDH) Between L4/5 and L5/S1 Level

Background

Percutaneous endoscopic lumbar discectomy (PELD) has become one of the most popular minimally invasive surgeries for lumbar disc herniation (LDH), however, very highly migrated LDH is still a tricky issue for PELD. This study reported a new endoscopic discectomy strategy for the treatment of very highly migrated LDH between the L4/5 and L5/S1 level.

Material/Methods

The current study retrospectively analyzed 12 patients who accepted PELD for very highly migrated LDH between the L4/5 and L5/S1 level. Under local anesthesia, the transforaminal approach was chosen for the L4/5 level and the interlaminar approach was chosen for the L5/S1 level. The 10-point visual analogue scale (VAS) was used to assess back pain (VAS-Back) and leg pain (VAS-Leg). Oswestry disability index (ODI) and Modified Mac Nab Criteria were adopted as the functional evaluation methods. All patients were followed in the outpatient department for at least 12 months after their operation.

Results

Our study showed that very highly migrated disc between L4/5 and L5/S1 level could be removed completely by this strategy. Except for 1 case of postoperative dysesthesia and 1 case of dural tear, no severe complication occurred. At the last follow-up, the average VAS-Back score of the study patients was reduced from 5.17±2.12 to 2.08±1.08 (P<0.05) and the average VAS-Leg score was reduced from 7.25±1.48 to 1.33±0.89 (P<0.05). The average ODI scores improved from 48.50±10.59 to 13.00±2.76 (P<0.05). According to the Modified Mac Nab Criteria, 83.33% of patients (10 out of 12 patients) received an excellent or good recovery and no poor result was reported. No recurrence was observed during follow up.

Conclusions

PELD via a transforaminal and interlaminar combined approach provides an alternative option for select patients with very highly migrated LDH between the L4/5 and L5/S1 level.

Risk Factors for Recurrent L5-S1 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Study

Background

This retrospective study aimed to investigate the risk factors associated with the recurrence of L5–S1 disc herniation after percutaneous endoscopic transforaminal discectomy (PETD).

Material/Methods

There were 484 patients L5–S1 disc herniation who underwent PETD who were divided into the recurrence group (n=46) and the non-recurrence group (n=438). Transforaminal endoscopic approaches included modifications of the Yeung endoscopy spine system (YESS) (the intraforaminal intradiscal approach) and the transforaminal endoscopic spine system (TESSYS) (intraforaminal extradiscal approach). Demographic and clinical characteristics and imaging data were analyzed. The two study groups were compared to determine the factors associated with the recurrence of L5–S1 disc herniation. The patients underwent postoperative follow-up for between one and four years.

Results

At follow-up, 9.504% of patients (46/484) with the recurrence of L5–S1 disc herniation following PETD when compared with the non-recurrence group showed no significant difference for time to return to work, gender, history of diabetes mellitus, trauma, duration of symptoms, smoking and alcohol history, hypertension, location of disc herniation, transverse process length, intervertebral space height, and pelvic incidence angle (P>0.05). However, age, body mass index (BMI), the degree of disc degeneration, sagittal range of motion, lumbar lordosis angle, and sacral slope were significantly associated with the recurrence of L5–S1 disc herniation following PETD (P<0.05). Logistic regression analysis supported these main associations.

Conclusions

The recurrence of L5–S1 disc herniation following PETD was significantly associated with increased age and BMI, more severe disc degeneration, increased sagittal range of motion, increased lumbar lordosis, and sacral slope.

Full Endoscopic Technique for High-Grade Up-Migrated Lumbar Disk Herniation via a Translaminar Keyhole Approach: Preliminary Series and Technical Note

Background and Study Aims Technically and anatomically, accessing a high-grade migrated lumbar disk herniation (LDH) using traditional full endoscopic lumbar diskectomy (FELD) approaches (either transforaminal or interlaminar) is challenging. The objective of this study was to present an effective and safe surgical approach for high-grade up-migrated LDH by translaminar FELD.

Patients and Methods Thirteen patients with soft high-grade up-migrated LDH treated with a translaminar FELD between May 2015 and July 2018 were reviewed in this study. Five of these patients had very high-grade up-migration. Clinical outcomes were assessed including preoperative and postoperative visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and MacNab criteria.

Results Overall, 7 of the 13 patients had disk-fragment migration at L4–L5: three at L5–S1, two at L3–L4, and the remaining one at L2–L3. In all cases, the highly up-migrated LDH was removed successfully through the translaminar approach, as confirmed by postoperative magnetic resonance imaging. The improvements of VAS for back and leg pain were 4.5 ± 0.9 to 1.3 ± 1.3 and 7.1 ± 1.0 to 1.6 ± 0.7, respectively (both p < 0.05). The ODI decreased from preoperative 41.9 ± 6.0 to postoperative 13.0 ± 4.1 (p < 0.05). According to the MacNab criteria, the satisfaction rate was 92.3% (excellent or good outcomes). None of the patients experienced any perioperative complications or recurrence during the follow-up period.

Conclusion Although full endoscopic technique via the translaminar keyhole route may not be used as a routine surgical approach, it could serve as a feasible alternative method for patients with highly up-migrated disk herniation.

Posterolateral Endoscopic Lumbar Decompression Rotate-to-Retract Technique for Foraminal Disc Herniation: A Technical Report

Background and Study Aim

Foraminal disc herniations present the unique surgical challenge for exiting nerve root retraction and decompression. The aim of current study is to describe an innovative maneuver and evaluate its usefulness for endoscopic decompression of foraminal disc herniations.

Material and Methods

A retrospective review was performed including cases of foraminal disc herniations who underwent endoscopic discectomy utilizing the rotate-to-retract technique. Data on patient demographics and improvement in VAS/ODI scores were collected and analyzed statistically.

Results

There were ten patients (three male; seven female) in the final analysis. Seven procedures were done at the L4-L5 level, two were done at the L5-S1 level, and one was done at the L3-L4 level. The average VAS scores improved from preoperatively 7.5 to postoperatively 4.4 (p= 0.001). The mean preoperative ODI was 67.8 and improved to 26.6 postoperatively (p< 0.001). None of the cases reported any neurological or dural complication.

Conclusion

Foraminal disc herniations can be safely and adequately addressed endoscopically with the use of rotate-to-retract technique.

Outcomes of percutaneous endoscopic trans-articular discectomy for huge central or paracentral lumbar disc herniation

PURPOSE

This study reports a new technique known as percutaneous endoscopic trans-articular discectomy (PETAD) for huge central/paracentral lumbar disc herniation (LDH).

METHODS

Sixteen patients with huge central/paracentral LDH who underwent PETAD in our department from July 2015 to July 2016 were retrospectively analyzed. Clinical outcomes were evaluated according to pre-operative and post-operative visual analog scale (VAS) and Oswestry disability index (ODI) scores and the MacNab criteria. Immediate post-operative MRI and CT were conducted to confirm complete removal of LDH along with follow-up flexion-extension X-ray to observe lumbar stability.

RESULTS

The huge central/paracentral LDH was completely removed by PETAD in 16 patients, as confirmed by post-operative MRI and CT. Leg pain was eased after removal of the disc herniations. The satisfactory (excellent/good) results were 93.7%. The mean follow-up duration was 15.6 (range, 3-24) months. The mean pre-operative VAS and ODI scores were 5.72 ± 1.18 (range, 4-9) and 60.1 (range, 51-87), respectively, which decreased to 1.26 ± 0.81 (range, 0-3) and 18.1 (range, 10-31), respectively at the third month post-operatively and to 0.78 ± 0.62 (range, 0-1) and 7.2 (range, 0-15), respectively by the last follow-up visit. No recurrence and segmental instability was observed in any of the 16 patients during the follow-up period.

CONCLUSION

PETAD could be a good alternative for treatment of huge central/paracentral LDH.

Risk factors for recurrent lumbar disc herniation after discectomy

PURPOSE

There are many reports about the risk factors for recurrence after lumbar disc surgery. However, there are none about whether lumbosacral transitional vertebrae (LSTV) are associated with recurrent lumbar disc herniation (LDH). We investigated various risk factors for recurrent LDH after discectomy including LSTV.

METHODS

A total of 119 patients who had undergone a discectomy for L4-5 disc herniation were evaluated with a minimum follow-up of two years. Clinical parameters including age, gender, body mass index (BMI), and smoking status, and radiological parameters including type of herniated disc, degree of disc degeneration, LSTV, and sagittal range of motion (SROM) in flexion-extension radiography were evaluated. SROM was measured by the difference of the lordotic angle between the flexion and extension view.

RESULTS

Recurrent disc herniation at L4-5 developed in 21 (17.6%) of the 119 patients. The mean period between primary surgery and recurrence was 17.6 ± 21.1 months. LSTV was found in 11 (52.4%) of the 21 patients who had recurrence and seven (7.1%) of the 98 patients in the non-recurrent group. SROM at L4-5 was 11.68 ± 4.24° in the recurrent group and 9.04 ± 3.65° in the non-recurrent group with a significant difference (p = 0.004). Multiple logistic regression analyses confirmed that LSTV and a larger SROM were significant risk factors for recurrent disc herniation at L4-5.

CONCLUSIONS

Lumbosacral transitional vertebrae and a hypermobile disc in flexion-extension radiography were found to be risk factors for recurrent lumbar disc herniation.

Percutaneous endoscopic lumbar discectomy via adjacent interlaminar space for highly down-migrated lumbar disc herniation: a technical report

The treatment of highly migrated lumbar disc herniation (LDH) is a challenge for percutaneous endoscopic lumbar discectomy (PELD). The purpose of this study was to determine the feasibility and efficacy of PELD for highly migrated LDH via the adjacent interlaminar space. We performed PELD via the adjacent interlaminar space in three patients with radiculopathy caused by highly migrated LDH using a full-endoscopic system (diameter of working channel: 4.1 mm, outer diameter: 6.9 mm). One case had a large interlaminar bone window that did not require enlargement. Enlargement of the bone window in other cases was performed with a 3.5-mm diameter high-speed drill. After the operation, we confirmed pain relief and evacuation of migrated LDH on magnetic resonance imaging in all patients. The mean operative time was 75.3 min, and no complication was observed. PELD via the adjacent interlaminar space is an appropriate operative approach for highly down-migrated LDH. Minimal laminectomy using a high-speed drill is conductive to this approach.

The Use of Tubular Retractors for Translaminar Discectomy for Cranially and Caudally Extruded Discs

BACKGROUND

The conventional interlaminar approach is adequate for access to most disc herniations in lumbar spine surgery. The access to cranially and caudally migrated disc fragments, by conventional interlaminar fenestration, requires an extension of the fenestration with the potential destruction of the facet joint complex and consequent postsurgical instability. To describe the technique and results of the translaminar technique of targeted discectomy using tubular retractors for the surgical treatment of cranially and caudally extruded discs.

MATERIALS AND METHODS

The study period extended from January 2008 to December 2014. All patients with lumbar herniated discs who failed conservative management were selected for surgery and underwent routine erect radiographs and magnetic resonance imaging (MRI) of the lumbar spine. The patients with cranially or caudally migrated discs were included in this study. The technique involves approaching migrated disc through an oval window (sculpted through an 18 mm tubular retractor using a burr) in the lamina precisely over the location of the migrated disc as predicted by the preoperative MRI (inferior lamina for inferior migration and superior lamina for superior migration). The perioperative parameters studied were operative time, blood loss, complications, Oswestry Disability Index (ODI), and visual analog scale (VAS) for leg pain before surgery and at last followup. In the study, 4 patients underwent a postoperative computed tomography-scan with a three-dimensional reconstruction to visualize the oval window and to rule out any pars fracture. All technical difficulties and complications were analyzed.

RESULTS

17 patients in the age group of 41-58 years underwent the translaminar technique of targeted discectomy. The migration of disc was cranial in 12 patients and caudal in 5 patients. Fourteen of the affected discs were at the L4-L5 level and three were at the L5-S1 level. The mean VAS (leg pain) scale improved from 8 to 1 and the mean ODI changed from 59.8 to 23.6. There were no intraoperative or postoperative complications encountered in this study. Furthermore, no patient in the present study required a conventional laminotomy or medial facetectomy. There was no evidence of iatrogenic pars injury or instability at the last followup. There were no recurrences till the last followup.

CONCLUSIONS

The targeted translaminar approach preserves structures important for segmental spinal stability thus causing minimal anatomical disruption. This approach allows access to the extruded disc fragment and intervertebral disc space comparable to classical approaches.

Comprehensive comparison of therapeutic efficacy of radiofrequency target disc decompression and nucleoplasty for lumbar disc herniation: a five year follow-up

PURPOSE

To compare the therapeutic efficacy of radiofrequency target disc decompression(TDD) and nucleoplasty for lumbar disc herniation.

METHODS

Two hundred sixty patients with lumbar disc herniation were divided into two groups: target disc decompression group (group T, n = 147) and nucleoplasty group (group N, n = 113). Visual analogue scale (VAS) and functional rating index (FRI) were measured at one, three, six, 12, 24, and 60 months after the surgery. Hospitalization time, operation time, complications, and recurrence/invalid were compared between the two groups.

RESULTS

Compared with the pre-operation, the VAS and FRI in both groups were significantly decreased in post-operation(P < 0.01). The VAS and FRI in group T have no significant difference compared to those in group N. The hospitalization and operation time of group T were significantly longer than those in group N. There was no significant difference of the occurrence of complications and disease recurrence/invalid during the follow-up between the two groups. Logstic regression analysis showed that operation time was an independent factor in the prognosis. Operation time affects the treatment effect. Shorter operation time leads to better therapeutic efficacy, and longer operation time leads to poor therapeutic efficacy.

CONCLUSIONS

Both TDD and nucleoplasty can reduce pain in patients with lumbar disc herniation and improve quality of life. Group N had shorter hospitalization and operation time than group T.

A retrospective study of epidural and intravenous steroids after percutaneous endoscopic lumbar discectomy for large lumbar disc herniation

OBJECTIVE

To assess the early curative effect of epidural or intravenous administration of steroids during a percutaneous endoscopic lumbar discectomy (PELD).

METHODS

28 consecutive patients who underwent PELD due to large lumbar disc herniation between November 2014 and January 2016 were followed up for 6 months. These patients were divided into two groups according to the treatment they received after PELD. 14 patients (Group A) were treated by PELD and epidural steroids, while the other 14 patients (Group B) were treated by PELD and intravenous steroids. We evaluated the effectiveness by the preoperative and postoperative visual analogue scale (VAS) scores for back and leg pain, and the postoperative Oswestry disability index (ODI) at 3 weeks after surgery via the clinical charts and telephone interview. Postoperative hospital stay and time return to work were investigated as well.

RESULTS

There is a significant decrease in VAS (back, leg), ODI, and time return to work (p < 0.05). For VAS (back), Group A showed a significant decrease compared with Group B at 1 day and 1 week after surgery (p = 0.011, p = 0.017). As for VAS (leg), Group A showed a significant decrease compared with Group B at 1 day, 1 week, 3 weeks, and 3 months follow-up examinations (p = 0.002, p = 0.006, p < 0.001, p < 0.001). For ODI, Group A showed a notable decrease compared with Group B (p < 0.001). The postoperative hospital stay in two groups was not statistically different (p = 0.636). But the time return to work in Group A was significantly shorter than that in Group B (p = 0.023).

CONCLUSION

Patients who underwent PELD with epidural steroid administration for large lumbar disc herniation showed favorable curative effect compared with those who underwent PELD with intravenous steroid administration.

Surgical Outcome of Two-Level Transforaminal Percutaneous Endoscopic Lumbar Discectomy for Far-Migrated Disc Herniation

Objective. To describe the two-level percutaneous endoscopic lumbar discectomy (PELD) technique in transforaminal approach for highly migrated disc herniation and investigate its clinical outcomes. Methods. A total of 22 consecutive patients with highly migrated lumbar disc herniation were enrolled for the study from June 2012 to February 2014. Results. There were 12 males and 10 females, with a mean age of 41.1 (range 23–67) years. The mean follow-up period was 18.05 (range 14–33) months. According to the modified MacNab criteria, the clinical outcome at the final follow-up was excellent in 14, good in 6, and fair in 2 patients and the satisfactory rate (excellent and good) was 90.9%. The improvements in VAS and ODI were statistically significant. One patient had recurrent herniation in 18 months after the first surgery and underwent open discectomy. One patient showed symptoms of postoperative dysesthesia (POD), but the POD symptom was transient and partial remission was achieved in two months after conservative treatment. Conclusion. Two-level PELD in transforaminal approach can be a safe and effective procedure for highly migrated disc herniation.

Navigation improves the learning curve of transforamimal percutaneous endoscopic lumbar discectomy

PURPOSE

Beginners usually need increased punctures and dozens of fluoroscopy in learning transforamimal percutaneous endoscopic lumbar discectomy (tPELD). Navigator-assisted spinal surgery (NASS) is a novel technique that could induce a definite trajectory. The retrospective study aimed to investigate the impact of a definite trajectory on the learning curve of tPELD.

METHODS

A total of 120 patients with symptomatic lumbar disc herniation who received tPELD between 2012 and 2014. Patients receiving tPELD with NASS technique by one surgeon were regarded as group A, and those receiving conventional methods by another surgeon were regarded as group B. Each group was divided into three subgroups (case 1-20, case 21-40, case 41-60).

RESULTS

The fluoroscopy times were 22.62 ± 3.80 in group A and 34.32 ± 4.78 in group B (P < 0.001). The pre-operative location time was 3.56 ± 0.60 minutes in group A and 5.49 ± 1.48 minutes in group B (P < 0.001). The puncture-channel time was 21.85 ± 4.31 minutes in group A and 34.20 ± 8.88 minutes in group B (P < 0.001). The operation time was 84.62 ± 9.20 minutes in group A and 101.97 ± 14.92 minutes in group B (P < 0.001), and the learning curve of tPELD in group A was steeper than that in group B. No significant differences were detected in patient-reported outcomes, hospital stay, patient satisfaction, and complication rate between the two groups (p > 0.05).

CONCLUSIONS

Definite trajectory significantly reduced the operation time, preoperative location time, puncture-channel time, and fluoroscopy times of tPELD by beginners, and thus reshaped the learning curve of tPELD and minimized the radiation exposure.