Transpedicular Lumbar Endoscopic Surgery for Highly Migrated Disk Extrusions: Preliminary Series and Surgical Technique

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.

Full Endoscopic Transpedicular Discectomy for a Rostrally Migrated L5-S1 Disc Herniation in the Setting of Previous Lumbar Surgery: A Case Report With Intraoperative Video

BACKGROUND AND IMPORTANCE

The surgical management of rostral disc herniations at L5-S1 poses challenges for conventional endoscopic approaches, particularly in patients who have had previous lumbar surgery. We present a full endoscopic transpedicular discectomy (FETD), whereby a pediculotomy is created to pass an endoscope through the pedicle for intracanal access. This addresses anatomic obstacles and potential complications associated with other endoscopic and minimally invasive or open techniques. To date, this is the only article to highlight this approach with a case report and intraoperative video.

CLINICAL PRESENTATION

A 76-year-old man with a history of L3-S1 laminectomy presented with left leg pain and a near-complete left foot drop. An MRI revealed a left paracentral rostrally migrated disc herniation arising from L5-S1 with impingement of the exiting left L5 nerve root at the inferomedial aspect of the pedicle of L5. The patient consented to the FETD procedure. Using sequential reamers of increasing diameter and a high-speed burr, a superolateral to inferomedial pediculotomy was performed. This approach allowed us to target the pathology at the point of maximum compression without traversing the prior operative field. A transforaminal endoscopic approach was not possible with the iliac crest obstructing rostral angulation. The disc was successfully removed without any intraoperative complications, and after surgery, the patient's radiculopathy resolved without any radiographic evidence of instability.

CONCLUSION

FETD is a unique approach that demonstrates the versatility of endoscopic spine surgery, offering advantages over conventional approaches particularly for rostral disc herniations at L5-S1 in the setting of prior lumbar surgery.

Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis

BACKGROUND

The surgical resection of very highly migrated lumbar disc herniation (VHM-LDH) is technically challenging owing to the absence of technical guidelines. Hence, in the present study, we introduced the transforaminal endoscopic lumbar discectomy (TELD) with two-segment foraminoplasty to manage VHM-LDH and evaluated its radiographic and midterm clinical outcomes.

MATERIALS AND METHODS

The present study is a retrospective analysis of 33 consecutive patients with VHM-LDH who underwent TELD with two-segment foraminoplasty. The foraminoplasty was performed on two adjacent vertebrae on the basis of the migration direction of disc fragments to fully expose the disc fragments and completely decompress the impinged nerve root. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. Additionally, imageological observations were evaluated immediately after the procedure via magnetic resonance image and computerized tomography. Clinical outcomes were evaluated by calculating the visual analog scale (VAS) score and Oswestry Disability Index (ODI). The MacNab criterion was reviewed to assess the patients' opinions on treatment satisfaction. The resection rate of bony structures were quantitatively evaluated on postoperative image. The segmental stability was radiologically evaluated at least a year after the surgery. Additionally, surgery-related and postoperative complications were evaluated.

RESULTS

The average age of the patients was 56.87 ± 7.77 years, with a mean follow-up of 20.95 ± 2.09 months. The pain was relieved in all patients immediately after the surgery. The VAS score and ODI decreased significantly at each postoperative follow-up compared with those observed before the surgery (P < 0.05). The mean operation duration, blood loss, and hospital stay were 56.17 ± 16.21 min, 10.57 ± 6.92 mL, and 3.12 ± 1.23 days, respectively. No residual disc fragments, iatrogenic pedicle fractures, and segmental instability were observed in the postoperative images. For both up- and down- migrated herniation in the upper lumbar region, the upper limit value of resection percentage for the cranial SAP, caudal SAP, and pedicle was 33%, 30%, and 34%, respectively; while those in the lower lumbar region was 42%, 36%, and 46%, respectively. At the last follow-up, the satisfaction rate of the patients regarding the surgery was 97%. Surgery-related complications including dural tear, nerve root injury, epidural hematoma, iatrogenic pedicle fractures, and segmental instability were not observed. One patient (3%) suffered from the recurrence of LDH 10 months after the initial surgery and underwent revision surgery.

CONCLUSIONS

The TELD with two-segment foraminoplasty is safe and effective for VHM-LDH management. Proper patient selection and efficient endoscopic skills are required for applying this technique to obtain satisfactory outcomes.

Full Endoscopic Transpedicular Technique in the Treatment of High Grade Down Migrated Herniated Disc: An Evaluation of Clinical Outcomes at 12 Months Follow-Up

OBJECTIVE

High-grade migrated lumbar disc herniation (LDH) such as up-migrated and down-migrated discs are challenging pathologies to treat. High-grade migrated discs are usually sequestered and situated adjacent to the medial pedicle wall. This can be easily addressed if the pedicle is used as an access route. The authors present a retrospective case series of high-grade migrated LDH treated using a full endoscopic transforaminal approach.

MATERIALS AND METHODS

This is a retrospective case series. The clinical outcomes in the patients were evaluated according to improvement in the symptoms as suggested by improvement in Visual Analog Score (VAS) and Oswestry Disability Index (ODI) scores in the immediate postoperative period and at the final follow-up. The radiological outcomes were evaluated using postoperative magnetic resonance imaging and computed tomography scans. After the data were collected and tabulated, descriptive statistics were used for continuous variables. The t test was used to determine the significance of changes in the VAS and ODI scores. Statistical significance was set at P < 0.05.

RESULTS

Five patients underwent discectomy using the transpedicular technique, and the mean preoperative VAS scores for the back and leg were 7.2 ± 0.83 and 8.4 ± 0.54, respectively. The mean VAS scores at the final follow-up for the back was 0.2 ± 0.4 and 0 for the leg (P < 0.05). The mean preoperative ODI score was 72 ± 8.3, which improved to 6 ± 4.69 at the final follow-up (P < 0.05). All patients had a hospital stay of 1 day.

CONCLUSIONS

The full endoscopic transpedicular approach is a good option for treating highly migrated LDH. Surgical planning, including pedicle morphometry and the angle of the approach, should be undertaken preoperatively for the best results.

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.

Percutaneous endoscopic interlaminar discectomy via inner border of inferior pedicle approach for downmigrated disc herniation: a retrospective study

Objective

To evaluate the efficacy and feasibility of percutaneous endoscopic interlaminar discectomy (PEID) via the inner border of the inferior pedicle approach for downmigrated disc herniation.

Methods

Seventeen patients who had downmigrated disc herniation were included in this study from May 2020 to February 2021. After PEID via the inner border of the inferior pedicle approach, a retrospective study was conducted on all patients. Radiologic findings were investigated, and based on the level of migration seen on preoperative magnetic resonance imaging (MRI), participants were divided into two types (high-grade and low-grade migrations). Preoperative, 1st post-operative day, 3rd post-operative month, and the final follow-up visual analogue scale (VAS) assessments for back and leg pain and preoperative, 3rd post-operative month, and the final follow-up Oswestry disability index (ODI) evaluations were performed. The clinical effects at the final follow-up were assessed by the modified MacNab criterion.

Results

All patients successfully completed surgery. There were 10 males and 7 females in the group. These patients were 42 years old on average (range, 25–68 years). Four and 13 patients had downmigrated disc herniation with high-grade and low-grade, respectively, on MRI. The mean follow-up duration was 10.47 ± 1.84 months (range, 8–14 months). The mean VAS score for back and leg improved from 5.18 ± 0.81 preoperatively to 1.35 ± 0.49 at the final follow-up (P < 0.05) and 6.94 ± 0.66 preoperatively to 1.47 ± 0.51 at the final follow-up (P < 0.05), respectively. The mean ODI score improved from 48.00 ± 3.64 preoperatively to 18.71 ± 1.31 at the final follow-up (P < 0.05). According to the modified MacNab criterion, 15 patients (88.2%) obtained excellent, while the rest 2 patients (11.8%) reported good outcomes.

Conclusion

PEID via the inner border of the inferior pedicle approach could be a good alternative option for the treatment of downmigrated disc herniation.

A Novel Trajectory for a Transpedicular Approach in the Treatment of a Highly Downward-Migrated Lumbar Herniation with a Full Endoscopic Technique

Background

To evaluate the clinical outcome of full endoscopic discectomy using a novel trajectory via a transpedicular approach.

Method

Thirty-five patients were enrolled in this retrospective study between July 2014 and October 2019 in the Beijing Haidian Hospital. All patients were treated with full-endoscopic lumbar discectomy via a transpedicular approach with an oblique trajectory. The imaging parameters, including pedicle height and angle of trajectory, were recorded. The preoperative and postoperative clinical data were collected for statistical analysis.

Results

All patients underwent successful surgery without severe complications. We compared the visual analogue scale and Oswestry disability index scores before and after surgery. The differences were statistically significant (p < 0.05). According to the modified Macnab criteria, the good-to-excellent rate was 85.7% at the last follow-up. The average angles of trajectory in the sagittal and coronal planes were 34.5° ± 2.9° and 47.1° ± 5.0°, respectively.

Conclusion

The new trajectory of the transpedicular approach with a full endoscopic technique for an extremely downward-migrated disc herniation showed excellent results in a small sample study. A precise surgical plan is required, comprising measurements of the pedicle height and angle of the bone tunnel.

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.

Foraminoplasty at the Base of the Superior Articular Process with Bone Drilling for Far-Downward Discs in Percutaneous Endoscopic Lumbar Discectomy: A Retrospective Study

Purpose

Percutaneous endoscopic lumbar discectomy (PELD) is usually used to treat lumbar disc herniation (LDH). This study aims to describe PELD by foraminoplasty in the treatment of far-downward migrated LDH and to demonstrate the clinical efficacy by a retrospective evaluation.

Patients and Methods

Between January 2017 and July 2018, 41 patients with far-downward migrated LDH were treated with PELD by foraminoplasty at the base of the superior articular process (SAP). Clinical efficacy was evaluated with a visual analogue scale (VAS) score, the Oswestry disability index (ODI), and the modified Macnab criteria. Postoperative follow-up data (1 month, 6 months, 18 months) were recorded.

Results

The surgical levels included L2/3 (1 patient), L3/4 (1 patient), L4/5 (17 patients), and L5/S1 (22 patients). The VAS and ODI scores indicated a significant improvement 18 months after surgery (mean ± standard deviation, VAS, 6.9±1.3 versus 0.5±0.8; ODI, 66.3±12.2 versus 14.0±8.2, respectively). Based on the modified Macnab criteria, 92.7% of patients had a good-to-excellent rate. There were three patients with a dural tear, and one patient had recurrent disc herniation.

Conclusion

PELD by foraminoplasty at the base of the superior articular process is a good method for treating far-downward migrated LDH.

[Two treatment approaches for lumbar disc herniation and sequester migration to the second and third McCulloch's windows: transpedicular and translaminar sequestrectomy (ridit analysis)]

A ridit analysis of results of transpedicular endoscopic and translaminar microsurgical surgeries for sequester migration to the second and third McCulloch's windows was carried out. The authors assessed pain syndrome, quality of life and neurological impairment.

OBJECTIVE

To compare the outcomes of transpedicular and translaminar sequestrectomy for lumbar disc herniation and sequester migration to the second and third McCulloch's windows.

MATERIAL AND METHODS

We analyzed treatment outcomes in 51 patients with lumbar disc herniation and severe sequester migration. We assessed lumbar and leg pain syndrome using then visual analogue scale, neurological impairment using the adapted Nurik scale and quality of life using the Oswestry questionnaire and the MacNab scale in early postoperative period, as well as in 2 weeks, 6 and 12 months after surgery. Ridit analysis was used for statistical processing of data.

RESULTS

Transpedicular sequestrectomy was performed in 24 patients, translaminar sequestrectomy - in 27 cases. Groups were comparable by gender, size and location of sequestration, somatic and neurological status, as well as pain severity. There was a higher probability of back (0.39) and leg (0.364) pain regression, neurological recovery (0.446) and improvement of quality of life according to the Oswestry questionnaire (0.389) after transpedicular surgery. According to the MacNab scoring system, excellent and good results were obtained in 84.21% and 15.79% of patients in 6 months after transpedicular surgery. In the second group, excellent, good and satisfactory results were obtained in 63%, 25.9% and 11.1% of patients, respectively.

CONCLUSION

Herniated intervertebral discs with severe sequester migration should be divided in accordance with localization of the main sequestration. Transpedicular endoscopic approach is advisable for sequester in the third and rarely the second McCulloch's windows. Translaminar microsurgical approach is preferred for sequestration in the second and rarely the third McCulloch's windows. Clinical outcomes after translaminar microsurgical sequestrectomy and transpedicular endoscopic surgeries are similar. However, postoperative back and leg pain regression, neurological recovery and improvement of quality of life according to the Oswestry scoring system are more common after transpedicular surgery.

A novel vertebral trench technique (VTT) involving transforaminal endoscopic lumbar foraminotomy (TELF) for very highly up-migrated lumbar disc herniation above L5

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has become popular for the treatment of symptomatic lumbar disc herniation (LDH). The very highly up-migrated lumbar disc herniation (VHUM-LDH) is difficult to remove under PELD. The purpose of this research is to investigate the feasibility, clinical efficacy and operative nuances of a novel VTT involving TELF for this type of herniation.

METHODS

Eleven patients with very highly up-migrated LDH who underwent VTT involving TELF discectomy from May 2016 to May 2019 were included in this study. The operative time, length of hospital stay, and postoperative complications were recorded. Pre-and postoperative radiologic findings were investigated. All the patients were followed more than 1 year. The visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores and modified MacNab criteria were used to assess surgical efficacy.

RESULTS

All the 11 patients underwent successful surgery. We compared the VAS, ODI, and JOA scores before and after surgery. The differences were statistically significant (P < 0.05). According to the modified MacNab criteria, 10 patients were assessed as "excellent", 1 patient was assessed as "good" at the last follow up.

CONCLUSION

The novel VTT involving TELF discectomy is a supplement to the traditional PELD. This technique enables the endoscope with working cannula to get closer the sequestrated nucleus pulposus without irritating the exiting nerve root, and facilitates the nucleus pulposus be removed successfully under direct visualization. The VTT involving TELF discectomy can be a safe, effective and feasible surgical procedure for the treatment of LDH with very highly up-migrated.

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.

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.

[Comparison of transpedicular endoscopic sequestrectomy and discectomy in the treatment of lumbar intervertebral disc herniation with a high degree of migration]

BACKGROUND

Surgical treatment of intervertebral disc herniation with a high degree of migration (beyond the vertebral pedicle) is a difficult problem without an unambiguous solution. In this manuscript, we compare the effectiveness of transpedicular endoscopy and standard discectomy in the treatment of patients with this disease.

OBJECTIVE

To compare transpedicular endoscopic sequestrectomy and discectomy in the treatment of lumbar intervertebral disc herniation with a high degree of migration.

MATERIAL AND METHODS

There were 28 patients divided into 2 groups: group 1 - 13 patients after transpedicular endoscopic sequestrectomy, group 2 - 15 patients after discectomy.

RESULTS

Transpedicular endoscopic sequestrectomy ensured significantly better intraoperative parameters (incision length, blood loss, surgery time) (p<0.01). In both groups, postoperative VAS score of leg pain was significantly reduced within a day after surgery from 7.4±1.3 to 0.7±0.7 and from 7.1±1 to 0.8±0.5, respectively. In the 1^st group, VAS score of back pain regressed from 5.2±0.7 to 1.1±0.89 by the end of the 1^st postoperative day. This value was 0.6±0.5 a year later. In the 2^nd group, VAS score of back pain regressed from 4.9±1 to 2.5±0.9 by the end of the 1^st postoperative day. This value was 2.8±2.3 a year later. According to McNab clinical outcome scale, excellent and good results after transpedicular endoscopic sequestrectomy were obtained in all 13 (100%) patients, after discectomy - in 80% of cases.

CONCLUSION

Transpedicular endoscopic sequestrectomy is optimal for intervertebral disc herniation with a high degree of migration due to fast postoperative recovery and no complications.

Transpedicular endoscopic removal of highly migrated disc herniations of lumbar spine

Background. Highly migrated disc herniations are usually localized in the area of pars interarticularis medially to the vertebral pedicle. Removal of disk herniations of this localization is a difficult technical task.

The study objective is to demonstrate the effectiveness of the transpedicular endoscopic discectomy in the treatment of patients with highly migrated disc herniations.

Materials and methods. The results of treatment of 12 patients with Macnab zone herniations who were in hospital from 2016 to 2018 were analyzed. All patients underwent transpedicular endoscopic sequestrectomy.

Results. Leg pain after surgery regressed in all patients from the initial 7.41 points (visual-analog scale) to 0.67 points by the end of the 1st day, and it was 0.35 points a year later. The average level of back pain by VAS before surgery was 5.25, on the 1st day after surgery – 1.25 points, 1 year after – 0.67 points. Neurological disorders completely regressed in 10 (91.6 %) patients, there were a slight residual L4 dermatome hypesthesia in 2 patients, without disrupting their quality of life. The average Oswestry Disability Index before surgery was 69.17, and 1 year after surgery was 14.12. There were no complications and reoperations.

Conclusion. Transpedicular endoscopic discectomy allowed us to achieve good treatment results in patients with migration of a lumbar hernia by the pedicle. It can be a safe and effective alternative to the transforaminal or interlaminar endoscopic technique.

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.

Transforaminal Endoscopic Surgery: Outside-In Technique

Transforaminal endoscopic lumbar discectomy (TELD) with the outside-in technique can be applied to nearly all cases of lumbar disc herniation (LDH), and transpedicular endoscopic lumbar discectomy can be used to treat highly migrated LDHs. The purpose of this study was to outline these 2 outside-in surgical techniques and to present their clinical outcomes. Between January 2018 and January 2019, a total of 137 patients underwent either transforaminal or transpedicular endoscopic lumbar discectomy. We performed TELD in 124 patients and transpedicular endoscopic lumbar discectomy in 13 cases. All surgical procedures were performed under conscious sedation. The patients’ mean age was 51.3 years; 51 were women and 86 were men. The overall disc recurrence rate was 5.12%. Visual analogue scale scores decreased significantly in both groups. According to the MacNab criteria, good and excellent results were obtained in 92.74% of patients after transforaminal and in 92.30% of patients after transpedicular endoscopic LDH treatment. The results suggest that TELD with the outside-in technique can be effective for the treatment of most cases of LDH. Transpedicular endoscopic lumbar discectomy can be considered as an alternative treatment for highly migrated LDH.

A Narrative Review of Development of Full-Endoscopic Lumbar Spine Surgery

In the first phase of development of lumbar endoscopic spine surgery, the focus was on removal of soft disc material through the working corridor of Kambin’s triangle using transforaminal endoscopic lumbar discectomy. With the introduction of the interlaminar approach and increased interest from both industry and surgeons, there has been an exponential development of endoscopic surgical equipment and a corresponding expansion of endoscopic techniques. Endoscopic treatment strategies are applied to conditions ranging from contained prolapsed intervertebral discs to noncontained migrated herniated discs, hard calcified discs, spinal stenosis in the central or lateral recess and the foraminal and extraforaminal region, and other combinations of degenerative conditions requiring decompression or fusion surgery. The further expansion of endoscopic surgical management involving complicated spinal cases and the final quartet of trauma, infections, tumors, and possibly deformities could be the future stage of endoscopic spine surgery development. This article covers the full range of current treatment strategies and presents possible future developments of endoscopic spine surgery for the management of lumbar spinal conditions.

Full-endoscopic transpedicular discectomy (FETD) for lumbar herniations: Case report and review of the literature

INTRODUCTION

One of the most challenging occurrences in full-endoscopic surgery for lumbar disc protrusions are up-migrated or down-migrated herniations. Those occurrences are difficult to retrieve with transforaminal or interlaminar approaches.

PRESENTATION OF CASE

We describe our experience in dealing with a right paramedian down-migrated L3-L4 disc herniation. The patient underwent full endoscopic transpedicular endoscopic discectomy (FETD), by reaming the right L4 peduncle for intracanal access and fragment retrieval. We also reviewed the recent literature to summarize the advantages of transpedicular approaches, along with current indications and contraindications for this procedure.

DISCUSSION

We highlighted how FETD is safe and feasible for down-migrated and up-migrated disc herniation showing excellent results in our patient and in the small cohorts of patients already published in the literature.

CONCLUSION

FETD was effective in treating up-migrated and down-migrated disc herniation, as well as discal cysts, showing the feasibility and safety of the technique from any level from L1 to S1.

Full-Endoscopic Lumbar Foraminoplasty for Symptomatic Cement Leakage with Exiting Nerve Root Impingement

BACKGROUND

Foraminal stenosis, a common disorder occurring in elderly patients, is often caused by narrowing of the foramen, resulting in the confinement of neural structures by the tissue and vertebrae. Full-endoscopic lumbar foraminoplasty (FELF) is an effective treatment option for patients with foraminal stenosis. However, to the best of our knowledge, no previous study has reported the treatment of symptomatic cement leakage. We report a case of symptomatic cement leakage treated with FELF with the patient under local anesthesia.

CASE DESCRIPTION

An 85-year-old woman was admitted to our spine unit because of lower back pain. The patient had presented with lower back pain and new-onset left thigh pain after vertebroplasty performed 3 months previously. The patient was not able to walk and was bedridden. To overcome this problem, T12 percutaneous vertebroplasty and left transforaminal L3-L4 foraminoplasty was performed with the patient under local anesthesia. After surgery, the patient was able to walk and was discharged 4 days postoperatively.

CONCLUSION

The present report has shown that FELF can successfully remove symptomatic cement leakage, resulting in pain relief.

Short- and long-term results of percutaneous full-endoscopic and microsurgical lumbar discectomy: prospective cohort study

Objective. To analyze immediate and long-term results of percutaneous endoscopic and microsurgical discectomy.

Material and Methods. A prospective cohort study in two groups of patients was conducted in 2015–2018. The observation period was 6–42 months. Group 1 included 110 patients who underwent percutaneous endoscopic lumbar discectomy, and Group 2 – 331 patients who underwent microdiscectomy. Efficiency was assessed using NRS-11, ODI, SF-36, and MacNab questionnaires.

Results. The operating time, bed day number, and disability period were shorter in Group 1 (p < 0.001). The average effective dose of radiation exposure to the patient was 4.4 mSv in transforaminal endoscopy, and 0.8 mSv in interlaminar and microsurgical discectomy. There were no significant intergroup differences in frequency and types of complications and reoperations. The portion of symptomatic hernia recurrence in Group 1 was 10 %, in Group 2 – 4.8 %. Significant differences in neurological outcomes and quality of life were not revealed. Good and excellent outcomes according to MacNab criteria were noted in 78.2 % and 84.9 %, in Groups 1 and 2, respectively.

Conclusion. The percutaneous endoscopic discectomy allows reducing hospital stay length and disability period, while having clinical efficacy equal to that of other disectomy methods. A statistically insignificant increase in the risk of hernia recurrence after percutaneous endoscopic discectomy was noted.

Transpedicular Endoscopic Surgery for Highly Downmigrated L5-S1 Disc Herniation

Endoscopic surgery for highly downmigrated disc herniation at level L5-S1 is a challenging technique. Most surgeons prefer the interlaminar access because of the special anatomy of the L5-S1 disc level, i.e., narrow neuroforamen and large interlaminar window. Transforaminal access to the neuroforamen L5-S1 is difficult in cases with high iliac crest. Here, the access to the highly downmigrated disc herniation with the recently reported technique of transpedicular endoscopic surgery by Krzok et al. was described. In 3 cases with highly downmigrated disc herniation of L5-S1, the sequester was removed successfully through the bone hole of S1 pedicle. This technique is demanding for experienced endoscopic surgeons.

Percutaneous endoscopic transpedicular approach for high-grade down-migrated lumbar disc herniations

BACKGROUND

Surgical options for removing high-grade down-migrated lumbar disc herniations located medial to the pedicle include an extensive laminectomy and facetectomy. A direct percutaneous endoscopic approach through the pedicle for reaching the herniated disc without risk of iatrogenic instability is feasible.

METHOD

The transpedicular approach consists of creating a tunnel through the pedicle. Subsequently, access to the parapedicular epidural space is obtained, and downward migrated disc can be removed.

CONCLUSION

This technique allows to reach migrated herniations medially to the pedicle safely and effectively.