Analysis of Clinical Results of Three Different Routes of Percutaneous Endoscopic Transforaminal Lumbar Discectomy for Lumbar Herniated Disk

Clinical Outcomes of Percutaneous Endoscopic Interlaminar Discectomy Using a Laminotomy Technique With Modified Stepwise Local Anesthesia

BACKGROUND

Percutaneous endoscopic interlaminar discectomy (PEID) has been widely used in minimally invasive treatment of lumbar disc herniation (LDH) but is difficult to perform because of the narrow interlaminar window and painful for the patient. Therefore, further research is needed to find a safe and effective method to facilitate the development of PEID.

METHODS

Seventy-one consecutive patients with LDH who underwent PEID using a laminotomy technique with modified stepwise local anesthesia between July 2017 and June 2020. All patients were followed up for at least 6 months. Preoperative patient demographics, perioperative outcomes, and clinical outcomes were recorded. Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and Macnab criteria were used to assess clinical results.

RESULTS

All patients underwent successful surgery under local anesthesia with no conversions to open surgery. The mean operation time was 79.56 ± 32.78 minutes and the average hospital stay was 6.44 ± 2.98 nights. Before surgery, the mean VAS score was 5.66 ± 1.206 and the mean ODI score was 68.41 ± 6.634; the respective scores were decreased to 0.65 ± 0.635 and 7.06 ± 1.594 after 4 weeks of follow-up (P < 0.001) and to 0.56 ± 0.691 and 7.11 ± 0.176 after 6 months (P < 0.001). According to the MacNab criteria, the outcome was excellent in 60 cases and good in the remaining 11 cases.

CONCLUSIONS

PEID via a laminotomy technique with stepwise local anesthesia is safe and effective for L4-5 and L5-S1 LDH.

An algorithm for selection of full endoscopic approach for symptomatic nerve root decompression

Background Context

Both Transforaminal (TF) and Interlaminar (IL) endoscopic approaches are established techniques of decompression for lumbar compressive radiculopathy. In the absence of adequate literature, there is always some dilemma in selecting the approach for endoscopic decompression leading to long learning curves and high chances of inadequate decompression, iatrogenic instability, dural tear, or dysesthesia. Hence authors propose a new surgical nomenclature and algorithm for selection of endoscopic approach.

Methods

This retrospective study included 396 of 626 consecutive patients who met the inclusion criteria, who underwent either TF (n=302) or IL (n=202) full endoscopic spine surgery. MRI findings of every patient were classified as per FAPDIS (Facet angle, Anterior pathology, Posterior pathology, Dorsal, Inferior, and Superior migration) algorithm. Inter-observer variations were calculated. The targeted nomenclature was used to define the selection of endoscopic TF or IL approach for symptomatic nerve root decompression. All patients were followed up for preop and postop 6 months VAS and Oswestry Disability Index score for validation of FAPDIS algorithm.

Results

Median age: 46.8 years; Sides and levels operated 330 single-level ipsilateral, 54 multiple-level ipsilateral, 6 single-level bilateral, and 6 multiple-level bilateral. Interobserver agreement in the selection of TF approach was 0.873 and IL approach was 0.882. Interobserver variability was also calculated for each FAPDIS factor, selection of P3 and P4 pathology was the main reason for disagreement. All other FAPDIS factors show good to excellent correlation. The overall VAS score decreased from a preoperative value of 9 to 1 at 6 months follow-up (p-value < 0.001), and the overall Oswestry Disability Index score improved from 89 to 12 (p-value <.001).

Conclusions

The author's new FAPDIS surgical nomenclature and algorithm is a reliable tool for describing the symptomatic nerve root compression for the selection of endoscopic surgical approach to achieve adequate decompression of offending neural structure with minimum challenges to minimize perioperative complication rate.

Minimally Neural Retractive, Total Annular Resection, Transforaminal Endoscopic (TARTE) Approach for Severely Canal Compromising Lumbar Disk Herniation Accompanied by a Neurologic Deficit

OBJECTIVE

 Treatment of severely canal compromising lumbar disk herniations (LDH), occupying more than 50% of the canal area, are associated with technical difficulty and worse outcomes. This study aimed to describe new techniques of transforaminal endoscopic lumbar diskectomy (TELD) with less neural retraction, and total annular resection for broad-based severely canal compromising disk herniation. We also evaluated the feasibility and safety of the techniques, and analyzed the clinical and radiologic outcomes of 32 patients presenting with neurologic deficits.

METHODS

 A retrospective cohort study was performed with 32 consecutive patients who underwent TELD for broad-based severely canal compromising LDH between January 2018 and January 2020. We removed the LDH using two novel techniques: (1) the "mobile outside-in" approach and total annular resection method and (2) internal decompression and subsequent pushdown method of the migrated fragment. The cross-sectional area (CSA) on magnetic resonance image was evaluated preoperatively and compared with the postoperative image within 7 days and between 6 months and 1 year. The visual analog scale (VAS) for back and leg pain, Oswestry disability index (ODI), MacNab's criteria, and motor power of the involved lower extremities were evaluated pre- and postoperatively.

RESULTS

 A total of 32 patients, with an average age of 37.5 years (range: 17-66), underwent surgery. The mean VAS score for back pain improved from 7.84 ± 1.02 to 1.31 ± 0.54 and the ODI score improved from 74.3 ± 7.82 to 20.4 ± 3.71 at final follow-up. According to MacNab's criteria, 23 patients had excellent and 9 patients had good outcomes at final follow-up. All patients operated on at the L4-L5 level had great toe/ankle dorsiflexion and/or ankle plantar flexion weakness; knee extension weakness was found at the L2-L3 and L3-L4 levels. Motor function improved significantly; the mean values and range preoperatively, and at 1 month, 3 months, and final follow-up, were 3.41 ± 0.95 (1-4), 4.56 ± 0.56 (3-5), 4.88 ± 0.34 (4-5), and 4.97 ± 0.18 (4-5), respectively (p < 0.001, at all follow-up). The mean values and range of the preserved CSA proportion, preoperatively and within 1 week after surgery, and at final follow-up were 34.9 ± 10.9 (15-61), 81.06 ± 10.24 (63-97), and 93.03 ± 5.37 (76-99), respectively (p < 0.001, at all follow-up).

CONCLUSION

 The transforaminal endoscopic approach for broad-based severely canal compromising LDH can be considered a feasible surgical option for an experienced surgeon. With total annular resection and pushdown of migrated fragments, safe and complete removal of LDH was possible in patients with a neurologic deficit. Total annular resection may increase the overall but not the early recurrence rate.

Factors associated with incomplete clinical improvement in patients undergoing transforaminal endoscopic lumbar discectomy for lumbar disc herniation

PURPOSES

To analyze the clinical and radiographic risk factors that might predict incomplete clinical improvement after transforaminal endoscopic lumbar discectomy (TELD).

METHODS

A retrospective analysis was conducted from 194 consecutive patients who underwent TELD due to lumbar disc herniation (LDH). Patients with incomplete clinical improvement were defined from patient-reported outcomes of poor improvement in pain or disability after surgery and patient dissatisfaction. Clinical and radiographic characteristics were evaluated to identify predicting factors of poor outcomes.

RESULTS

Of 194 patients who underwent TELD procedures, 32 patients (16.5%) had incomplete clinical improvement and 12 patients (6.1%) required revision surgery. The mean ages were 46.4 years and most of the patients suffered from predominant leg pain (48.9%). The most common surgical level was L4-5 (63.9%). Overall, the Oswestry Disability Index (44.3-15), visual analog scores of back pain (4.9-1.8) and leg pain (7.3-1.6) were significantly improved after surgery. Multivariate logistic regression analysis demonstrated that high body mass index, history of previous surgery, preoperative disability, weakness, and disc degeneration were related to incomplete clinical improvement. There were 15 recurrent LDH (7.7%) with a total of 12 revision surgeries (6.2%).

CONCLUSIONS

We identified independent risk factors associated with incomplete clinical improvement following TELD, including overweight, significant preoperative disability or weakness and history of previous surgery. Advanced age, disc degeneration, vacuum phenomenon, and spondylolisthesis were also possible risk factors. Recognizing these risk factors would help decide whether patients are good candidates for TELD, and optimize the surgical planning preoperatively to achieve good surgical results.

Risk Factors Involved in the Early and Medium-Term Poor Outcomes of Percutaneous Endoscopic Transforaminal Discectomy: A Single-Center Experience

Objective

To investigate the risk factors involved in the early and medium-term poor outcomes of percutaneous endoscopic transforaminal discectomy (PETD) treatment of lumbar disc herniation (LDH) at the L4-5 level.

Methods

Between January 2015 and May 2020, we recruited 148 LDH patients at the L4-5 level who underwent PETD surgery. The patients were divided into Groups A and B, according to the surgical outcomes. Good and excellent outcomes were categorized into Group A, and generally good and poor outcomes were categorized into Group B. Clinical parameters (age, gender, symptom duration, hospital stay, operation time, blood loss, straight-leg raising (SLR), visual analog scale (VAS), Oswestry Disability Index (ODI) score and modified MacNab criteria) and radiologic parameters (foraminal height (FH), intervertebral height index (IHI), intervertebral angle (IVA), sagittal range of motion (sROM), and lumbar lordosis (LL)) were collected and analyzed using univariate and multiple logistic regression analyses.

Results

At the 6-month follow-up post operation, univariate analysis revealed that the symptom duration, SLR, IHI, and sROM were strongly associated with poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes. At the 2-year follow-up post operation, univariate analysis suggested that advanced age, prolonged symptom duration, large preoperative VAS score, small FH, small IHI, and large sROM were potential risk factors for poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes.

Conclusion

Our study demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes immediately following PETD at the L4-5 level. However, prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes at medium-term post PETD at the L4-5 level.

Full-Endoscopic Lumbar Decompression with Minimal Nerve Root Retraction for Impending Neurologic Deficit in Degenerative Lumbar Spine Diseases

OBJECTIVES

 The aim of this retrospective case study was to analyze the outcomes of minimal nerve root retraction in patients with impending neurologic deficit in degenerative lumbar spine disease using the full-endoscopic spine surgery.

MATERIALS AND METHODS

 Thirty-seven consecutive patients with impending neurologic deficit underwent endoscopic spine surgery through either the transforaminal or the interlaminar approach. Their clinical outcomes were evaluated with visual analog scale (VAS) leg pain score, Oswestry Disability Index (ODI), and MacNab's criteria. The outcome of motor deficitis was evaluated with the Medical Research Council (MRC) grade. Completeness of decompression was documented with a postoperative magnetic resonance imaging (MRI) and computed tomography (CT) scan.

RESULTS

 A total of 40 lumbar levels of 37 patients were operated, VAS score of the leg improved from 7.7 ± 1 to 1.9 ± 0.6 (p < 0.0001). ODI score improved from 74.7 ± 6.5 to 25.4 ± 3.49 (p < 0.0001). Motor weakness improved significantly immediately after surgery. The mean MRC grade increased to 1.97, 3.65, 4.41, and 4.76 preoperatively, at 1 week, at 3 months, and at the final follow-up, respectively, and all the patients with foot drop and cauda equina syndrome symptom recovered completely. One patient with great toe drop recovered partially to MRC grade 3. Mean follow-up of the study was 13.3 ± 6.1 months. According to MacNab's criteria, 30 patients (80.1%) had good and 7 patients (18.9%) had excellent results. Three patients required revision surgery.

CONCLUSIONS

 Minimal nerve root retraction during full-endoscopic spine surgery is safe and effective for treatment of the impending neurologic deficit. We could achieve a thorough decompression of the affected nerve root with acceptable clinical outcome and minimal postoperative morbidity.

Application of a targeted and quantificational foraminoplasty device in percutaneous transforaminal endoscopic discectomy for L5-S1 disc herniation: preliminary clinical outcomes

OBJECTIVE

Percutaneous transforaminal endoscopic discectomy (PTED) is minimally invasive and has been widely used to treat patients with lumbar disc herniation (LDH) due to its safety and efficiency. However, due to the unique anatomy of the L5-S1 level, the PTED procedure is often difficult to perform in the region. ZESSYS, a targeted and quantificational foraminoplasty device, may help to overcome these anatomical limitations. In this study, we assessed the efficiency and the short-term effects of PTED with ZESSYS at the L5-S1 level.

METHODS

Between January and August of 2018, fifty-six patients with lumbar disc herniation at the single level of L5-S1 and who underwent percutaneous transforaminal endoscopic discectomy were enrolled in this retrospective cohort study. They were segregated into the transforaminal endoscopic surgical system (TESSYS) group and the ZESSYS group. The puncture time, foraminoplasty time, decompression time, and fluoroscopy time were evaluated for operation efficiency. Clinical outcomes were assessed by the visual analog scale (VAS) score and Oswestry Disability Index (ODI) score. The MacNab criteria were used to evaluate patient subjective satisfaction at 12-month follow-up postoperatively.

RESULTS

The average puncture time (5.29 ± 2.05 min), foraminoplasty time (12.82 ± 2.52 min), and fluoroscopy time (26.29 ± 5.96 s) were all significantly shorter in the ZESSYS group than in the TESSYS group (average puncture time 8.07 ± 3.13 min, p < 0.01; foraminoplasty time, 17.18 ± 2.92 min, p < 0.01; fluoroscopy time, 34.73 ± 6.86 s; p < 0.01). No significant differences were observed between the 2 groups in the decompression time (p = 0.057). The VAS score of low back pain and leg pain, as well as the ODI score, improved at all time points postoperatively compared with preoperative, in both the TESSYS group and the ZESSYS group (P < 0.05). There were no significant differences in the VAS score of low back pain, VAS score of leg pain, and ODI score between the TESSYS group and the ZESSYS group at the same time points (P > 0.05). According to the MacNab criteria, the excellent and good rate at 12-month follow-up postoperatively was 85.7% in the TESSYS group and 89.3% in the ZESSYS group (P > 0.05).

CONCLUSION

The targeted and quantificational foraminoplasty device named ZESSYS was more efficient in the puncture and foraminoplasty procedures, effectively protecting the exiting nerve and minimizing the level of radiation exposure. The device is efficient and safe for PTED in treating lumbar disc herniation at the L5-S1 level.

How I do it? Full endoscopic transforaminal approach for lumbar disc herniation that migrated bilaterally to four corners

BACKGROUND

Despite of the evolution of endoscopic surgery, the literature on technique uniportal transforaminal endoscopic lumbar discectomy (TELD) for bilateral lesions is scarce.

METHODS

Unilateral TELD was performed in a patient with bilateral superior and inferior migrated, broad-based disc herniation presenting with an impaired neurological state. The key surgical steps focus on free mobility in Kambin triangle with the mobile outside-in technique and accessibility to contralateral lesions with an extensive annular resection procedure.

CONCLUSION

TELD can be a surgical option for treating bilateral multiple direction migrated lumbar disc herniation with benefits of minimal neural retraction and facet joint preservation.

Evolution of endoscopic transforaminal lumbar approach for degenerative lumbar disease

Endoscopic spine surgery has evolved dramatically in last 30 years; with the development of new improved endoscopic optics and instrumentation limitation of endoscopic spine surgery has significantly reduced. The transforaminal approach has been limited in its indications due to its optimized approach and obstacles of bony or neural structures. As the initial transforaminal approach is based on the inside out technique, there were many limitations on the indications. Outside-in approach has been developed to address these limitations. However, the outside-in approach was not free from anatomical obstacles. The mobile outside-in approach technique has advantage of both inside-out and outside-in technique. It is equally safe as inside-out technique and provides an easy handling of structures, while it is equally versatile as outside-in technique in managing different types of disc prolapse such as central, paracentral, foraminal, far lateral, and up and down migration, and in high-canal compromise cases. The mobile outside in technique, however, demands a longer learning curve and beginners need to be patient while learning the technique.

Correlation between preoperative CT imaging parameters and clinical outcome of lumbar spinal stenosis treated with endoscopic transforaminal decompression

Objective

To evaluate clinical effects, and their correlations with preoperative computed tomography imaging parameters, in cases of lumbar spinal stenosis treated by endoscopic transforaminal decompression.

Methods

This retrospective study included orthopaedic patients who had undergone percutaneous endoscopic lumbar discectomy (PELD) for lumbar spinal stenosis. Clinical symptoms were evaluated by visual analogue scale (VAS), Oswestry Disability Index (ODI) and claudication distance. Overall clinical efficacy was evaluated by Macnab score.

Results

A total of 87 patients were included. Postoperative wound healing was good without complications. Macnab scores following PELD were ‘excellent’ in 41 cases (47.12%), ‘good’ in 30 cases (34.48%), ‘generally good’ in seven cases (8.04%), and ‘poor’ in nine cases (10.34%). The overall rate of optimal surgery was 81.60%. Postoperative pain (VAS) and ODI scores, and claudication distance, were significantly improved versus preoperative values. The soft tissue invasion ratio of the vertebral canal and invasion ratio of the nerve root canal were correlated with clinical efficacy.

Conclusion

Positive correlations were observed between clinical efficacy of endoscopic transforaminal decompression and preoperative vertebral canal soft tissue invasion ratio and nerve root canal invasion ratio in patients with lumbar spinal stenosis.

Percutaneous endoscopic thoracic discectomy via posterolateral approach: A case report of migrated thoracic disc herniation

RATIONALE

Minimally invasive surgeries for thoracic disc herniation (TDH) evolved rapidly in recent years, and multiple approaches have been put forward. Thoracic discectomy via percutaneous spine endoscopy (PSE) is inadequately documented because of the low prevalence of TDH and the high difficulty of thoracic spine endoscopy techniques. Herein, we present a TDH case who underwent percutaneous endoscopic thoracic discectomy.

PATIENT CONCERNS

A 28-year-old male suffered backpain and partial paralysis in lower extremities.

DIAGNOSES

Magnet resonance imaging demonstrated T11-12 TDH, with cranially migrated disc fragment.

INTERVENTIONS

The patient underwent percutaneous endoscopic thoracic discectomy via posterolateral approach with the assistance of endoscopic reamer in the procedure of foramino-laminaplasty.

OUTCOMES

The patient's muscle force improved immediately, and the backpain relieved after 5 days post-surgery. In the 6-month follow-up, he had normal muscle force without paresthesia in lower limbs.

LESSONS

The innovative design of endoscopic reamer provides effective plasty and access establishment with lower risk and difficulty, which ensures the vision and the operating space of the procedure of decompression. With this technique, the indications of thoracic PSE were broadened to both ventral and dorsal thoracic stenosis.

Evolution of Spinal Endoscopic Surgery

Innovations in the development of endoscopic spinal surgery were classified into different generations and reviewed. Future developments and directions for endoscopic spinal surgery were discussed. Surgical therapy for spinal disease has been gradually changing from traditional open surgery to minimally invasive spinal surgery. Recently, endoscopic spinal surgery, which initially was limited to the treatment of soft tissue lesions, has expanded to include other aspects of spinal disease and good clinical results have been reported. As the paradigm of spinal surgery shifts from open surgery to endoscopic surgery, we discussed the evolution of endoscopic spine surgery in our literature review. Through this description, we presented possibilities of future developments and directions in endoscopic spine surgery.

Percutaneous Transforaminal Endoscopic Radiofrequency Ablation of the Sinuvertebral Nerve in an Olympian with a Left L5 Pedicle/Pars Interarticularis Fracture-Associated Left L5-S1 Disk Desiccation

Background

Irritation of the sinuvertebral nerve by a posterior or posterolateral disk desiccation can cause somatic referred pain that can mimic a lumbar radiculopathy. We present a case of a patient presenting with this condition and the positive result in pain improvement after endoscopic radiofrequency ablation of the sinuvertebral nerve.

Case Description

An 18-year-old Olympic runner presented to our clinic with back pain and left leg pain in a clear L5 distribution. He did not have a history of trauma. His imaging did not demonstrate any lesion causing compression of the left L5 nerve root as expected. He was found to have a left healing L5 pedicle fracture and ipsilateral chronic L5 pars interarticularis fracture. He was also found to have an ipsilateral minor left L5-S1 disk desiccation. His visual analog scale (VAS) score was 7. After a positive provocative diskogram, the patient underwent percutaneous transforaminal endoscopic radiofrequency ablation of the left L5 sinuvertebral nerve, which was irritated by the left L5-S1 disk desiccation. At his 6-month follow-up visit, the patient's VAS score was 1.

Conclusions

It is important for clinicians to remember that back-associated leg pain can be caused by somatic referred pain because of irritation of the sinuvertebral nerve. Endoscopic radiofrequency of this nerve can be beneficial in pain control, but further randomized prospective trials are needed to study these techniques further.

Clinical efficacy of percutaneous transforaminal endoscopic discectomy in treating adolescent lumbar disc herniation

Ten years ago, endoscopic techniques began to prevail in clinical treatment of lumbar disc herniation (LDH), but to date, few studies have reported the clinical efficacy of percutaneous transforaminal endoscopic discectomy (PTED) in treating adolescent LDH. This study aimed to evaluate the surgical outcomes of PTED in treating adolescent patients with LDH.Between June 2012 and June 2016, retrospective analysis of 43 adolescent patients diagnosed with single-segment LDH at spine surgery at the Second Affiliated Hospital of Anhui Medical University. The patients' lower limb pain was evaluated using visual analogue scale (VAS) scores and the Oswestry Disability Index (ODI). The VAS is the most commonly-used quantitative method for assessing the degree of pain in clinical practice. The measurement method is to draw a 10 cm horizontal line on a piece of paper, 1 end of which is 0, indicating no pain, while the other end is 10, which means severe pain, and the middle part indicates different degrees of pain. The clinician then asks the patient to make a mark on the line to indicate the degree of pain based on how he or she feels. The ODI is the most widely-used assessment method internationally for lumbar or leg pain at present. The ODI questionnaire is composed of 10 questions, covering pain intensity, independent living, carrying, walking, sitting, standing, sleep, travel, sex, and social life. Every category comprises 6 options, with the highest score for each question being 5 points. Thus the 1st option is worth 0 points, the last option scores 5 points, and higher scores represent more serious dysfunction. Patient satisfaction was evaluated using the modified MacNab score. Clinical outcomes were measured preoperatively, and at 3 days, 6 months, and 12 months postoperatively.All 43 patients were followed up for 12 to 24 months. The average follow-up time was 18.33 months. The VAS scores and ODI scores at 3 days, 6 months, and 12 months postoperatively were significantly lower than before surgery. The difference was statistically significant (P < .001). The differences in VAS scores and ODI scores at 3 days, 6 months, and 12 months after surgery were also statistically significant (P < .001). According to the modified MacNab criteria, 26 cases were rated excellent, 14 cases were good, and 3 cases were acceptable at the final follow-up, and 93.02% of these patients had excellent outcomes.The PTED is an effective and safe surgical method for the treatment of adolescent patients with LDH, but high-quality randomized controlled trials are still required to further verify these findings.

Preliminary results of a novel pure endoscopic procedure in the treatment of degenerative lumbar spinal disorders: double endoscopic technique

BACKGROUND

With increased experience and the availability of new technical instrumentations, the surgical endoscopic indications for lumbar spinal pathologies have moved from simple prolapsed disk to canal stenosis. The available endoscopes come in two different sizes (10 mm and 6.3 mm in diameter); however, one is too bulky to use inside the spinal canal and the other is too small to achieve a fast bone decompression.

METHODS

In order to overcome such problems, we developed and used a different surgical technique called: Double Endoscopic Technique. Using this approach, we operated and prospectively collected clinical information on 17 patients (Group A) suffering from a mixed (ligament-bone hypertrophy and prolapsed disk) single segmental lumbar canal stenosis. At a median of 13 months from surgery, all the patients in this group had a very good outcome with an improvement of the VAS and ODI. These clinical results were compared with those from another group of patients who had undergone surgery in the same Unit, but using standard MIS technique (Group B). Both groups were similar in terms of number, age, symptoms and stenosis location. In particular we compared the pre- and post-operative VAS and ODI values, the amount of postoperative pain killers used during the first week post-surgery, the length of in-hospital stay as well as the blood loss during surgery.

RESULTS

Although our aim was only to present a novel surgical endoscopic technique, the results, with all the study limitations including small numbers and short follow-up, have shown that this procedure is safe and effective, yielding an outcome comparable to the standard MIS approach. Furthermore, it is less disruptive towards the involved anatomy, it gives less post-operative pain, it requires a smaller skin incision and the blood loss is negligible.

CONCLUSIONS

Thus, this technique may guarantee a faster clinical recovery.

Percutaneous endoscopic lumbar discectomy by transfacet joint approach: A case report

RATIONALE

The accurate and smooth establishment of a working cannula guarantees rapid and minimally invasive treatment effects using percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation (LDH). With anatomic variations such as a hyperplastic superior articular process (SAP), the conventional transforaminal approach cannot achieve an ideal result.

PATIENT CONCERNS

A 48-year-old male patient suffered waist and left lower limb pain, with exacerbation of symptoms after exertion.

DIAGNOSES

L5-S1 disc herniation, hyperplastic SAP of S1.

INTERVENTIONS

To demonstrate the segment responsible for compression, a lumbar nerve root block was carried out. This was followed by PELD via a transfacet joint approach at L5-S1.

OUTCOMES

The patient experienced an improved quality of life postoperatively (i.e., visual analog score for pain = 1 and Oswestry disability index  = 88). Lumbar function and stability were preserved as of the 1-month postoperative follow-up.

LESSONS

The transfacet joint approach could extend the indications for PELD and present an alternative option in selected cases. A new concept of "subsidence foramen" is raised to characterize this anatomic variation, and it may guide working access establishment of PELD. In addition, reading imaging results carefully and individualizing treatments promote the use of PELD as minimally invasive surgery.

A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are two techniques for the introduction of a working cannula with respect to disc-outside-in and inside-out. The aim of this prospective study is to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse. A total of 184 consecutive patients with unilateral lower limb radiculopathy due to lumbar disc prolapse were operated on with the mobile outside-in technique of PETLD. Their clinical outcomes were evaluated based on the type of disc prolapse they had, a visual analog scale (VAS) leg pain score, the Oswestry Disability Index (ODI), and the Macnab criteria. The completeness of the decompression was documented with a postoperative magnetic resonance imaging. The mean age of the patients was 50 ± 16 years and the male/female ratio was 2:1. The mean follow-up was 19 ± 6 months. A total of 190 lumbar levels were operated on (L1-L2: n = 4, L2-L3: n = 17, L3-L4: n = 27, L4-5: n = 123, and L5-S1: n = 19). Divided into types, the patient distribution was central: n = 14, paracentral: n = 74, foraminal: n = 28, far lateral: n = 13, superior-migrated: n = 8, inferior migrated: n = 38, and high canal compromise: n = 9. The mean operative time was 35 ± 12 (25 - 56) min and the mean hospital stay was 1.2 ± 0.5 (1-3) days. The VAS score for leg pain improved from 7.5 ± 1 to 1.7 ± 0.9. The ODI improved from 70 ± 8.3 to 23 ± 5. According to the Macnab criteria, 75 patients (40.8%) had excellent results, 104 patients (56.5%) had good results, and 5 patients (2.7%) had fair results. Recurrence (including early and late) was seen in 15 out of the 190 levels that were operated on (7.89%). This article presents a novel outside-in approach that relies on a precise landing within the foramen in a mobile manner and does not solely depend upon the enlargement of the foramen. It is more versatile in application and useful in the management of all types of disc prolapse, even in severe canal compromise and high migration.

Feasibility of Full Endoscopic Spine Surgery in Patients Over the Age of 70 Years With Degenerative Lumbar Spine Disease

Background/Aims

Degenerative spine disease, encompassing disc prolapse and stenosis, is a common ailment in old age. This prospective study was undertaken to evaluate the role of endoscopic spine surgery in elderly patients (above 70 years of age) with clinical and radiological follow-up.

Methods

In this study, a retrospective analysis was conducted of 53 patients with lumbar disc prolapse or spinal stenosis who were treated with percutaneous endoscopic discectomy or decompression from November 2015 to June 2017. Clinical follow-up was done at 1 week, 3 months, and 1 year, and at yearly intervals thereafter. The outcomes were assessed using the modified Macnab criteria, a visual analogue scale, and the Oswestry Disability Index.

Results

Of the 53 patients, 21 were men and 32 were women. Their mean age was 76±4 years. The mean follow-up period was 17 months. Percutaneous endoscopic discectomy was performed in 24 patients and endoscopic decompression in 24 patients, while 5 patients underwent combined surgery. An excellent outcome in terms of the MacNab criteria was observed in 9 patients (16.98%), a good outcome in 38 patients (71.7%), and a poor outcome in 6 patients (11.3%). Of the 6 patients with a poor outcome, 5 (9.4%, 5 of 53) developed recurrent disc prolapse, and 1 developed hematoma with motor weakness. All 6 of these cases required revision surgery.

Conclusion

Managing degenerative spine disease in elderly patients with multiple comorbidities is a challenging task. Percutaneous endoscopic spine surgery is pivotal for addressing this concern. The authors have shown that optimal results can be achieved with various types of disc prolapse and stenosis with favorable long-term outcomes.

Transforaminal percutaneous endoscopic lumbar discectomy: outcome and complications in 270 cases

BACKGROUND

The endoscopic approach was introduced in the clinical practice in 1980 with the aim to remove the prolapsed disk and free the compressed nerve using the least disruptive surgical technique, assuring in the same time, the resolution of the symptoms and a faster return back to normal life activity. Over the years, thanks to an extraordinary technical improvement either in terms of quality of images or development of many different tailored instrumentations there has been a huge spreading of the endoscope use across the different surgical fields. For this reason, the transforaminal percutaneous endoscopic lumbar discectomy can be considered, at the moment, the least invasive procedure for the removal of lumbar disc prolapsed. The aim of this study was to analyze the clinical outcome and complications rate on a large cumulative series operated on in two years period.

METHODS

We presented a retrospective series involving 270 cases of lumbar disk herniation managed surgically only by a percutaneous transforaminal endoscopic technique in two units and by two surgeons. All patients had a minimum follow-up of 6 months. Primary study end points were evaluation of outcomes using the visual analogue scale and Oswestri Disability Index preoperatively and at 3, 6 and 12 months as well as the complications and the recurrence rates.

RESULTS

Our results, with a positive outcome around 93%, confirmed the effectiveness of transforaminal percutaneous endoscopic discectomy in the treatment of lumbar disc herniation when compare to open microdiscectomy. Also, the complications (5.5%) and the recurrence rate (4.1%) could be considered within the standard results.

CONCLUSIONS

The transforaminal percutaneous endoscopic lumbar discectomy is a safe and effective procedure to treat lumbar disc prolapsed. Surgical experience and correct patients' selection are crucial factors affecting the outcome.

Short-term clinical efficacy of percutaneous transforaminal endoscopic discectomy in treating young patients with lumbar disc herniation

Background

In the last decades, full-endoscopic techniques to treat lumbar disc herniation (LDH) have gained popularity in clinical practice. However, few studies have described the safety and efficacy of percutaneous transforaminal endoscopic discectomy (PTED) in treating younger patients with LDH. This study aims to evaluate the preliminary surgical outcome and complication of PTED in treating younger patients with LDH.

Methods

Between June 2012 and June 2016, 72 young patients (< 45 years old) who underwent PTED for single-level LDH were prospectively followed up. All patients were followed up for at least 12 months (range 12–35 months). Pain was measured using visual analogue scale (VAS) scores. Patient satisfaction was evaluated using the MacNab outcome scale. Clinical outcomes were measured preoperatively, at 2 days and 6 months, and 12 months postoperatively.

Results

The mean VAS score for back pain was 5.1 ± 2.3 preoperatively and 3.1 ± 1.2, 2.1 ± 0.5, and 2.0 ± 0.7 at 2 days, 6 months, and 12 months postoperatively, respectively. The VAS score for leg pain was 7.1 ± 2.6 preoperatively and 3.0 ± 1.1, 2.1 ± 1.3, and 1.9 ± 0.8 at 2 days, 6 months, and 12 months postoperatively, respectively. These postoperative scores were all significantly different when compared with preoperative scores (P < 0.001). According to the modified MacNab outcome scale, excellent was obtained in 43 patients, good was obtained in 25 patients, and fair was obtained in 4 patients, and 94.44% of these patients had excellent and good outcomes at the final follow-up. There were no complications related to surgery, and no spinal instability was detected.

Conclusion

PTED appears to be an effective and safe intervention for younger patients with LDH. High-quality randomized controlled trials are required to further study the efficacy and safety of PTED in treating younger patients with LDH.