Percutaneous endoscopic intra-annular subligamentous herniotomy for large central disc herniation: a technical case report

MRI changes of adjacent segments after transforaminal lumbar interbody fusion (TLIF) and foraminal endoscopy: A case-control study

BACKGROUND

Intervertebral foramen endoscopy has developed rapidly, but compared with transforaminal lumbar interbody fusion (TLIF), the progress of degeneration is unknown. We aim to compare the changes of intervertebral disc and intervertebral foramen in adjacent segments after TLIF and endoscopic discectomy for patients with lumbar disc herniation (LDH).

METHODS

From 2014 to 2017, 87 patients who were diagnosed with single-level LDH and received surgery of TLIF (group T, n = 43) or endoscopic discectomy (group F, n = 44) were retrospectively analyzed. X-ray, MRI, CT and clinical symptoms were recorded before operation and at the last follow-up (FU). The neurological function was originally evaluated by the Japanese Orthopaedic Association (JOA) scores. Radiological evaluation included the height of intervertebral space (HIS), intervertebral foramen height (FH), intervertebral foramen area (FA), lumbar lordosis (CA) and intervertebral disc degeneration Pfirrmann scores.

RESULTS

There was no significant difference in baseline characteristics, JOA improvement rate, reoperation rate and complications between the two groups. The age, average blood loss, average hospital stays and average operation time in group F were lower than those in group T. During the last FU, HIS, CA and FA decreased in both groups, and the changes in group T were more significant than those in group F (P < .05). There was no significant difference in FH changes between the two groups (P > .05).

CONCLUSION

Both TLIF and endoscopic surgery can achieve good results in the treatment of LDH, but the risk of lumbar disc height loss and intervertebral foramina reduction in the adjacent segment after endoscopic surgery is lower.

Percutaneous Endoscopic Lumbar Discectomy Using a Double-Cannula Guide Tube for Large Lumbar Disc Herniation

Objective

To compare the effect of percutaneous endoscopic lumbar discectomy (PELD) using a double‐cannula guide tube (DGT), traditional PELD, and open lumbar discectomy (OLD) to treat large lumbar disc herniations (LLDHs).

Methods

Seventy patients who presented with LLDH without cauda equina syndrome and were treated with surgery in our hospital from October 2015 to October 2017 were included. The detailed index included the visual analog scale (VAS) for back and radicular leg pain and the Oswestry Disability Index (ODI) in the immediate preoperative period and at the final follow‐up. The operation time, radiation exposure time, surgical satisfaction rate, and modified MacNab criteria score were also recorded.

Results

The leg and back pain of the patients in these groups improved significantly in the postoperative period. No significant differences were observed in leg pain improvement between the other two groups; however, patients in the PELD group (with or without DGT) presented with significantly higher improvement in back pain than the OLD group (t = 9.965, p < 0.001). The final ODI scores were 12.1 ± 4.9, 11.2 ± 2.9, and 16.4 ± 3.6 in the PELD, PELD‐DGT, and OLD groups, respectively. Patients in the PELD and PELD‐DGT groups presented with significantly lower postoperative ODI scores than those in the OLD group (t = 20.834, p < 0.001). The mean postoperative hospital stays were significantly shorter in the PELD group and PELD with DGT group than in the OLD group (t = 46.688, p < 0.001). The mean operation time was significantly shorter in the PELD‐DGT group than those in the PELD group (t = 25.281, p = 0.001). No perioperative complications were observed in either group. Based on the modified MacNab criteria, excellent and good outcomes were achieved in 20 out of 21 patients (95.2%) in the PELD group, 23 out of 24 patients (95.8%) in the PELD‐DGT group, and 22 out of 25 patients (88.0%) in the OLD group. The rates of excellent and good outcomes were higher in the PELD and PELD‐DGT groups than in the OLD group, but there were no significant differences (χ² = 1.454, p = 0.835).

Conclusions

PELD using DGT is a safe and effective option for LLDH and features advantages such as improvements in back pain, a lower hospitalization cost than OLD, a shorter operation time, and less fluoroscopy than traditional PELD.

Percutaneous endoscopic transforaminal discectomy for the treatment of L5-S1 lumbar disc herniation and the influence of iliac crest height on its clinical effects

The present study aimed to explore the clinical effects of percutaneous endoscopic transforaminal discectomy using a transforaminal endoscopic spine system (TESSYS) technique for the treatment of L5-S1 lumbar disc herniation and to analyse the influence of iliac crest height on these clinical effects. The clinical data of 76 patients with L5-S1 single-segment disc herniation treated with TESSYS at The Second Affiliated Hospital and Third Affiliated Hospital of Xi'an Jiaotong University between January and December 2016 were retrospectively analysed. Patients were divided into the following three groups according to the positional relation between the highest point of the iliac crest and the L4 and L5 pedicles in the lateral lumbar, as determined by X-ray: Group I, iliac crest height below the upper edge horizontal line of the L5 pedicle (n=42); group II, iliac crest height between the lower edge horizontal line of the L4 pedicle and the upper edge horizontal line of the L5 pedicle (n=29) and group III, iliac crest height above the lower edge horizontal line of the L4 pedicle (n=5). Changes in the postoperative visual analogue scale (VAS) pain score and Oswestry disability index (ODI) of the lower back and lower limbs were observed, and the effects were compared among the three groups. The mean operating time was 86.5±13.5 min. A single patient experienced cerebrospinal fluid leakage due to a mild tear of the dura mater during the operation, which improved after symptomatic treatment. The same operation was repeated in one patient due to the recurrence of disc herniation. In all patients, the VAS pain score and ODI of the lower back and lower limbs at 1 week and 1, 3 and 12 months following the operation were significantly lower than those before the operation (all P<0.05). Furthermore, the postoperative VAS pain score and ODI of the lower back and lower limbs were poorer in group III (L5-S1 lumbar disc herniation complicated with high iliac crest) than in groups I and II (P<0.05). These results suggested that TESSYS was effective in treating lumbar disc herniation. Whether the iliac crest is higher than the lower edge horizontal line of the L4 pedicle is suggested to be one of the factors influencing the outcome of the operation.

Chemonucleolysis with Chondroitin Sulfate ABC Endolyase for Treating Lumbar Disc Herniation: Exploration of Prognostic Factors for Good or Poor Clinical Outcomes

Background and Objectives: Chondroitin sulfate ABC endolyase (condoliase) was launched as a new drug for chemonucleolysis in 2018. Few studies assessed its clinical outcomes, and many important factors remain unclear. This study aimed to clarify the preoperative conditions in which condoliase could be highly effective. Materials and Methods: Of 47 patients who received condoliase, 34 were enrolled in this study. The mean age of the patients was 33 years. The average duration since the onset of disease was 8.6 months. We evaluated patients’ low back and leg pain using a numerical rating scale (NRS) score at two time points (before therapy and 3 months after therapy). We divided the patients into two groups (good group (G): NRS score improvement ≥ 50%, poor group (P): NRS score improvement < 50%). The parameters evaluated were age, disease duration, body mass index (BMI), and positive or negative straight leg raising test results. In addition, the loss of disc height and preoperative radiological findings were evaluated. Results: In terms of low back and leg pain, the G group included 9/34 (26.5%) and 21/34 (61.8%) patients, respectively. Patients’ age (low back pain G/P, 21/36.5 years) was significantly lower in the G group for low back pain (p = 0.001). High-intensity change in the protruded nucleus pulposus (NP) and spinal canal occupancy by the NP ≥ 40% were significantly high in those with leg pain in the G groups (14/21, p = 0.04; and 13/21, p = 0.03, respectively). Conclusions: The efficacy of improvement in leg pain was significantly correlated with high-intensity change and size of the protruded NP. Condoliase was not significantly effective for low back pain but could have an effect on younger patients.

Trans-foraminal endoscopic uniportal decompression in degenerative lumbar spondylolisthesis: a technical and case report

Background

Degenerative spondylolisthesis is a common spinal pathology. Traditionally, spinal fusion is an accepted standard surgical treatment for listhesis. But fusion is a major intervention with its known pitfalls. With technological progression, minimally invasive spinal fusion (MISF) procedures are becoming mainstream. Percutaneous trans-foraminal endoscopic lumbar discectomy/decompressions (PTELD) without stabilization has many advantages over even a MISF for select group of patients.

Case presentation

In this case report, we describe using a uniportal unilateral trans-foraminal approach (TFA) for stable listhesis with lumbar disc herniation (LDH) causing chronic bilateral radicular symptoms and back pain with acute exacerbation. Under local anesthesia, we used a flat entry for PTELD, which facilitates an approach to both disc sides ventrally and even dorsal aspect lateral recess decompression on the dominant ipsilateral side. No fixation was done. An excellent outcome is obtained immediately at 6 weeks and maintained at 39 months of follow-up.

Conclusion

PTELD is worth considering as an intermediate procedure before fusion is offered in lateral recess stenosis in stable listhesis patients who have consented and understand the progressive cascade of spinal degeneration.

Percutaneous Stenoscopic Lumbar Decompression with Paramedian Approach for Foraminal/Extraforaminal Lesions

The lumbar foramen is affected by different degenerative diseases, including extraforaminal disc herniation, foraminal stenosis (FS), and degenerative or spondylolytic spondylolisthesis. The purpose of this study was to describe percutaneous stenoscopic lumbar decompression with a paramedian approach (para-PSLD) for foraminal/extraforaminal lesions. All operative procedures were performed using a complete uniportal endoscopic instrument system. The para-PSLD can be easily applied to patients with FS and narrow disc space or facet joint hypertrophy. The anatomical view of a para-PSLD is similar to that of a conventional open surgery and allows for good visualization of the foraminal/extraforaminal areas. We suggest that para-PSLD is an alternative and minimally invasive procedure to treat degenerative lumbar foraminal/extraforaminal stenoses.

Intraoperative Disc Prolapse During Percutaneous Endoscopic Lumbar Discectomy

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) is regarded as an alternative treatment for lumbar disc herniation. Although the indication for PELD has expanded with remarkable evolution of the technique, sometimes unexpected complications have occurred during PELD. We report 3 cases of de novo disc prolapse during PELD.

CASE DESCRIPTION

In 3 patients who underwent PELD for lumbar disc herniation with local anesthesia, postoperative magnetic resonance imaging demonstrated newly developed up-migrated disc herniation. Compared with their preoperative states, these patients experienced decreased intensity of both leg and back pain. There were no neurologic deficits. PELD was repeated for L1-L2 disc herniation only to relieve compression of the conus medullaris.

CONCLUSIONS

Although the incidence was very low (0.3%) and the lesions were nonsymptomatic, de novo disc prolapse may be associated with an inside-out PELD technique. Discography and insertion of the obturator should be handled gently. The possibility of de novo disc prolapse should be kept in mind when performing PELD.

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.

Comparison Between Percutaneous Endoscopic Lumbar Discectomy and Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Disc Herniation with Biradicular Symptoms

OBJECTIVE

To compare the clinical outcomes of patients with lumbar disc herniation with bi-radicular symptoms undergoing percutaneous endoscopic lumbar discectomy (PELD) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

METHODS

From January 2008 to January 2016, 89 consecutive patients with lumbar disc herniation with biradicular symptoms were treated with PELD or MIS-TLIF. The data were collected prospectively for analysis including clinical and radiographic results after revision surgery and complications.

RESULTS

During the follow-up period, the postoperative data between the 2 treatment groups showed no significant difference in the mean total postoperative visual analog score for leg pain and the Japanese Orthopedic Association and Oswestry disability index scores. In the MIS-TLIF group, the recovery rate and satisfaction rate were higher than those in the PELD group, and the difference was statistically significant. The only postoperative factor that was significantly different was postoperative back pain, which was lower in the MIS-TILF group. The other significant differences between the 2 treatment groups were associated with the complications such as intervertebral infection and adjacent segment disease.

CONCLUSIONS

Both PELD and MIS-TLIF, as treatments for lumbar disc herniation with biradicular symptoms, showed favorable clinical outcomes. Compared with MIS-TLIF, PELD had the following advantages: 1) it is performed under local anesthesia and 2) there is rare possibility of "fusion disease," such as ASD. However, the PELD is also revealed several problems, including a relatively lower success rate and satisfaction, a relative higher rate of postoperative long-term chronic low back pain and the possibility of recurrence, despite the low incidence.

A novel preoperative trajectory evaluation method for L5-S1 transforaminal percutaneous endoscopic lumbar discectomy

BACKGROUND CONTEXT

L5-S1 transforaminal percutaneous endoscopic lumbar discectomy (PELD) is a demanding procedure because of structures such as iliac crest, L5 transverse process, hypertrophic L5-S1 facet joint, and sacral ala. There has been no definite preoperative evaluation method to evaluate the surgical validity of L5-S1 transforaminal PELD.

PURPOSE

The authors report a new preoperative trajectory evaluation method for L5-S1 transforaminal PELD using magnetic resonance imaging (MRI) or computed tomography (CT) examinations.

STUDY DESIGN/SETTING

This is a technical report study.

PATIENT SAMPLE

Patients who were diagnosed L5-S1 soft disc herniation were included in the present study.

OUTCOME MEASURES

Success rate of transforaminal PELD according to height of iliac crest was measured.

METHODS

Twelve patients who were diagnosed L5-S1 disc herniation were preoperatively evaluated with this new method. A skin marker is attached to patient's back as a tentative skin entry point, which was determined by usual preoperative MRI or CT. A new tilted axial and coronal MRI or CT scan is performed according to axis of L5-S1 transforaminal working channel. The images show good relationship between working channel and iliac crest.

RESULTS

Six patients underwent a transforaminal PELD, and the results were successful. The other six patients were considered to be "unsuitable" for transforaminal PELD because of the probable blockade by iliac crest.

CONCLUSIONS

The tilted MRI or CT provides precise evaluation for L5-S1 transforaminal PELD trajectory and may achieve good outcome.

Significance and pitfalls of percutaneous endoscopic lumbar discectomy for large central lumbar disc herniation

Background

Percutaneous endoscopic lumbar discectomy (PELD) is a relatively less invasive treatment for lumbar disc herniation (LDH). The present study focused on the transforaminal approach (TFA) and investigated the significance of PELD via this approach for large central LDH.

Methods

LDH that did not show cerebrospinal fluid (CSF) on axial T2-weighted magnetic resonance images was defined as large central LDH. PELD via the TFA was performed in 11 patients with large central LDH. Pre- and post-operative statuses were evaluated using the modified Japanese Orthopedic Association (mJOA) and Numerical Rating Scale (NRS) scores.

Results

The patients' mean age was 44.1 years; there was single-level involvement, mostly at L4/5 (seven cases). The mean recovery rate of the mJOA score was 48.7%, and mean pre- and post-operative NRS scores were 7.1 and 1.5, respectively. The mean operative time was 38.1 min. Although there were no major complications, the dura was accidentally punctured at the initial operative step for discography in one case. LDH recurred in one case at 5 months after the operation, and the patient was treated by PELD via the TFA on the contralateral side.

Conclusions

The TFA for PELD is a safe, minimally invasive, effective treatment for large central LDH. However, the operator should pay attention to malpositioning of the flat and laterally expanded dural sac.

Percutaneous Endoscopic Laminotomy with Flavectomy by Uniportal, Unilateral Approach for the Lumbar Canal or Lateral Recess Stenosis

OBJECTIVE

To evaluate clinical feasibility and safety of percutaneous endoscopic decompression by a uniportal, unilateral approach for lumbar canal or lateral recess stenosis.

METHODS

In this retrospective study, the procedure was performed with endoscopic instruments in the same way as conventional microscopic laminotomy and flavectomy. Clinical outcomes (visual analog scale, Oswestry Disability Index, modified MacNab criteria) were evaluated. Surgical outcomes, including operative time, hospital stay, and complications, were recorded.

RESULTS

Decompression was performed in 213 patients (232 lumbar levels) for spinal canal or lateral recess stenosis (unilateral laminotomy, n = 80; bilateral laminotomy, n = 152). Mean follow-up period was 26.45 months. Mean visual analog scale for leg pain, and back pain and mean Oswestry Disability Index improved from 8.24%, 5.35%, and 67.8% at baseline to 1.93% (P < 0.001), 2.05% (P < 0.001), and 17.14% (P < 0.001) at final follow-up. Based on modified MacNab criteria, excellent or good results were obtained in 93.8% of patients. Average operative time was 105.3 ± 56 minutes. In the late period of the learning curve, mean operative time was shortened by two thirds, and mean hospital stay was 2.45 days. There were 12 cases of transient postoperative dysesthesia, 3 cases of motor weakness, and 6 cases of dural tear. No patient had postoperative infection, hematoma, or need for revision surgery for incomplete decompression.

CONCLUSIONS

Percutaneous endoscopic decompression by a uniportal, unilateral approach is a safe, clinically feasible, and effective surgical technique for treatment of lumbar stenosis.

Consideration of proper operative route for interlaminar approach for percutaneous endoscopic lumbar discectomy

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) is one of the less invasive treatments of lumbar disc herniation (LDH), and has three different operative approaches. This study focused on the interlaminar approach (ILA) and investigated the appropriate operative route for this approach.

METHODS

ILA was performed in 41 patients with LDH. The width of the interlaminar space, LDH size, and positional relation between LDH and the corresponding nerve root were radiologically evaluated. Thirty-three LDHs were removed via the shoulder of the corresponding nerve root and eight were removed via the axilla of the corresponding nerve root and dural sac. Pre- and postoperative status were evaluated using the modified Japanese Orthopedic Association (mJOA) and numerical rating scale (NRS) scores.

RESULTS

The mean age was 41.5 years; there was single-level involvement, mostly at L5/S1 (33 cases). The mean recovery rate of mJOA score was 59.8% and mean pre- and postoperative NRS scores were 5.8 and 0.98, respectively. Relatively severe complications developed in three patients treated by ILA via the shoulder. There was persistent numbness in the corresponding nerve area, transient muscular weakness, and transient bladder and rectal disturbance, may be due to excessive compression of the nerve root and/or dural sac by the endoscopic sheath.

CONCLUSIONS

ILA can be used to treat LDH revealing an interlaminar space of ≥20 mm. The procedure is minimally invasive and effective; however, appropriate selection of an operative route is important to avoid operative complications. Particularly for large LDH, the operative route via the axilla should be considered.

Foraminoplastic Superior Vertebral Notch Approach with Reamers in Percutaneous Endoscopic Lumbar Discectomy : Technical Note and Clinical Outcome in Limited Indications of Percutaneous Endoscopic Lumbar Discectomy

To describe the details of the foraminoplastic superior vertebral notch approach (FSVNA) with reamers in percutaneous endoscopic lumbar discectomy (PELD) and to demonstrate the clinical outcomes in limited indications of PELD. Retrospective data were collected from 64 patients who underwent PELD with FSVNA from August 2012 to April 2014. Inclusion criteria were high grade migrated disc, high canal compromised disc, and disc protrusion combined with foraminal stenosis. The clinical outcomes were assessed using by the visual analogue scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria. Complications related to the surgery were reviewed. The procedure used a unique approach, using the superior vertebral notch as the target and performing foraminoplasty with only reamers under C-arm control. The mean age of the 55 female and 32 male patients was 52.73 years. The mean F/U period was 12.2±4.2 months. Preoperative VAS (8.24±1.25) and ODI (67.8±15.4) score improved significantly at the last follow-up (VAS, 1.93±1.78; ODI, 17.14±15.7). Based on the modified MacNab criteria, excellent or good results were obtained in 95.3% of the patients. Postoperative transient dysthesia (n=2) and reoperation (n=1) due to recurred disc were reported. PELD with FSVNA could be a good method for treating lumbar disc herniation. This procedure may offer safe and efficacious results, especially in the relatively limited indications for PELD.

Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10,228 cases

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has remarkably evolved with successful results. Although PELD has gained popularity for the treatment of herniated disc (HD), the risk of surgical failure may be a major obstacle to performing PELD. We analyzed unsuccessful cases requiring reoperation.

OBJECTIVE

To find common causes of surgical failure and elucidate the limitations of the conventional PELD technique.

METHODS

A retrospective review was performed on all patients who had undergone PELD between January 2001 and December 2012. Unsuccessful PELD was defined as a case requiring reoperation within 6 weeks after primary surgery. Chart review was done, and preoperative, intraoperative, and postoperative radiographic reviews were performed. All unsuccessful PELD cases were classified according to the type of HD, location of herniation, extruded disc migration, working channel position, and intraoperative and postoperative findings.

RESULTS

In 12 years, 10,228 patients had undergone PELD; 436 (4.3%) cases were unsuccessful. The causes were incomplete removal of HDs in 283 patients (2.8%), recurrence in 78 (0.8%), persistent pain even after complete HD removal in 41 (0.4%), and approach-related pain in 21 (0.2%). Incomplete removal of the HD was caused by inappropriate positioning (95 cases; 33.6%) of the working channel and occurred in central HDs (91 cases; 32.2%), migrated HDs (70 cases; 24.7%), and axillary type HDs (63 cases; 22.3%).

CONCLUSION

Proper surgical indications and good working channel position are important for successful PELD. PELD techniques should be specifically designed to remove the disc fragments in various types of HD.