Strategies for Noncontained Lumbar Disc Herniation by an Endoscopic Approach : Transforaminal Suprapedicular Approach, Semi-Rigid Flexible Curved Probe, and 3-Dimensional Reconstruction CT with Discogram

Outcome of Transforaminal Endoscopic Discectomy in Rural India in a Single-Level Lumbar Disc Prolapse Under Local Anesthesia

Aim  The aim of this study was to undertake a clinical study to evaluate the outcomes of transforaminal endoscopic discectomy under local anesthesia and to study the complication rate. Study Design  It is a prospective study. Methods  We prospectively analyzed outcomes of 60 patients with a single-level lumbar disc prolapse in rural India from December 2018 to April 2020 who underwent endoscopic discectomy under local anesthesia. Follow-up was done using the visual analogue score (VAS) and Oswestry Disability Index (ODI) scoring systems with a minimum follow-up up to 1 year postoperatively. Results  In our study of 60 patients, there was 38 cases of L4-L5 disc pathology, 13 L5-S1 discs, and 9 L3-L4 discs. Our study showed a significant clinical reduction in mean VAS score that was 7.07/10 preoperatively and reduced to 3.88/10 at the third month and 3.64/10 at 1 year of follow-up ( p -value < 0.05) showing clinical significance. The ODI scoring done preoperatively was an average mean of 57.37% pointing to how crippled the patients were with lumbar disc prolapse and showed a significant reduction to 29.32% postoperatively at 1 year ( p -value < 0.05) showing clinical significance. This reduction in ODI directly corelates to how almost all patients returned to normal life coping to all activities and were completely pain free at 1 year of follow-up. Conclusion  Endoscopic spine surgery in lumbar disc prolapse is highly effective and can deliver a good functional outcome if done with correct preoperative planning and approach.

Extraforaminal Full-Endoscopic Approach for the Treatment of Lateral Compressive Diseases of the Lumbar Spine

Background: The authors conducted a 2-year retrospective follow-up to investigate the efficiency of an extraforaminal full-endoscopic approach with foraminoplasty used to treat lateral compressive diseases of the lumbar spine in 247 patients. Methods: The visual analogue scale (VAS), Oswestry disability index (ODI), and MacNab scale were used to analyze the results collected during the preoperative and postoperative periods. Results: The most common diagnosis was disk herniation with lateral recess stenosis, and the most common surgical level among patients was between L4 and L5 on the left side. Pain decreased over time, as determined during sessions held to evaluate pain in the lumbar, gluteal, led, and foot regions. The ODI demonstrated significant enhancement over the evaluation period and the MacNab scale classified the surgery as good or excellent. The most common complication was dysesthesia. Conclusions: An extraforaminal full-endoscopic approach with foraminoplasty can be recommended in cases of lateral herniation or stenosis for patients with symptoms of radiculopathy, and for those who have not responded to conventional rehabilitation treatment or chronic pain management. Few complications arose as a result of this approach, and most of them were treated clinically.

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.

Endoscopic interlaminar lumbar discectomy: How to decrease the learning curve

Background:

Herniated lumbar disc is a common cause of lumbosacral pain. Endoscopic interlaminar lumbar discectomy (ILD) is a well-established technique that provided comparable results to micro-discectomy. The aim of the study is to describe the learning curve of endoscopic ILD and explore measures that could improve effectiveness and decrease blood loss and operative time with accumulation of reasonable experience.

Methods:

This retrospective cohort study included 65 patients presenting with symptomatic herniated lumbar disc who underwent endoscopic ILD. Patients were divided into two groups: Group I (standard technique) and Group II (modified technique). Collected data included patients’ age, gender, preoperative manifestations, visual analog score (VAS) for pain, Oswestry Disability Index (ODI), disc level, operative time, intraoperative blood loss, complications, and follow-up data at 1, 6, and 12 months postoperatively. Primary outcomes included total operative time, amount of intraoperative blood loss, and post-operative improvement in pain. Secondary outcomes included intraoperative complications, rate of conversion to open surgery, and recurrence.

Results:

Post-operative VAS and ODI improved significantly in both groups. Mean total surgical time and intraoperative blood loss were significantly lower in Group II compared to Group I (P < 0.001). The learning curves for operative time and intraoperative blood loss were shallow in Group I, and almost flattened in Group II. Complications were recorded in only three cases, and no symptomatic recurrences were reported.

Conclusion:

The learning curve of endoscopic ILD was shallow with standard technique, indicating difficulties in mastering the procedure. The proposed modified technique helped reaching the required level of proficiency in the early phase of the curve, providing a significant reduction in operative time and blood loss, with comparable effectiveness and safety as the standard technique.

Technical Considerations of the Transforaminal Approach for Lumbar Disk Herniation

Transforaminal full endoscopic lumbar diskectomy (TELD) is a typical minimally invasive surgery, with the associated benefit of decreased possibility of anatomic structural injury, and is an effective alternative to open diskectomy. Among the various endoscopic spinal surgical techniques currently available, TELD is the most basic and traditional surgery that can be performed through the transforaminal route; it has been used for >30 years. Recently, with the advancements in surgical techniques, TELD has been successfully performed for patients with lumbar disk herniation of different types. However, beginner surgeons are unfamiliar with the anatomy of transforaminal endoscopic surgery and this surgery has a steep learning curve to date. If not well prepared, operators may experience complications that require reoperation in the early stages. These complications may include symptomatic incomplete decompression, exiting nerve root injury, dural tearing, and rarely, hematoma, infection, and visceral injury. Here, we propose several technical guidelines for TELD to increase the possibility of successful lumbar diskectomy and to reduce the incidence of complications. The first step is the accurate anatomic understanding of Kambin triangle and determining the appropriate endoscopic access angle, depending on the type of disk herniation. The second step is to determine a safe and easily accessible entry point and then landing and docking the working sleeve as close to the target as possible without causing exiting nerve root injury. The third step is complete decompression of the symptomatic nerve with free mobilization of the neural tissue. The final step involves performing foraminoplasty using an advanced technique to overcome the limitations associated with TELD in difficult cases.

Deep learning-based lumbosacral reconstruction for difficulty prediction of percutaneous endoscopic transforaminal discectomy at L5/S1 level: A retrospective cohort study

BACKGROUND

Deep learning has been validated as a promising technique for automatic segmentation and rapid three-dimensional (3D) reconstruction of lumbosacral structures on CT. Simulated foraminoplasty of percutaneous endoscopic transforaminal discectomy (PETD) through the Kambin triangle may benefit viability assessment of PETD at L5/S1 level.

MATERIAL AND METHODS

Medical records and radiographic data of patients with L5/S1 lumbar disc herniation (LDH) who received a single-level PETD from March 2013 to February 2018 were retrospectively collected and analyzed. Deep learning was adopted to achieve semantic segmentation of lumbosacral structures (nerve, bone, disc) on CT, and the segmented masks on reconstructed 3D models. Two observers measured the area of the Kambin triangle on 6 selected deep learning-derived 3D (DL-3D) models and ground truth-derived 3D (GT-3D) models, and intraclass correlation coefficient (ICC) was calculated to assess the test-retest and interobserver reliability. Foraminoplasty of PETD was simulated on L5/S1 lumbosacral 3D models. Patients with extended foraminoplasty or stuck canula occurs on simulations were predicted as PETD-difficult cases (Group A). The remaining patients were regarded as PETD-normal cases (Group B). Clinical information and outcomes were compared between the two groups.

RESULTS

Deep learning-derived 3D models of lumbosacral structures (nerves, bones, and disc) from thin-layer CT were reliable. The area of the Kambin triangle was 161.27 ± 40.10 mm² on DL-3D models and 153.57 ± 32.37 mm² on GT-3D models (p = 0.206). Reliability test revealed strong test-retest reliability (ICC between 0.947 and 0.971) and interobserver reliability of multiple measurements (ICC between 0.866 and 0.961). The average operation time was 99.62 ± 17.39 min in Group A and 88.93 ± 21.87 min in Group B (P = 0.025). No significant differences in patient-reported outcomes or complications were observed between the two groups (P > 0.05).

CONCLUSION

Deep learning achieved accurate and rapid segmentations of lumbosacral structures on CT, and deep learning-based 3D reconstructions were efficacious and reliable. Foraminoplasty simulation with deep learning-based lumbosacral reconstructions may benefit surgical difficulty prediction of PETD at L5/S1 level.

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.

Transforaminal Endoscopic Lumbar Discectomy: Clinical Outcomes and Complications

Objective  To evaluate the clinical and functional results of transforaminal endoscopic lumbar discectomy. Materials and Methods  From August 2015 to January 2017, 101 patients with lumbar disc hernia refractory to clinical treatment underwent endoscopic discectomy. Through clinical evaluation by the Visual Analogue Scale and functional evaluation by the Oswestry Disability Index questionnaire, the patients were analyzed in the preoperative period, the immediate postoperative period, at 1 month, 3 months, 6 months and 1 year after surgery. Results  The mean age of the participants was 48.1 years. The most affected disc levels were L4-L5 and L5-S1. A total of 29 patients were treated at 2 disc levels. After 1 month of postoperative follow-up, the mean scores on the questionnaires (VAS and ODI) decreased significantly ( p  < 0.001). Conclusion  Transforaminal endoscopic Lumbar discectomy has been shown to be a safe, effective and minimally-invasive alternative for the treatment of lumbar disc herniation. The procedure has advantages, such as short hospital stay, surgery performed under local anesthesia and sedation, early return to daily activities, and low rate of complications.

[Percutaneous Lumbar Endoscopic Discectomy: Presentation of 60 Cases Intervened in Argentina with Awake Patients]

INTRODUCTION

Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive technique that has been used in different countries since the late eighties for the treatment of herniated discs.

OBJECTIVE

The objective of this study was to describe the results of PELD in a series of awake patients, treated with epidural anesthesia and mild sedation.

MATERIALS AND METHODS

In a group of 60 patients, who together had 77 discs operated on between April 2016 and March 2018, data were collected on patient age and gender, clinical presentation, and MRI abnormalities. The main outcome of interest was the difference between preoperative and postoperative Oswestry (Oswestry disability index [ODI]) scores 8 weeks after the procedure. Macnab criteria, operation duration, length of hospitalization, surgical complications, and the need for reoperation were other outcomes evaluated. All patients received epidural anesthesia and mild sedation.

RESULTS

The average reduction in ODI at 8 weeks was 48 points (standard deviation [SD] = 5), representing an average percentage reduction of 85% (SD = 8). By Macnab's criteria, 85% of patients experienced either an excellent or good result, while 10% and 5% had a fair and poor result, respectively. Average surgery time was 50 min and in-hospitalization stay 8.6 h.

CONCLUSIONS

In our series of surgical patients with lumbar disc herniations, PELD yielded very good results, manifest as significantly reduced pain, brief procedural durations, no complications, and short hospital stays. Patients accepted the option of being awake and immediately ambulatory, and the approach proved highly feasible to execute.

Pseudoaneurysm of a segmental lumbar artery following a full-endoscopic transforaminal lumbar discectomy: a rare approach-related complication

Full-endoscopic transforaminal lumbar discectomy is based on a puncture technique using a guide needle to reach the target area of the foramen via a percutaneous posterolateral/lateral approach. It may correlate with specific approach-related complications, as exiting nerve root injury. We report the first case of pseudoaneurysm of the lumbar segmental artery secondary to a transforaminal full-endoscopic surgery in the treatment of a lumbar herniated disc. A 39-year-old man underwent left L4-L5 full-endoscopic transforaminal lumbar discectomy for a herniated disc. Three hours after surgery, he experienced acute progressive abdominal pain. An abdomen CT scan showed contrast extravasation in the left paraspinal compartment at L4 vertebral body level. The selective left lumbar angiogram revealed a pseudoaneurysm of a side branch of the left lumbar segmental artery, which was treated by endovascular coiling. The patient made a rapid postoperative recovery without further complications and was discharged 4 days later. This report identifies a rare complication of transforaminal full-endoscopic surgery in the treatment of a herniated lumbar disc. To our knowledge this is the first case of pseudoaneurysm formation of the lumbar artery following a full-endoscopic transforaminal lumbar discectomy.

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.

Lumbar Scoliosis Combined Lumbar Spinal Stenosis and Herniation Diagnosed Patient Was Treated with "U" Route Transforaminal Percutaneous Endoscopic Lumbar Discectomy

The objective was to report a case of a 63-year-old man with a history of low back pain (LBP) and left leg pain for 2 years, and the symptom became more serious in the past 5 months. The patient was diagnosed with lumbar scoliosis combined with lumbar spinal stenosis (LSS) and lumbar disc herniation (LDH) at the level of L4-5 that was confirmed using Computerized Topography and Magnetic Resonance Imaging. The surgical team preformed a novel technique, “U” route transforaminal percutaneous endoscopic lumbar discectomy (PELD), which led to substantial, long-term success in reduction of pain intensity and disability. After removing the osteophyte mass posterior to the thecal sac at L4-5, the working channel direction was changed to the gap between posterior longitudinal ligament and thecal sac, and we also removed the herniation and osteophyte at L3-4 with “U” route PELD. The patient's symptoms were improved immediately after the surgical intervention; low back pain intensity decreased from preoperative 9 to postoperative 2 on a visual analog scale (VAS) recorded at 1 month postoperatively. The success of the intervention suggests that “U” route PELD may be a feasible alternative to treat lumbar scoliosis with LSS and LDH patients.

Percutaneous endoscopic lumbar discectomy: Results of first 100 cases

BACKGROUND

Lumbar disc herniation is a major cause of back pain and sciatica. The surgical management of lumbar disc prolapse has evolved from exploratory laminectomy to percutaneous endoscopic discectomy. Percutaneous endoscopic discectomy is the least invasive procedure for lumbar disc prolapse. The aim of this study was to analyze the clinical outcome, quality of life, neurologic function, and complications.

MATERIALS AND METHODS

One hundred patients with lumbar disc prolapse who were treated with percutaneous endoscopic discectomy from May 2012 to January 2014 were included in this retrospective study. Clinical followup was done at 1 month, 3 months, 6 months, 1 year, and at yearly interval thereafter. The outcome was assessed using modified Macnab's criteria, visual analog scale, and Oswestry Disability Index.

RESULTS

The mean followup period was 2 years (range 18 months - 3 years). Transforaminal approach was used in 84 patients, interlaminar approach in seven patients, and combined approach in nine patients. An excellent outcome was noted in ninety patients, good outcome in six patients, fair result in two patients, and poor result in two patients. Minor complications were seen in three patients, and two patients had recurrent disc prolapse. Mean hospital stay was 1.6 days.

CONCLUSIONS

Percutaneous endoscopic lumbar discectomy is a safe and effective procedure in lumbar disc prolapse. It has the advantage that it can be performed on a day care basis under local anesthesia with shorter length of hospitalization and early return to work thus improving the quality of life earlier. The low complication rate makes it the future of disc surgery. Transforaminal approach alone is sufficient in majority of cases, although 16% of cases required either percutaneous interlaminar approach or combined approach. The procedure definitely has a learning curve, but it is acceptable with adequate preparations.

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.

Endoscopic inter laminar management of lumbar disease

Discectomy for lumbar disc provides faster relief in acute attack than does conservative management. Long-term results of open, microscopy-, and endoscopy-assisted discectomy are same. Early results of endoscopy-assisted surgery are better as compared to that of open surgery in terms of better visualization, smaller incision, reduced hospital stay, better education, lower cost, less pain, early return to work, and rehabilitation. Although microscopic discectomy also has comparable advantages, endoscopic-assisted technique better addresses opposite side pathology. Inter laminar technique (ILT) and trans foraminal technique (TFT) are two main endoscopic approaches for lumbar pathologies. Endoscopy-assisted ILT can be performed in recurrent, migrated, and calcified discs. All lumbar levels including L5-S1 level, intracanalicular, foraminal disc, lumbar canal and lateral recess stenosis, multiple levels, and bilateral lesions can be managed by ILT. Migrated, calcified discs, L5-S1 pathology, lumbar canal, and lateral recess stenosis can be better approached by ILT than by TFT. Most spinal surgeons are familiar with anatomy of ILT. It can be safely performed in foramen stenosis and in uncooperative and anxious patients. There is less risk of exiting nerve root damage, especially in short pedicles and in presence of facet osteophytes as compared to TFT. On the other hand, ILT is more invasive than TFT with more chances of perforations of the dura matter, pseudomeningocele formation, and cerebrospinal fluid fistula in early learning curve. Obtaining microsurgical experience, attending workshops, and suitable patient selection can help shorten the learning curve. Once adequate skill is acquired, this procedure is safe and effective. The surgeon must be prepared to convert to an open procedure, especially in early learning curve. Spinal endoscopy is likely to achieve more roles in future. Endoscopy-assisted ILT is a safer alternative to the microscopic technique.

Learning Curve of Percutaneous Endoscopic Lumbar Discectomy Based on the Period (Early vs. Late) and Technique (in-and-out vs. in-and-out-and-in): A Retrospective Comparative Study

Objective

To report the learning curve of percutaneous endoscopic lumbar discectomy (PELD) for a surgeon who had not been previously exposed to this procedure based on the period and detailed technique with a retrospective matched comparative design.

Methods

Of 213 patients with lumbar disc herniation encountered during the reference period, 35 patients who were followed up for 1 year after PELD were enrolled in this study. The patients were categorized by the period and technique of operation : group A, the first 15 cases, who underwent by the 'in-and-out' technique; group B, the next 20 cases, who underwent by the 'in-and-out-and-in' technique. The operation time, failure rate, blood loss, complication rate, re-herniation rate, the Visual Analogue Scale (VAS) for back and leg were checked. The alteration of dural sac cross-sectional area (DSCSA) between the preoperative and the postoperative MRI was checked.

Results

Operative time was rapidly reduced in the early phase, and then tapered to a steady state for the 35 cases receiving the PELD. After surgery, VAS scores for the back and leg were decreased significantly in both groups. Complications occurred in 2 patients in group A and 2 patients in group B. Between the two groups, there were significant differences in operative time, improvement of leg VAS, and expansion of DSCSA.

Conclusion

PELD learning curve seems to be acceptable with sufficient preparation. However, because of their high tendency to delayed operation time, operation failure, and re-herniation, caution should be exercised at the early phase of the procedure.

Lumbar Endoscopic Microdiscectomy: Where Are We Now? An Updated Literature Review Focused on Clinical Outcome, Complications, and Rate of Recurrence

Endoscopic disc surgery (EDS) for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. Rate of recurrence/residual, complications, and outcomes, in comparison with standard microdiscectomy (MD), is still debated and need further data. We performed an extensive review based on the last 6 years of surgical series, systematic reviews, and meta-analyses reported in international, English-written literature. Articles regarding patients treated through endoscopic transforaminal or interlaminar approaches for microdiscectomy (MD) were included in the present review. Papers focused on endoscopic surgery for other spinal diseases were not included. From July 2009 to July 2015, we identified 51 surgical series, 5 systematic reviews, and one meta-analysis reported. In lumbar EDS, rate of complications, length of hospital staying, return to daily activities, and overall patients' satisfaction seem comparable to standard MD. Rate of recurrence/residual seems higher in EDS, although data are nonhomogeneous among different series. Surgical indication and experience of the performing surgeon are crucial factors affecting the outcome. There is growing but still weak evidence that lumbar EDS is a valid and safe alternative to standard open microdiscectomy. Statistically reliable data obtained from randomized controlled trials (better if multicentric) are desirable to further confirm these results.

Minimally invasive percutaneous endoscopic 2 levels adjacent lumbar discectomy through 1 portal skin incision: Preliminary study

Background:

Acute lumbar disc herniation can occur in every lumbar intervertebral disc space and in multiple levels simultaneously. In the cases of 2 levels adjacent lumbar disc herniations of severe unilateral radiculopathic leg pain caused by compression of the nerve roots, respectively, multiple incision or long incision is generally needed for simultaneous removal of disc fragment in 2 levels.

Objectives:

We proposed the minimally invasive one portal skin incision endoscopic discectomy is effective and safe method to treat 2 levels adjacent lumbar disc herniation.

Materials and Methods:

We have experimented total 8 cases of 2 levels adjacent lumbar disc herniation having unilateral radiculopathic pain respectively. All cases are 2 levels adjacent lumbar disc herniation. We have tried a percutaneous endoscopic transforaminal approach through minimal one portal skin incision and remove the two herniated disc materials in the adjacent levels.

Results:

The L2-L3 level was involved in 2 patients, L3-L4 level in 6 patients, while the L4-L5 level was involved in 7 patients, L5-S1 level in 1 patient. The mean follow-up was 18.5 months. The mean visual analogue score (VAS) of the patients prior to surgery was 7.75, and the mean postoperative VAS was 2.375. According to Macnab's criteria, 3 patients had excellent results, 4 patients had good results, 1 patient had fair results, and no patient had a poor result; satisfactory results were obtained in 87.5% of the cases.

Conclusion:

The percutaneous endoscopic transforaminal approach through 1 skin portal incision could be effective surgical method in unilateral adjacent 2 levels lumbar disc herniation.

CT guided method for access to extremely difficult disc spaces without bony penetration or local anesthesia deeper than skin

Gaining needle access to the intervertebral discs for discography has been performed with fluoroscopic guidance but can be challenging when sedation cannot be used. Avoidance of the exiting L5 nerve roots is particularly challenging when the disc space is severely narrowed with overhanging endplates or osteophytes. We describe our experience on 28 discs in 10 consecutive patients referred for presurgical evaluation using low-dose computed tomography oblique axial and sagittal reformats aligned to the needle for guidance into the disc.

The surgical treatment of single level multi-focal subarticular and paracentral and/or far-lateral lumbar disc herniations: the single incision full endoscopic approach

BACKGROUND

Surgery for same level multi-focal extruded lumbar disc herniations is technically challenging and the optimal method controversial. The subarticular disc herniation may pose the most challenging subtype requiring partial or complete facetectomy with or without fusion. The far-lateral disc herniation, often treated using a Wiltse approach, can also be difficult to access especially in the obese patient. When both the subarticular and far-lateral subtypes are simultaneously present at the same level with or without a paracentral disc herniation, a total facetectomy and interbody fusion (TLIF) or a total disc replacement (TDR) may be necessary. Endoscopic surgical techniques may reduce the need for these more invasive methods.

METHODS

Fifteen patients (6 male and 9 female) who had same level multi-focal (subarticular as well as far-lateral and/or paracentral) extruded disc herniations underwent single incision unilateral endoscopic disc excision by the same surgeon at a single institution. Patients were prospectively followed for an average of 15.3 months (range 14-18 months) and outcomes were evaluated radiographically and clinically (Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI).

RESULTS

The mean operative time was 52 minutes with minimal blood loss in all cases. Fourteen of the 15 patients were discharged to home on the day of their surgery. The mean ODI and leg VAS scores improved from 22.9 ± 3.2 to 12.9 ± 2.7 (p < 0.005), and from 8.6 ± 1.6 to 2.1 + 0.4 (p < 0.005), respectively.

CONCLUSIONS

After an average of 15.3 months of follow-up, the clinical and radiographic results of full endoscopic surgical treatment of single level multi-focal (subarticular as well as far-lateral and/or paracentral) disc herniations are excellent. This study is a case series with mid-term follow-up (Level IV).

CLINICAL RELEVANCE

Foraminal and extra-foraminal full endoscopic decompression appears to offer a safe minimally invasive solution to a complex pathologic problem.

Effectiveness of heat-sensitive moxibustion in the treatment of lumbar disc herniation: study protocol for a randomized controlled trial

BACKGROUND

Lumbar disc herniation is a common and costly problem. Moxibustion is employed to relieve symptoms and might therefore act as a therapeutic alternative. Many studies have already reported encouraging results in heat-sensitive moxibustion for lumbar disc herniation. Hence, we designed a randomized controlled clinical trial to investigate the effectiveness of heat-sensitive moxibustion compared with conventional moxibustion.

METHODS

This trial is a multicenter, prospective, randomized controlled clinical trial. The 316 eligible patients are randomly allocated to two different groups. The experimental group is treated with heat-sensitive moxibustion (n = 158); while the control group (n = 158) is treated with conventional moxibustion. The moxibustion locations are different for the groups. The experimental group selects heat-sensitization acupoints from the region which consists of bilateral Da Changshu (BL25) and Yao Shu (Du2). Meanwhile, fixed acupoints are used in control group; patients in both groups receive 18 sessions in 2 weeks.

DISCUSSION

The study design guarantees a high internal validity for the results. It is one large-scale randomized controlled trial to evaluate the efficacy of heat-sensitive moxibustion compared to conventional moxibustion and may provide evidence for this therapy as a treatment for moderate and severe lumbar disc herniation. Moreover, the result may uncover the inherent laws to improve the therapeutic effect with suspended moxibustion.