Foraminoplastic transfacet epidural endoscopic approach for removal of intraforaminal disc herniation at the L5-S1 level

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.

Working Cannula-Based Endoscopic Foraminoplasty: A Technical Note

Purpose

Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive disc surgery that can be performed under local anesthesia and requires only an eight-mm skin incision. For the patients with lumbar foraminal stenosis, the migrated disc is difficult to remove with a simple transforaminal approach. In such cases, the foraminoplasty techniques can be used. However, obtaining efficient foramen enlargement while minimizing radiation exposure and protecting the nerves can be challenging.

Methods

In this study, we propose a new technique called the Kiss-Hug maneuver. Under endoscopic viewing, we used the bevel tip of a working cannula as a bone reamer to enlarge the foramen. This allowed us to efficiently enlarge the lumbar foramen endoscopically without the redundancy and complications associated with reamers or trephines.

Results

Details of the four steps of the Kiss-Hug maneuver are reported along with adverse events. The advantages of this new technique include minimizing radiation exposure to both the surgeon and the patient and decreasing the overall operation time.

Conclusion

The endoscopic Kiss-Hug maneuver is a useful and reliable foraminoplasty technique that can enhance the efficiency of foraminoplasty while ensuring patient safety and reducing radiation exposure.

Midline lumbar fusion using cortical bone trajectory screws. Preliminary report

INTRODUCTION

Midline lumbar fusion (MIDLF) using cortical bone trajectory is an alternative method of transpedicular spinal fusion for degenerative disease. The new entry points' location and screwdriving direction allow the approach-related morbidity to be reduced.

AIM

To present our preliminary experience with the MIDLF technique on the first 5 patients with lumbar degenerative disease and with follow-up of at least 6 months.

MATERIAL AND METHODS

Retrospective analysis was performed on the first 5 patients with foraminal (4) or central (1) stenosis operated on between December 2014 and February 2015. Three patients were fused at L4-L5 and two at the L5-S1 level.

RESULTS

No intra- or post-operative complications occurred with this approach. An improvement regarding the leading symptom in the early postoperative period (sciatica 4/4, claudication 1/1) was achieved in all patients. The mean improvements in the visual analogue scale for low back and leg pain were 2.2 and 4.8 respectively. The mean Oswestry Disability Index scores were 52% (range: 16-82%) before surgery and 33% (range: 12-56%) at 3-month follow-up (mean improvement 19%). At the most recent follow-up, 4 patients reported the maintenance of the satisfactory result. The early standing and follow-up X-rays showed satisfactory screw placement in all patients.

CONCLUSIONS

In our initial experience, the MIDLF technique seems to be an encouraging alternative to traditional transpedicular trajectory screws when short level lumbar fusion is needed. Nevertheless, longer observations on larger groups of patients are needed to reliably evaluate the safety of the method and the sustainability of the results.

Three-dimensional intraoperative imaging with O-arm to establish a working trajectory in percutaneous endoscopic lumbar discectomy

Introduction

Successful percutaneous endoscopic lumbar discectomy (PELD) requires an appropriate working trajectory. Due to the complexity of spinal anatomy, this is difficult to verify with conventional 2-dimensional fluoroscopy.

Aim

Here we assessed the feasibility and utility of the O-arm for establishing the working trajectory for PELD.

Material and methods

We retrospectively reviewed the records of 89 patients with lumbar disc herniation who underwent PELD using the O-arm. The working trajectory was evaluated with standard fluoroscopic images or 3-dimensional, volumetric computed tomography scan. Based on the detail provided by the multiplanar view, we confirmed the ideal working trajectory and adjusted the surgical approach accordingly.

Results

At the 12-month follow-up, based on MacNab's criteria, 85.9% of patients showed an excellent or good outcome. There were no major complications.

Conclusions

The O-arm provides detailed multiplanar intraoperative high-quality imaging for PELD, and enables the surgeon to ascertain the surgical anatomy, determine the optimal working trajectory, and improve the accuracy of surgery.