Full Endoscopic Technique for High-Grade Up-Migrated Lumbar Disk Herniation via a Translaminar Keyhole Approach: Preliminary Series and Technical Note

Full Endoscopic Translaminar Keyhole Diskectomy for Highly Upmigrated Lumbar Disk Herniation: A Case Report

CASE

A 49-year-old man underwent full endoscopic translaminar keyhole diskectomy for highly upmigrated disk herniation at L5-S1. This scope-in-scope technique involved creation of a targeted fenestration in the lamina using a large working cannula (13.7 mm) and endoscope (10 mm). This was followed by advancement of a smaller working cannula (7.5 mm) and endoscope (6.3 mm) into the fenestration to remove the upmigrated disk fragment. Surgery resulted in excellent outcomes.

CONCLUSION

This can be a safe and effective surgical option for highly upmigrated disk herniation. It limits the amount of bone removal by directly targeting the herniated fragment and reduces the chances of neural injury.

A Novel Classification of Migrated Lumbar Disk Herniation Based on Magnetic Resonance Imaging and Algorithm Recommendations for Full-Endoscopic Discectomy

STUDY DESIGN

Retrospective clinical study.

OBJECTIVE

The purpose of this study was to establish a novel classification of migrated lumbar disk herniation (LDH) based on magnetic resonance imaging and provide appropriate treatment strategies for each type through algorithms.

SUMMARY OF BACKGROUND DATA

Full-endoscopic lumbar discectomy is a surgical technique that has been developed rapidly in recent years. For migrated LDH, few surgeons currently classify it with multiplanar positioning, and there is no consensus on the choice of treatment strategy. Therefore, we established a new multiplanar classification criteria that can localize the lesions more accurately than previous studies.

METHODS

A total of 263 eligible patients from March 2017 to March 2022 were included. Protrusions for each patient were located based on our classification and the surgical approach was selected according to our algorithms. The clinical symptoms of all patients before surgery, and at 1 day, 1 month, 3 months, 6 months, and 12 months after surgery were collected. Evaluations were performed using visual analogue scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria. We used the chi-squared test, one-way analysis of variance (ANOVA), and t-test to compare perioperative results and postoperative 3-month, 6-month, and 12-month follow-up results.

RESULTS

VAS (low back pain) scores were reduced from 5.33 ± 2.67 to 0.73 ± 0.77 (p < 0.001), and VAS (leg pain) scores were reduced from 7.44 ± 2.21 to 0.37 ± 0.51 (p < 0.001). ODI scores improved from 58.46 ± 8.04 to 12.57 ± 2.51 (p < 0.001). According to the modified MacNab criteria, the excellent and good rate reached 92.78% at the 12-month follow-up. Twenty-six patients developed complications, all of which improved after treatment. Recurrence occurred in 13 patients, and four of them underwent secondary surgery.

CONCLUSIONS

This is an innovative classification method using multi-plane positioning, and the algorithm used with it can help surgeons make appropriate choices when using endoscopic technology to treat migrated LDH. Statistical analysis of follow-up data confirmed that this is a safe and effective strategy.

Unilateral biportal endoscopic discectomy via translaminar approach for highly upward-migrated lumbar disc herniation: a technical note and preliminary treatment outcomes

STUDY DESIGN

A technical note and retrospective case series.

OBJECTIVE

Highly upward-migrated lumbar disc herniation (LDH) is challenging due to its problematic access and incomplete removal. The most used interlaminar approach may cause extensive bony destruction. We developed a novel translaminar approach using the unilateral portal endoscopic (UBE) technique, emphasizing effective neural decompression, and preserving the facet joint's integrity.

METHODS

This retrospective study included six patients receiving UBE translaminar discectomy for highly upward-migrated LDHs from May 2019 to June 2021. The migrated disc was removed through a small keyhole on the lamina of the cranial vertebra. The treatment results were evaluated by operation time, hospital stays, complications, visual analog scale (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) score, and modified MacNab criteria.

RESULTS

The mean pre-operative VAS for back pain (5.0 ± 4.9), VAS for leg pain (9.2 ± 1.0), JOA score (10.7 ± 6.6), and ODI (75.7 ± 25.3) were significantly improved to 0.3 ± 0.5, 1.2 ± 1.5, 27.3 ± 1.8, 5.0 ± 11.3 respectively at the final follow-up. Five patients had excellent, and one patient had good outcomes according to the Modified MacNab criteria. The hospital stay was 2.7 ± 0.5 days. No complication was recorded. The MRI follow-up showed complete disc removal, except for one patient with an asymptomatic residual disc.

CONCLUSIONS

UBE translaminar discectomy is a safe and effective minimally invasive procedure for highly upward-migrated LDH with satisfactory treatment outcomes and nearly 100% facet joint preservation.

Comparison of Full Endoscopic Lumbar Diskectomy Using the Transforaminal Approach versus Interlaminar Approach for L5-S1 Lumbar Disk Herniation Treatment: A Meta-Analysis

BACKGROUND

 Numerous studies have examined the clinical effectiveness of transforaminal full endoscopic lumbar diskectomy (T-FELD) and interlaminar full endoscopic lumbar diskectomy (I-FELD) for L5-S1 lumbar disk herniation (LDH), with mixed findings. The goal of this systematic review and meta-analysis was to evaluate the perioperative outcomes, clinical results, and complications of T-FELD and I-FELD to determine their efficacy and safety for treating L5-S1 LDH and to examine the features of complications in depth.

METHODS

 Several databases were searched for articles that matched all of the inclusion criteria. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to assess the clinical results. Information on perioperative outcomes and complications was gathered and analyzed.

RESULTS

 Eight studies with 756 participants were included. There were no significant differences in postoperative bed time (p = 0.44) and hospitalization time (p = 0.49) between T-FELD and I-FELD. When compared with I-FELD, T-FELD was associated with substantially longer fluoroscopy time (p < 0.0001) and operating time (p < 0.0001). There were no significant differences in the preoperative and postoperative VAS and ODI scores between T-FELD and I-FELD. The rates for overall complications, postoperative dysesthesia, postoperative lower extremity pain, incomplete decompression, recurrence, and conversion to open surgery were comparable for T-FLED and I-FELD.

CONCLUSION

 T-FELD and I-FELD had equal clinical results and safety for treatment of L5-S1 LDH. Fluoroscopy and operative times were shorter for I-FELD than for T-FELD.

Translaminar Full Endoscopic Technique with Tom Shidi Needles for Highly- and Dorsally-Migrated Lumbar Disc Herniations

BACKGROUND

Thirty years have passed since Kambin's first clinical series of lumbar disc herniations (LDH) treated by arthroscopic microdiscectomy. Despite several advances in this interim, sequestrated LDHs over the dorsal aspect of the dura, and high-grade up- or downward disc migration have been a relative limitation of the transforaminal endoscopic technique. The interlaminar window was the next step to deal with such highly migrated LDHs. Favorable outcomes were obtained in 70-90% of the patients in the long-term, but recurrence rates remained high (approximately 12%), and the approach could be limited by the size of the interlaminar window. Few relevant studies have addressed the role of translaminar full endoscopic technique for migrated LDHs. To describe an innovative modification of the translaminar full endoscopic approach with Tom Shidi needles.

METHODS

This technical modification is presented in a detailed fashion for treating these challenging LDHs and illustrated through a clinical case.

RESULTS

The patient underwent successful translaminar full endoscopic technique with complete pain resolution postoperatively. The postprocedural course was uneventful. A follow-up imaging showed no evidence of residual LDHs fragments.

CONCLUSIONS

Translaminar full endoscopic technique with Tom Shidi needles is a promising modification of the previously presented interlaminar and translaminar endoscopic routes in the treatment of migrated LDHs to fasten surgical procedures and increase the safety of spinal canal manipulation.

Full-Endoscopic Lumbar Discectomy Approach Selection: A Systematic Review and Proposed Algorithm

STUDY DESIGN

A systematic review of the literature to develop an algorithm formulated by key opinion leaders.

OBJECTIVE

This study aimed to analyze currently available data and propose a decision-making algorithm for full-endoscopic lumbar discectomy for treating lumbar disc herniation (LDH) to help surgeons choose the most appropriate approach [transforaminal endoscopic lumbar discectomy (TELD) or interlaminar endoscopic lumbar discectomy (IELD)] for patients.

SUMMARY OF BACKGROUND DATA

Full-endoscopic discectomy has gained popularity in recent decades. To our knowledge, an algorithm for choosing the proper surgical approach has never been proposed.

MATERIALS AND METHODS

A systematic review of the literature using PubMed and MeSH terms was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient samples included patients with LDH treated with full-endoscopic discectomy. The inclusion criteria were interventional research (randomized and nonrandomized trials) and observation research (cohort, case-control, case series). Exclusion criteria were case series and technical reports. The criteria used for selecting patients were grouped and analyzed. Then, an algorithm was generated based on these findings with support and reconfirmation from key expert opinions. Data on overall complications were collected. Outcome measures included zone of herniation, level of herniation, and approach (TELD or IELD).

RESULTS

In total, 474 articles met the initial screening criteria. The detailed analysis identified the 80 best-matching articles; after applying the inclusion and exclusion criteria, 53 articles remained for this review.

CONCLUSIONS

The proposed algorithm suggests a TELD for LDH located in the foraminal or extraforaminal zones at upper and lower levels and for central and subarticular discs at the upper levels considering the anatomic foraminal features and the craniocaudal pathology location. An IELD is preferred for LDH in the central or subarticular zones at L4/L5 and L5/S1, especially if a high iliac crest or high-grade migration is found.

Independent reliability and availability analyses of modified classification for migrated lumbar disc herniation

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to evaluate the reliability of modified classification system of migrated nucleus pulposus and its clinical application value.

METHODS

We retrieved 1000 lumbar MRI of different patients in Hangzhou Hospital of Traditional Chinese Medicine from January 2016 to December 2019 for interpretation, and screened 105 migrated lumbar MRI for inclusion in the study. Three spinal surgeons made classification according to the modified classification method. Two weeks later, the sorting data of the patients were shuffled and the classification was judged by three doctors again. The consistency and repeatability of the improved classification were evaluated by Kappa coefficient. The general data of the included patients were collected. The patients were followed up for 2 years, and the risk factors of surgical treatment of patients with migrated lumbar disc herniation were analyzed. The treatment plan, surgical approach, operation time, VAS score, ODI score and other relevant data of the included patients were collected to evaluate the guiding effect of the classification system on clinical practice.

RESULTS

In this study, the incidence of migrated lumbar disc herniation was about 10.5%, and most of the patients were male. Patients with higher BMI are more likely to develop this disease. Our study confirmed that the modified classification has moderate to high confidence. During the 2-year follow-up period, 66 patients (62.9%) were treated conservatively, and the patients with conservative treatment were mainly A2 and B2 type (59.1%). Thirty-nine patients (37.1%) underwent surgical treatment. The patients recovered well after operation, and the low back pain and ODI index were significantly improved at 1 year after operation (P < 0.05). We suggest that type A1 and B1 migrated nucleus pulposus can be removed by posterior approach. For type A2, B2, C1, C2, the lateral approach is recommended to remove the nucleus pulposus directly. Logistic regression and ROC analysis showed that disease duration (≥ 1 year) and BMI (≥ 24) maybe were risk factors for surgical treatment of patients with migrated lumbar disc herniation.

CONCLUSION

The modified classification has good reliability. In the current study, the experience level of spine surgeons does not affect the reliability of the classification system. Our study confirmed that this classification has a good reference value for guiding the treatment plan and the choice of surgical approach.

Postoperative Pain Management after Full Endoscopic Lumbar Discectomy: An Observational Study

Background: Surgical incision pain, rebound pain, and recurrence can manifest themselves in different forms of postoperative pain after full endoscopic lumbar discectomy (FELD). This study aims to evaluate various postoperative pains after FELD and summarize their characteristics. Methods: Data about the demographic characteristics of patients, pain intensity, and functional assessment results were collected from January 2016 to September 2019. Clinical outcomes including Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, were obtained. Results: A total of 206 patients were enrolled. ODI and VAS of the patients significantly decreased after FELD at 12-month follow-up. A total of 193 (93.7%) patients had mild surgical incision pain after FELD and generally a VAS < 4, and it mostly resolved on its own within 3 days. A total of 12 (5.8%) patients experienced rebound pain, which was typically characterized by pain (mainly leg pain with or without back pain), generally occurring within 2 weeks after FELD and lasting < 3 weeks. The pain levels of rebound pain were equal to or less than those of preoperative pain, and generally scored a VAS of < 6. The recurrence rate was 4.4%. Recurrence often occurs within three months after surgery, with the pain level of the recurrence being greater than or equal to the preoperative pain. Conclusions: Different types of postoperative pain have their own unique characteristics and durations, and treatment options are also distinct. Conservative treatment and analgesia may be indicated for rebound pain and surgical incision pain, but recurrence usually requires surgical treatment.

Unilateral BIPORTAL endoscopic translaminar approach to treat up-migrated lumbar disc herniation: 12 cases report

OBJECTIVE

There are difficulties on removing migrated disc herniation (MDH) using a microscope. The purpose of this study was to introduce a unilateral biportal endoscopic (UBE) translaminar approach to treat up-migrated lumbar disc herniation (LDH).

PATIENTS AND METHODS

A total of 12 patients from March 2021 to February 2022 with up-migrated LDH were treated with a UBE translaminar approach. Clinical outcomes such as a visual analog scale (VAS) (back and leg pain) and MacNab criteria were assessed preoperative, postoperative, and 1 month after surgery.

RESULTS

Seven patients were diagnosed with high-grade up-migrated LDH, while five patients presented very-high grade up-migrated LDH. In all cases, the migrated LDH were removed completely and were confirmed by postoperative magnetic resonance imaging. The VAS for back pain were improved from 4.5 (SD = 3.1) to 2.0 (SD = 1.0) and 1.0 (SD = 1.0) for immediately postoperative and in 1-month follow-up, respectively, showing a statistically significant difference (p < 0.001). VAS for leg pain was 6.5 (SD = 2.5) preoperatively to 2.3 (SD = 1.1) and 0.8 (SD = 0.4) immediately postoperative and 1-month follow-up, respectively, also showing a significant difference (p < 0.001). According to the MacNab criteria, we observed excellent outcomes in 66.6% and good outcomes in 33.3%.

CONCLUSION

The UBE translaminar approach showed a high success rate with high patient satisfaction for the management of up-migrated LDH. It could be considered a feasible alternative surgical option to treat up-migrated LDH.

Current Status and research hotspots in the field of full endoscopic spine surgery: A bibliometric analysis

Purpose

We aimed to comprehensively analyze the current status, hotspots, and trends in full endoscopic spine surgery (FESS) research using bibliometric analysis and knowledge domain mapping.

Methods

The Web of Science database was used to screen FESS-related articles published between January 1, 1993 and June 10, 2022. The evaluation involved the following criteria: total number of articles; H-index; and contributions from countries/regions, institutions, journals, and authors.

Results

A total of 1,064 articles were included. Since 2016, there have been a significant number of publications in the field of FESS. The country/region contributing the largest number of articles was China (37.8%), followed by South Korea (24%), the United States (16.1%), Japan (5.7%), and Germany (5.1%). South Korea (35) had the highest H-index, followed by the United States (27), China (22), Japan (21), and Germany (20). World Neurosurgery (15.7%) published the largest number of FESS-related articles. However, among the top 10 most cited articles, six were published in Spine. The author who contributed the most was S.H. Lee (5.4%), and the largest number of contributions in this field originated from Wooridul Spine Hospital (South Korea; 6.1%). Notably, six of the 10 most published authors in this field were from South Korea. Of the top five productive institutions, three were from South Korea. The keywords with the strongest citation bursts in the field of FESS were “lumbar spine,” “discectomy,” “interlaminar,” “surgical technique,” “follow-up,” “excision,” “thoracic spine,” and “endoscopic surgery.” The 10 clusters generated in this study were: “endoscopic discectomy” (#0), “thoracic myelopathy” (#1), “recurrent lumbar disc herniation” (#2), “low back pain” (#3), “cervical vertebrae” (#4), “lumbar spinal stenosis” (#5), “transforaminal lumbar interbody fusion” (#6), “radiation exposure” (#7), “management” (#8), and “lumbar spine” (#9).

Conclusion

Global research on FESS is mostly concentrated in a few countries/regions and authors. South Korea has made the largest contribution to the field of FESS. Based on the most cited keyword bursts and clusters, the focus of FESS research was found to include its indications, management, and applications.

Full-endoscopic foraminoplasty for highly down-migrated lumbar disc herniation

BACKGROUND AND STUDY AIMS

Multiple surgical approaches have been studied and accepted for the removal of highly downward migrated lumbar disc herniation (LDH). Here, we investigated the efficacy and safety of full-endoscopic foraminoplasty for highly downward migrated LDH.

PATIENTS AND METHODS

Thirty-seven patients with highly down-migrated LDH treated by the full-endoscopic foraminoplasty between January 2018 and January 2020 were retrospectively investigated. Clinical parameters were evaluated preoperatively and 1, 6, and 12 months postoperatively, using pre- and post-operative Oswestry Disability Index (ODI) scores for functional improvement, visual analog scale (VAS) for leg and back pain, and modified MacNab criteria for patients satisfactory.

RESULTS

Thirty-seven patients with highly downward migrated LDH were successfully removed via the transforaminal full-endoscopic discectomy. The average VAS back and leg pain scores were significantly reduced from 7.41 ± 1.17 and 8.68 ± 1.06 before operation to 3.14 ± 0.89 and 2.70 ± 0.46 at postoperative 1 month, and 1.76 ± 0.59 and 0.92 ± 0.28 at postoperative 12 months, respectively (P < 0.05). The average ODI scores were reduced from 92.86 ± 6.41 to 15.30 ± 4.43 at postoperative 1 month, and 9.81 ± 3.24 at postoperative 12 months (P < 0.05). Based on the modifed MacNab criteria, 36 out of 37 patients (97.30%) were rated as excellent or good outcomes.

CONCLUSION

The full-endoscopic foraminoplasty can be used successfully for surgical removal of high grade down-migrated LDH, and it could serve as an efficient alternative technique for patients with highly downward migrated LDH.

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.

The Evolution of Transforaminal Endoscopic Spine Surgery

Transforaminal endoscopic spine surgery (T-ESS) has become a well-accepted technique. The first attempts at percutaneous discectomy by Kambin and Hijikata opened a new chapter of endoscopic spine surgery. By the last quarter of the twentieth century, spine surgeons had begun to adopt this novel technique. Many researchers helped advance endoscopic spine surgery, but the turning point was the description of a safe transforaminal triangle of safety by Parviz Kambin. Since then, the indications for T-ESS have increased as a result of the description of different surgical approaches such as inside-out, outside-in, and half-and-half. We present a review of crucial historical advancements in T-ESS and also discuss the evolution of endoscopes, the techniques used, development of endoscopic instruments and equipment, transforaminal thoracic endoscopy, transforaminal endoscopic interbody fusions, the growth of extended indications, and the future direction of T-ESS. This review provides a detailed description of key historical moments and a bird's-eye view of the vast scope of T-ESS.

Modified Interlaminar Endoscopic Lumbar Discectomy for Highly Upmigrated Disc Herniation: A Proctorship Description of the Technique via Translaminar Route

Lumbar disc herniation (LDH) comprises one of the most common causes of low back pain. 35%–72% of LDH is associated with disc fragment migration. The migration of the disc fragments can be high-grade up, low-grade up, high-grade down, and low-grade down. Spine surgeons deal with unique challenges during surgical management of migrated discs. Operational challenges with open surgery include extensive lamina excision, pars excision, and potential for iatrogenic instability without fixation. In contrast, rigid instruments and poor visualization are the challenges with transforaminal endoscopic spine surgery (ESS). Hence interlaminar approach with ESS is an excellent choice with these migrated LDH. The creation of a translaminar crater in the cranial lamina without dealing with the interlaminar window or ligamentum flavum could be an excellent option to deal with these herniations face front. The lamina is the only anatomical barrier between the endoscope and the migrated disc fragment. Hence with a translaminar approach, unnecessary flavectomy can be avoided. In this technical report and video, we demonstrate the surgical technique of performing the translaminar ESS for highly upmigrated LDH with the preservation of optimal natural anatomy.