Foraminoplasty at the Base of the Superior Articular Process with Bone Drilling for Far-Downward Discs in Percutaneous Endoscopic Lumbar Discectomy: A Retrospective Study

Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis

BACKGROUND

The surgical resection of very highly migrated lumbar disc herniation (VHM-LDH) is technically challenging owing to the absence of technical guidelines. Hence, in the present study, we introduced the transforaminal endoscopic lumbar discectomy (TELD) with two-segment foraminoplasty to manage VHM-LDH and evaluated its radiographic and midterm clinical outcomes.

MATERIALS AND METHODS

The present study is a retrospective analysis of 33 consecutive patients with VHM-LDH who underwent TELD with two-segment foraminoplasty. The foraminoplasty was performed on two adjacent vertebrae on the basis of the migration direction of disc fragments to fully expose the disc fragments and completely decompress the impinged nerve root. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. Additionally, imageological observations were evaluated immediately after the procedure via magnetic resonance image and computerized tomography. Clinical outcomes were evaluated by calculating the visual analog scale (VAS) score and Oswestry Disability Index (ODI). The MacNab criterion was reviewed to assess the patients' opinions on treatment satisfaction. The resection rate of bony structures were quantitatively evaluated on postoperative image. The segmental stability was radiologically evaluated at least a year after the surgery. Additionally, surgery-related and postoperative complications were evaluated.

RESULTS

The average age of the patients was 56.87 ± 7.77 years, with a mean follow-up of 20.95 ± 2.09 months. The pain was relieved in all patients immediately after the surgery. The VAS score and ODI decreased significantly at each postoperative follow-up compared with those observed before the surgery (P < 0.05). The mean operation duration, blood loss, and hospital stay were 56.17 ± 16.21 min, 10.57 ± 6.92 mL, and 3.12 ± 1.23 days, respectively. No residual disc fragments, iatrogenic pedicle fractures, and segmental instability were observed in the postoperative images. For both up- and down- migrated herniation in the upper lumbar region, the upper limit value of resection percentage for the cranial SAP, caudal SAP, and pedicle was 33%, 30%, and 34%, respectively; while those in the lower lumbar region was 42%, 36%, and 46%, respectively. At the last follow-up, the satisfaction rate of the patients regarding the surgery was 97%. Surgery-related complications including dural tear, nerve root injury, epidural hematoma, iatrogenic pedicle fractures, and segmental instability were not observed. One patient (3%) suffered from the recurrence of LDH 10 months after the initial surgery and underwent revision surgery.

CONCLUSIONS

The TELD with two-segment foraminoplasty is safe and effective for VHM-LDH management. Proper patient selection and efficient endoscopic skills are required for applying this technique to obtain satisfactory outcomes.

Comparison of bone reamer and trephine for foraminoplasty in percutaneous endoscopic lumbar discectomy based on 3D slicer and Digimizer software

OBJECTIVE

To explore the applicability of bone reamer and trephine for foraminoscopy in percutaneous endoscopic lumbar discectomy (PELD), and to provide a theoretical basis for foraminoplasty options in clinical practice.

METHODS

This study was a prospective cohort study. Sixty-three consecutive patients who underwent PELD for lumbar disc herniation between May 2021 and July 2022 were analysed. Foraminoplasty were performed by bone reamer or trephine. The amount of bone removed and the foramen area enlarged during foraminoplasty by both tools were measured by 3D slicer and Digimizer software, and the numbers of fluoroscopic views were recorded.

RESULTS

The bone reamer removed less bone in the Superior Articular Process (SAP) than the trephine (t = 17.507, P < 0.001), and the area enlarged by the bone reamer was smaller than that of the trephine (t = 10.042, P = 0.002). The overall numbers of fluoroscopic views were significantly more in the bone reamer group than in the trephine group (t = 19.003, P < 0.001). In the bone reamer group, when the area of preoperative (FPZ) was no less than 54.55 mm2, the mean number of fluoroscopic views significantly decreased (t = 14.443, P = 0.001).

CONCLUSION

Bone reamer was safer and trephine was more efficient for foraminoscopy in PELD. An area of preoperative (FPZ) of 54.55 mm2 can be used as a critical value: bone reamer reduced the risk for cases above the value, while trephine improved the efficiency for cases less than the value.

One-hole split endoscope technique for migrated lumbar disc herniation: a single-centre, retrospective study of a novel technique

BACKGROUND

Lumbar disc herniation (LDH) is one of the most common diseases of the spine, and migrated LDH is a more serious type, associated with nerve root function injury or abnormality. Regarding the increasing surgery adoption of treating migrated LDH, we aimed to investigate the clinical efficacy and safety of discectomy with a novel technique-one-hole split endoscope (OSE) technique.

METHODS

This was a retrospective analysis of migrated LDH treated between December 2020 and September 2021. Hospitalization time, operative duration, intraoperative blood loss, number of fluoroscopy exposures, incision length, postoperative facet preservation rate, number of excellent-good cases, lower back and leg visual analogue score (VAS), Oswestry Disability Index (ODI) and surgical complications were compared between high-grade migration group (82 cases) and low-grade migration group (148 cases). The Macnab criteria was used to evaluate the clinical outcome. The Shapiro‒Wilk test was used to test measurement data, and the χ² test was used to test counting data.

RESULTS

There was no significant difference in hospitalization time, operative duration, intraoperative blood loss, number of fluoroscopy exposures, incision length or postoperative facet preservation rate between the two groups by independent sample t test or nonparametric test. At any time point, the lower back and leg VAS and ODI of the two groups were significantly improved compared to those before the operation, but there was no significant difference between the two groups at the same time point by two-way repeated measures ANOVA. There were two cases of postoperative nerve root stimulation symptoms in the high-grade migration group and three cases in the low-grade migration group. There was one patient reoperated in the high-grade migration group. There was no significant difference in number of excellent-good cases between the two groups. The overall excellent-good rate was 89.6%.

CONCLUSION

The OSE technique has the advantages of less trauma, faster recovery, complete removal of the nucleus pulposus and a satisfactory early clinical efficacy in the treatment of migrated LDH.

A Novel Trajectory for a Transpedicular Approach in the Treatment of a Highly Downward-Migrated Lumbar Herniation with a Full Endoscopic Technique

Background

To evaluate the clinical outcome of full endoscopic discectomy using a novel trajectory via a transpedicular approach.

Method

Thirty-five patients were enrolled in this retrospective study between July 2014 and October 2019 in the Beijing Haidian Hospital. All patients were treated with full-endoscopic lumbar discectomy via a transpedicular approach with an oblique trajectory. The imaging parameters, including pedicle height and angle of trajectory, were recorded. The preoperative and postoperative clinical data were collected for statistical analysis.

Results

All patients underwent successful surgery without severe complications. We compared the visual analogue scale and Oswestry disability index scores before and after surgery. The differences were statistically significant (p < 0.05). According to the modified Macnab criteria, the good-to-excellent rate was 85.7% at the last follow-up. The average angles of trajectory in the sagittal and coronal planes were 34.5° ± 2.9° and 47.1° ± 5.0°, respectively.

Conclusion

The new trajectory of the transpedicular approach with a full endoscopic technique for an extremely downward-migrated disc herniation showed excellent results in a small sample study. A precise surgical plan is required, comprising measurements of the pedicle height and angle of the bone tunnel.