Percutaneous lumbar discectomy with a working endoscope and laser assistance

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.

The "inside out" transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: results and a review of the literature

Surgical management of back and leg pain is evolving and changing due to a better understanding of the patho-anatomy well correlated with its pathophysiology. Pain is better understood with in vivo visualization and probing of the pain generators using an endoscopic access rather than just relying on symptoms diagram and image correlation. This has resulted in a shared decision making involving patient and surgeon, focused on a broader spectrum of surgical as well as non-surgical treatments, and not just masking the pain generator. It has moved away from decisions based on diagnostic images alone, that, while noting the image alterations, cannot explain the pain experienced by each individual as images do not always show variations in nerve supply and patho-anatomy. The ability to isolate and visualize "pain" generators in the foramen and treating persistent pain by visualizing inflammation and compression of nerves, serves as the basis for transforaminal endoscopic (TFE) surgery. This has also resulted in better pre surgical planning with more specific and defined goals in mind. The "Inside out" philosophy of TFE surgery is safe and precise. It provides basic access to the disc and foramen to cover a large spectrum of painful pathologies.

Percutaneous endoscopic treatment of foraminal and extraforaminal disc herniation at the L5-S1 level

BACKGROUND

Microsurgery of foraminal and extraforaminal disc herniation at the L5-S1 level remains a challenge because of the limited access by a high iliac crest, the sacral ala, large transverse processes of L5 and hidden disc fragments lateral to the zygapophyseal joint. Our aim was to present the outcome of percutaneous endoscopic lumbar discectomy (PELD) of these lateral and far lateral disc herniations at the L5-S1 level using the newly described foraminal retreat technique in a group of patients with similar preoperative diagnostic studies.

METHODS

A total of 22 patients, 13 males and 9 females, with foraminal and extraforaminal lumbar disc herniation at the L5-S1 level were treated by applying the PELD between September 2004 and April 2010. The clinical findings and MRI were the main diagnostic methods. Preoperative evaluation was performed with clinical examinations, the Visual Analog Pain Scale (VAS) and Oswestry Low Back Disability Index (ODI).

FINDINGS

According to the Macnab criteria, overall excellent or good outcomes were obtained in 18 patients (81.8 %), fair outcomes in 3 patients (13.6 %) and a poor outcome in 1 patient (4.5 %) at the last follow-up. The mean ODI was 67.3 ± 19.4 preoperatively and 26.7 ± 23.4 postoperatively. Preoperative VAS was 88.6 ± 7.6 and 28.6 ± 22.8 at 2 days, 40.5 ± 22.8 at 3 weeks, 34.3 ± 25.1 at 6-months and 32 at the last follow-up. At follow-up, two patients (9.1 %) had recurrent disc herniations that were corrected with open surgery. At the time of surgery, 16 patients held jobs. Fifteen (15) patients (93.8 %) returned to their original jobs postoperatively; one patient could not return to his original job postoperatively because of a comorbidity.

CONCLUSIONS

Percutaneous endoscopic discectomy using the foraminal retreat technique is an effective treatment method for patients with foraminal and extraforaminal disc herniations at the L5-S1 level on appropriately selected patients.

The obturator guiding technique in percutaneous endoscopic lumbar discectomy

In conventional percutaneous disc surgery, introducing instruments into disc space starts by inserting a guide needle into the triangular working zone. However, landing the guide needle tip on the annular window is a challenging step in endoscopic discectomy. Surgeons tend to repeat the needling procedure to reach an optimal position on the annular target. Obturator guiding technique is a modification of standard endoscopic lumbar discectomy, in which, obturator is used to access triangular working zone instead of a guide needle. Obturator guiding technique provides more vivid feedback and easy manipulation. This technique decreases the steps of inserting instruments and takes safer route from the peritoneum.

Symptomatic post-discectomy pseudocyst after endoscopic lumbar discectomy

OBJECTIVE

The objectives of this study were to determine the frequency of symptomatic postdiscectomy pseudocyst (PP) after endoscopic discectomy and to compare the results of surgical and conservative management of them.

METHODS

Initial study participants were 1,503 cases (1,406 patients) receiving endoscopic lumbar discectomy by 23-member board of neurosurgeons from March 2003 to October 2008. All patients' postoperative magnetic resonance imaging (MRI) scans were evaluated. On the postoperative MRI, cystic lesion of T2W high and T1W low at discectomy site was regarded as PP. Reviews of medical records and radiological findings were done. The PP patients were divided into two groups, surgical and conservative management by treatment modality after PP detection. We compared the results of the two groups using the visual analogue scale (VAS) for low back pain (LBP), VAS for leg pain (LP) and the Oswestry disability index (ODI).

RESULTS

Among 1,503 cases of all male soldiers, the MRIs showed that pseudocysts formed in 15 patients, about 1.0% of the initial cases. The mean postoperative interval from surgery to PP detection was 53.7 days. Interlaminar approach was correlated with PP formation compared with transforaminal approach (p=0.001). The mean VAS for LBP and LP in the surgical group improved from 6.5 and 4.8 to 2.0 and 2.3, respectively. The mean VAS for LBP and LP in the conservative group improved from 4.4 and 4.4 to 3.9 and 2.3, respectively. There was no difference in treatment outcome between surgical and conservative management of symptomatic PP.

CONCLUSION

Although this study was done in limited environment, symptomatic PP was detected at two months' postoperative period in about 1% of cases. Interlaminar approach seems to be more related with PP compared with transforaminal approach.

Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature

The study design includes a systematic literature review. The objective of the study was to evaluate the effectiveness of transforaminal endoscopic surgery and to compare this with open microdiscectomy in patients with symptomatic lumbar disc herniations. Transforaminal endoscopic techniques for patients with symptomatic lumbar disc herniations have become increasingly popular. The literature has not yet been systematically reviewed. A comprehensive systematic literature search of the MEDLINE and EMBASE databases was performed up to May 2008. Two reviewers independently checked all retrieved titles and abstracts and relevant full text articles for inclusion criteria. Included articles were assessed for quality and outcomes were extracted by the two reviewers independently. One randomized controlled trial, 7 non-randomized controlled trials and 31 observational studies were identified. Studies were heterogeneous regarding patient selection, indications, operation techniques, follow-up period and outcome measures and the methodological quality of these studies was poor. The eight trials did not find any statistically significant differences in leg pain reduction between the transforaminal endoscopic surgery group (89%) and the open microdiscectomy group (87%); overall improvement (84 vs. 78%), re-operation rate (6.8 vs. 4.7%) and complication rate (1.5 vs. 1%), respectively. In conclusion, current evidence on the effectiveness of transforaminal endoscopic surgery is poor and does not provide valid information to either support or refute using this type of surgery in patients with symptomatic lumbar disc herniations. High-quality randomized controlled trials with sufficiently large sample sizes are direly needed to evaluate if transforaminal endoscopic surgery is more effective than open microdiscectomy.