Full-endoscopic lumbar discectomy via lateral superior articular process approach for treating far lateral lumbar disc herniation: a retrospective study and technical note

PURPOSE

This study aims to evaluate the efficacy and safety of the full-endoscopic lumbar discectomy (FELD) via lateral superior articular process (LSAP) approach and full-endoscopic transforaminal discectomy (FETD) for treating far lateral lumbar disk herniation (FFLDH).

METHODS

From January 2020 to June 2022, patients who were diagnosed as FLLDH underwent the FELD via LSAP approach or FETD. The operation time, estimated blood loss, length of hospital stays, and complications were recorded. The visual analog scale (VAS) for back pain, VAS for leg pain, and the Oswestry Disability Index (ODI) scores was measured during preoperative and postoperative follow-up.

RESULTS

Thirty-two patients were enrolled in this study, of which 12 patients were treated with the FELD via LSAP approach (LSAP-FELD group) and 20 patients underwent FETD (FETD group). The LSAP-FELD group exhibited significantly shorter operation times and hospital stays compared to the FETD group, while no statistically significant differences were observed in intraoperative blood loss and complication rates. There were no significant differences in the VAS for back pain, the VAS for leg pain, and the ODI score between the two groups preoperatively and three days, three months, and the last follow-up postoperatively.

CONCLUSIONS

Both the FELD via LSAP approach and FETD have demonstrated favourable clinical efficacy in the treatment of FLLDH. Notably, the FELD via LSAP approach shows the advantages of shorter operation time and hospital stays.

Development and Validation of a Nomogram to Predict the Risk of Recurrent Lower Extremity Radiating Pain Within 1 Week Following Full-Endoscopic Lumbar Discectomy

BACKGROUND

Accurately predicting the risk of lower extremity (LE) radiating pain after surgery is an important endeavor for spinal surgeons. Our study aimed to identify risk factors for LE radiating pain after decompression with full-endoscopic lumbar discectomy (FELD) and develop a nomogram.

METHODS

We retrospectively reviewed the medical data of patients with lumbar disc herniation who underwent FELD. Two hundred thirty-five patients diagnosed at our hospital from January 2015 to December 2020 were used for model development. The independent risk factors for LE radiating pain after surgery were determined by least absolute shrinkage and selection operator logistic regression and multivariate logistic regression analysis. A nomogram was developed to predict the risk of LE radiating pain based on independent risk factors. Receiver operating characteristic curve, calibration curve, and decision curve analyses were used to evaluate the predictive performance. The nomogram was further verified by an independent cohort.

RESULTS

Three hundred seventy-five patients were enrolled in this study, with 102 patients in the training cohort reporting LE radiating pain after FELD, while 133 patients did not. In the validation cohort, 57 patients reported LE radiating pain after FELD, while 83 patients did not. The model was established by multivariate logistic regression analysis. The risk factors included a higher Michigan State University classification of herniated discs, increased disease course, increased time of surgery, reduced lateral recess width, and an interlaminar surgical approach, compared to transforaminal approach. The C-indices and the area under the receiver operating characteristic curve of the predictive model demonstrated good discrimination. Good predictive performance and accuracy were also observed in the validation cohort.

CONCLUSIONS

A novel nomogram for predicting recurrent LE radiating pain within 1 week after FELD was established and validated. More aggressive pain management strategies should be considered for patients at high risk of LE radiating pain after surgery, as predicted by this model.

Full-Endoscopic Lumbar Discectomy for Recurrent Lumbar Disc Herniation: A Retrospective Study with Patient-Reported Outcome Measures

Introduction

Revision surgery for recurrent lumbar disc herniation after surgical treatment is at times challenging due to epidural adhesions and scar. This study aimed to review the clinical results and safety of full-endoscopic lumbar discectomy via interlaminar (FELD-IL) and transforaminal (FELD-TF) approaches for revision surgery.

Methods

We conducted a retrospective study including 52 lumbar disc herniation revision patients (mean age, 51.8 years; male/female, 13/39), with 17 FELD-IL and 35 FELD-TF cases. Complication incidences were assessed by reviewing surgical videos and postoperative magnetic resonance images of nerve decompression outcomes. Patients' responses to Japan Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and numerical rating scales (NRS) for lumbar pain, leg pain, and leg numbness were recorded before and during follow-up. The Wilcoxon-signed rank tests were utilized to compare pre- and postoperative group variables.

Results

The average operation time was 33.0 min in FELD-IL and 31.7 min in FELD-TF. Seven FELD-IL cases required lamina excavation with high-speed drill bars for scar tissue dissection from the lamina. Dura injury occurred during the excavation in one case. No complication was noted in the FELD-TF group. Successful decompression of the nerve was achieved in all cases. Complete sets of JOABPEQ and NRS were obtained in 64.5% of FELD-IL and in 82.9% of FELD-TF. The mean follow-up period was 18.6 months. All the subdomain of JOABPEQ and NRS improved significantly postoperative in both groups. There was no difference regarding the improvement of scores between the procedures except NRS for lumbar pain, which was more favorable in FELD-IL. Recurrence of herniation occurred in one patient (6%) after FELD-IL and two patients (6%) after FELD-TF.

Conclusions

Both FELD-IL and FELD-TF are safe and effective revision procedures for recurrent lumbar disc herniation. FELD-TF could be performed employing the same procedure as primary surgery in revisions, regardless of the previous surgical approach.

Evaluation of full-endoscopic lumbar discectomy in the treatment of obese adolescents with lumbar disc herniation: a retrospective study

Background

Obese patients are at risk of complications after spinal surgery. Full-endoscopic lumbar discectomy (FELD) has advantages over conventional open surgery in the treatment of obese adult patients with lumbar disc herniation (LDH) because it can decrease perioperative complications and enhance the degree of patient satisfaction. However, no clinical studies have evaluated the efficacy of FELD in obese adolescents with LDH (ALDH). This study aimed to evaluate the efficacy of FELD for the treatment of obese ALDH.

Methods

We retrospectively collected clinical data from 208 patients with single-segment ALDH who underwent FELD in our hospital between January 2015 and December 2019. According to the WHO classification of obesity, the patients were divided into obese (BMI ≥30 kg/m²) and non-obese (BMI < 30 kg/m²) groups (control group). Based on the preoperative baseline data of the two groups, propensity score matching was performed to select patients from these groups for a comparative study. Perioperative data included operative time, intraoperative blood loss, and length of postoperative hospitalization. The visual analog scale (VAS), Oswestry disability index (ODI), and modified MacNab criteria were recorded as the main indicators of the surgical outcome. Recurrence rate and incidence of complications were recorded as minor indicators.

Results

Twenty-eight patients and 80 patients were included in the obese and non-obese groups, respectively, after 1:4 propensity score matching. Both groups showed improvements in VAS and ODI scores after surgery and at each follow-up time point (p < 0.05). However, there was no significant statistical difference in the surgical outcomes between the two groups at each follow-up time point (p > 0.05). The differences in operative time, intraoperative blood loss, and length of postoperative hospitalization were not statistically significant between the two groups (p > 0.05).

Conclusion

FELD is a safe and effective minimally invasive technique for treating obese patients with ALDH. The efficacy of FELD in obese and non-obese patients with ALDH was comparable.

Functional outcomes of full-endoscopic spine surgery for high-grade migrated lumbar disc herniation: a prospective registry-based cohort study with more than 5 years of follow-up

BACKGROUND

Full-endoscopic lumbar discectomy (FELD) is an alternative to posterior open surgery to treat a high-grade migrated herniated disc. However, because of the complexity of the surgery, success is dependent on the surgeon's skill. Therefore, patients are frequently treated using open discectomy. Anatomical constraints and technical difficulties can lead to the incomplete removal of high-grade migrated discs.

METHODS

We retrospectively reviewed patients who had undergone FELD performed by a single surgeon between January 2010 and January 2014 from a prospective spine registry in an institute. Perioperative records and data of the Oswestry Disability Index, visual analog scale scores (preoperatively and 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and 5 years after the operation), and MacNab criteria were collected.

RESULTS

Of 58 patients with a follow-up duration of > 5 years, (41 and 17 patients had undergone transforaminal endoscopic lumbar discectomy [TELD] and interlaminar endoscopic lumbar discectomy [IELD], respectively), the satisfaction rate was 87.8% (five unsatisfactory cases) for TELD and 100% for IELD. The overall percentage of patients with good to excellent results according to modified MacNab criteria was 91.3% (53/58 patients). Two patients had residual discs. Two patients needed an open discectomy due to recurrent disc herniation. One IELD patient received spinal fusion surgery due to segmental instability after 5 years.

CONCLUSION

FELD has a high success rate for the management of high-grade migrated herniated discs. In patients with high-grade disc migration from L1 to L5, TELD is effective and safe. However, for L4-L5 and L5-S1 high-grade upward and downward disc migration, IELD is the favorable option and provides high patient satisfaction.

Posterolateral Transforaminal Full-Endoscopic Lumbar Discectomy for Foraminal or Extraforaminal Lumbar Disc Herniations

BACKGROUND

Surgical procedures via the posterior median or paramedian approach for lateral lumbar disc herniation require significant bone resection to reach the herniation. In contrast, posterolateral transforaminal full-endoscopic lumbar discectomy (FELD) allows direct access to the lateral disc herniation. This study aimed to determine the efficacy and safety of this procedure.

METHODS

A total of 118 patients who underwent posterolateral transforaminal FELD were retrospectively examined. Data on surgical time, perioperative complications, and reoperation rate were reviewed from the medical records. Clinical evaluations were completed in 78 patients using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and numeric rating scale (NRS) for low back pain, lower limb pain, and lower limb numbness obtained at baseline and during a follow-up of more than 12 months.

RESULTS

The mean operative time was 33.9 min. Postoperative transient dysesthesia occurred in 11 of 118 patients (9.3%). No other complications were observed. Reoperation was performed in nine patients (5.9%). All domains of JOABPEQ and NRS significantly improved during the follow-up period. The effectiveness rates of the JOABPEQ for measuring low back pain, lumbar function, walking ability, social life function, and mental health were 70.4%, 46.5%, 62.0%, 59.2%, and 32.4%, respectively. Using the Macnab criteria, excellent or good results were achieved in 52 patients (73%).

CONCLUSIONS

Successful clinical results were obtained with a few complications and improvements in the domains of JOABPEQ and NRS. Posterolateral transforaminal FELD for lateral lumbar disc herniations is an effective and safe surgical option with minimal invasiveness and sufficient decompression.

Suprapedicular Retrocorporeal Technique of Transforaminal Full-Endoscopic Lumbar Discectomy for Highly Downward-Migrated Disc Herniation

OBJECTIVE

Anatomical barriers (e.g., pedicles, narrow foramina) can hinder direct access to, and removal of, disc fragments that have migrated far downward. Using transforaminal full-endoscopic lumbar discectomy (FELD), we devised a modified technique, the suprapedicular retrocorporeal approach, for herniations in which the disc has migrated to the axilla of the traversing nerve roots. In the present report, we have described our preliminary results.

METHODS

Soft, highly downward-migrated disc herniation was treated with transforaminal FELD through the suprapedicular retrocorporeal approach in 22 patients from June 2017 to May 2019. The clinical outcomes were evaluated, including the preoperative and postoperative visual analog scale scores for the back and leg, Oswestry disability index, and MacNab criteria for surgical success.

RESULTS

The affected discs were at L4-L5 in 14 patients, L3-L4 in 6 patients, and L5-S1 in 2 patients. In each case, the affected disc was successfully removed using the suprapedicular retrocorporeal approach. The mean follow-up was 18.1 ± 5.7 months. The mean visual analog scale scores for back and leg pain improved significantly (P < 0.05 for both). The mean Oswestry disability index had decreased from 62.5 ± 14.2 preoperatively to 10.5 ± 5.9 postoperatively (P < 0.05). Using the MacNab criteria, 13 patients reported excellent outcomes and 9, good outcomes. No complications or recurrence developed during follow-up.

CONCLUSIONS

The suprapedicular retrocorporeal technique is a feasible and effective surgical option in transforaminal FELD for the treatment of herniation in which the disc has migrated to the axilla of the traversing nerve roots.

The role of full-endoscopic lumbar discectomy in patients with neurodegenerative disorders: Technical note and short literature review

Background:

Motor neuron disease includes a spectrum of neurodegenerative diseases with progressive courses and unfavorable prognoses. Here, we described a patient with a lumbar disc herniation (LDH) and isolated bulbar palsy (IBP), who successfully underwent a transforaminal full-endoscopic discectomy (TFED) without incurring the added risks of general anesthesia.

Case Description:

A 58-year-old male with IBP had an LDH at the L4-L5 level. Avoiding general anesthesia, a TFED was successfully performed under local anesthesia with mild sedation. There were no perioperative complications, and the patient was discharged on the 1^st postoperative day. The patient experienced complete relief of radicular symptomatology 1 year postoperatively.

Conclusion:

Here, we present a rare instance of a patient with IBP who successfully underwent a TFED for an LDH performed under local anesthesia utilizing mild sedation, avoiding the risks of general anesthesia.

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.

The Role of Full-Endoscopic Lumbar Discectomy in Surgical Treatment of Recurrent Lumbar Disc Herniation: A Health-Related Quality of Life Approach

Objective

To investigate the utility of full-endoscopic lumbar discectomy (FELD) in surgical treatment of recurrent lumbar disc herniation (RLDH).

Methods

Forty-five patients were prospectively studied. All patients were subjected to FELD for RLDH. They were assessed preoperatively and in regular intervals at 6 weeks and 3 months, 6 months, and 12 months postoperatively. Evaluation was conducted with visual analogue scale for leg (VAS-LP) and low back (VAS-BP) pain. Short-Form 36 Health Survey Questionnaire was utilized for health-related quality of life assessment.

Results

All studied parameters featured statistically significant amelioration at all follow-up intervals. Maximal improvement was in general at 6 weeks observed, with subsequent lesser improvement until 6 months and stabilization until the end of follow-up. Comparative assessment indicated that VAS-BP displayed quantitatively lower improvement, whereas physical function, bodily pain, and role-emotional parameters demonstrated greater amelioration.

Conclusion

FELD is associated with a favorable impact in postoperative daily life of patients with RLDH.

Full-Endoscopic Lumbar Discectomy for Lumbar Disc Herniation with Posterior Ring Apophysis Fracture: A Retrospective Study

OBJECTIVE

The present retrospective study evaluated the clinical results of full-endoscopic lumbar discectomy (FELD) for the treatment of lumbar disc herniation (LDH) with lumbar posterior ring apophysis fracture (PRAF) using an interlaminar or a transforaminal approach at an inpatient surgery center.

METHODS

Patients with single-level LDH with type III PRAF who had undergone FELD using an interlaminar or a transforaminal approach from January 2010 to December 2015 were enrolled. The general data recorded included sex, age, location, surgical approach, operative time, hospital stay, perioperative complications, and recurrence. The presence of mobile and immobile fragments was documented. The clinical outcomes were evaluated using a visual analog scale for low back and leg pain. The Oswestry Disability Index was used for the functional assessment and the modified MacNab criteria for patient satisfaction.

RESULTS

FELD was performed successfully in all cases and no serious perioperative complications were observed. A mobile fragment of PRAS was present in 18 patients and an immobile fragment in 15 patients. Complications occurred in 2 of the 33 included patients; 1 dual tear (3.0%) and 1 transient dysesthesia (3.0%) that did not require further treatment. Recurrence developed in 1 patient (3.0%) and required reoperation. The visual analog scale and Oswestry Disability Index scores had significantly improved postoperatively at 3, 6, and 12 months and the final follow-up visit (P < 0.05). Using the modified MacNab criteria, an excellent or good rate of 93.4% was achieved.

CONCLUSIONS

FELD is a safe and effective minimally invasive approach for the treatment of LDH with type III PRAF. Sufficient preparation and experience are required to achieve satisfactory results.