Early Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for L4-5 Highly Down-Migrated Disc Herniation: Interlaminar Approach Versus Transforaminal Approach

doi:10.1016/j.wneu.2020.10.105

World Neurosurgery

Volume 146, February 2021, Pages e413-e418

https://doi.org/10.1016/j.wneu.2020.10.105 Get rights and content

Objective

This study is a retrospective evaluation of patients with L4-5 highly down-migrated lumbar disc herniation (LDH) operated with interlaminar endoscopic lumbar discectomy (IELD) versus transforaminal endoscopic lumbar discectomy (TELD).

Methods

From January 2015 to December 2018, 77 patients with L4-5 highly down-migrated LDH were divided into 2 groups according to different surgical approaches. There were 40 patients who underwent IELD, and 37 patients who underwent TELD. The operation time, hospital stay, Oswestry Disability Index, clinical outcome according with modified MacNab criteria, Visual Analog Scale (VAS) scores, and complications were compared between the IELD and TELD groups.

Results

Seventy-seven patients were included, 40 and 37 patients underwent IELD and TELD, respectively. The IELD and TELD groups both achieved a significant improvement in Oswestry Disability Index, back and leg VAS scores, and clinical outcome postoperation. Mean operating and x-ray times during operation were significantly shorter in the IELD group than in the TELD group (41.8 vs. 50.3, 1.8 vs. 13.7). There were 3 patients who experienced recurrence in the IELD group and 2 in the TELD group. In the TELD group, there were 3 patients who required revision surgery due to incompletely removed disc fragment. All patients in the IELD group were treated successfully. There was no other complication in these cases.

Conclusions

Both IELD and TELD could be a good alternative option for highly down-migrated LDH in L4-L5. IELD may have advantages in operation time and x-ray times during operation compared with TELD.

Introduction

Since the introduction of the concept of indirect decompression of the spinal canal via a posterolateral approach using a Craig cannula for evacuation of a protruded disc by Kambin and Gellman¹ in 1983, the application of techniques of percutaneous endoscopic lumbar discectomy (PELD) has widened with the help of the development of instrumentations. Most concurrent PELD techniques are based on the Kambin transforaminal approach; now the transforaminal approach is indicated even for migrated lumbar disc herniation (LDH).² Two techniques reported by Seungcheol Lee were ‘‘half-and-half’’ technique for near-migrated discs and ‘‘epiduroscopic’’ technique used for far-migrated discs. The major difference between these two approaches is the extent to which the working sheath is introduced into the epidural space, i.e., partially or completely.²

Although transforaminal endoscopic lumbar discectomy (TELD) is a minimally invasive surgical technique for down-migrated LDH by an experienced hand, the distal end of the fragment may be difficult to approach, especially in highly down-migrated cases. Interlaminar endoscopic lumbar discectomy (IELD) has less risk of injury to the exiting root and may be applied comfortably even for less experienced surgeons owing to the anatomy for highly down-migrated LDH.³

IELD is useful when TELD is difficult to perform because of high iliac wing or migrated LDH, particularly at L5-S1.⁴^,⁵ There is no doubt that IELD has advantage in L5S1 migrated LDH with high iliac wing. However, there are relatively few reports of IELD for highly down-migrated LDH at L4-5. Which approach is better for down-migrated LDH at L4-L5 is still controversial; therefore this study aimed to evaluate clinical outcomes of IELD and TELD for highly down-migrated LDH at L4-5.

Section snippets

Methods

The medical records and radiologic images of patients with highly down-migrated LDH at L4-L5 who underwent TELD and IELD by the senior author between June 2014 and December 2017 were reviewed. The inclusion criteria were as follows: 1) unilateral radicular leg pain with or without sensory change; 2) intractable symptoms despite >6 weeks of conservative treatment; 3) symptoms corresponding with magnetic resonance imaging (MRI); and 4) L4-L5 highly down-migrated LDH without any other segment

General Information

Seventy-seven patients with L4-L5 highly down-migrated disc herniation were admitted into this study and divided into the IELD and TELD groups according to the surgical approach. Forty patients who underwent IELD and 37 patients who underwent TELD were ultimately included. There was no significant difference in sex, age, or duration of follow-up between the IELD and TELD groups. The sociodemographic and clinical details are shown in Table 1.

Clinical follow-ups were taken at the end of 1 month,

Discussion

Percutaneous endoscopic discectomy, which includes IELD and TELD, has been considered as a minimally invasive alternative to conventional open discectomy for LDH.⁸ Compared with IELD, TELD has its advantages for large central LDH and recurrent LDH.⁹ Development of instrumentation and surgical technique has widened the indications for TELD as a minimally invasive technique.⁶^,¹⁰ However, TELD is still technically demanding and results in less favorable outcome for migrated disc herniation and

Conclusions

Both TELD and IELD can be used in the treatment of L4-L5 highly down-migrated LDH safely and effectively. IELD was superior to TELD regarding removing the herniation completely, operation and fluoroscopy times. However, IELD had more postoperative skin paresthesia than TELD in our study. Considering the retrospective design of this study, small sample size, short-term follow-up period, a prospective, randomized study with a larger sample size and long-term follow-up should be undertaken to

CRediT authorship contribution statement

Kelun Huang: Conceptualization, Methodology, Data curation, Writing - original draft. Guoliang Chen: Data curation, Writing - original draft. Sheng Lu: Visualization, Investigation. Chaowei Lin: Investigation, Formal analysis. Shiyang Wu: Investigation, Formal analysis. Bi Chen: Writing - review & editing. Jinwei Ying: Validation. Minyu Zhu: Supervision. Honglin Teng: Supervision, Project administration.

References (16)

N.A. Ebraheim et al.
The location of the intervertebral lumbar disc on the posterior aspect of the spine
Surg Neurol
(1997)
J. Chen et al.
Percutaneous endoscopic lumbar discectomy for L5S1 lumbar disc herniation using a transforaminal approach versus an interlaminar approach: a systematic review and meta-analysis
World Neurosurg
(2018)
M.H. Daghighi et al.
Migration patterns of herniated disc fragments: a study on 1,020 patients with extruded lumbar disc herniation
Spine J
(2014)
Z.Z. Li et al.
The strategy and early clinical outcome of full-endoscopic L5/S1 discectomy through interlaminar approach
Clin Neurol Neurosurg
(2015)
P. Kambin et al.
Percutaneous lateral discectomy of the lumbar spine a preliminary report
Clin Orthop Relat Res
(1983)
S. Lee et al.
Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches
Eur Spine J
(2007)
C.H. Kim et al.
Surgical outcome of percutaneous endoscopic interlaminar lumbar discectomy for highly migrated disc herniation
J Spinal Disord Tech
(2012)
S. Ruetten et al.
Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study
Spine
(2008)

There are more references available in the full text version of this article.

Cited by (15)

Clinical Outcomes of Percutaneous Endoscopic Interlaminar Discectomy Using a Laminotomy Technique With Modified Stepwise Local Anesthesia
2023, World Neurosurgery
Percutaneous endoscopic interlaminar discectomy (PEID) has been widely used in minimally invasive treatment of lumbar disc herniation (LDH) but is difficult to perform because of the narrow interlaminar window and painful for the patient. Therefore, further research is needed to find a safe and effective method to facilitate the development of PEID.
Seventy-one consecutive patients with LDH who underwent PEID using a laminotomy technique with modified stepwise local anesthesia between July 2017 and June 2020. All patients were followed up for at least 6 months. Preoperative patient demographics, perioperative outcomes, and clinical outcomes were recorded. Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and Macnab criteria were used to assess clinical results.
All patients underwent successful surgery under local anesthesia with no conversions to open surgery. The mean operation time was 79.56 ± 32.78 minutes and the average hospital stay was 6.44 ± 2.98 nights. Before surgery, the mean VAS score was 5.66 ± 1.206 and the mean ODI score was 68.41 ± 6.634; the respective scores were decreased to 0.65 ± 0.635 and 7.06 ± 1.594 after 4 weeks of follow-up (P < 0.001) and to 0.56 ± 0.691 and 7.11 ± 0.176 after 6 months (P < 0.001). According to the MacNab criteria, the outcome was excellent in 60 cases and good in the remaining 11 cases.
PEID via a laminotomy technique with stepwise local anesthesia is safe and effective for L4-5 and L5-S1 LDH.
Early Postoperative Iatrogenic Neuropraxia After Lumbar Disc Herniation Surgery: Analysis of 87 Cases
2023, World Neurosurgery
Citation Excerpt :
These data have been accepted as far from supporting the existence of intraoperative iatrogenic neuropraxia. An iatrogenic neuropraxia is a common occurrence after LDH surgery.4-6 However, the rapid improvement of the clinical finding may cause it not to be considered as a diagnosis.
Postoperative early neuropraxia after lumbar disc herniation surgery is common. The emergence of new paresthesia findings with increased sensory and motor deficits in the postoperative period suggests iatrogenic neuropraxia. This study aimed to discuss the causes and prognosis of iatrogenic neuropraxia detected in the early postoperative period in patients who have been operated on for lumbar disc herniation.
Cases with postoperative iatrogenic neuropraxia were determined retrospectively. Deficits were evaluated at intervals of 0–2 hours, 2–12 hours, 12–24 hours, and 24–48 hours. The cases were evaluated in 2 groups as those who underwent aggressive discectomy and simple discectomy. In addition, the treatment results were compared between the 2 groups as the cases that were treated and not treated with methylprednisolone.
The iatrogenic neuropraxia rate was significantly higher in patients who underwent aggressive discectomy. Although it was observed that paresthesia findings improved more rapidly in cases treated with methylprednisolone, no difference was found between the 2 groups in terms of its effects on the motor deficit.
Iatrogenic neuropraxia is a finding whose cause cannot be determined by quantitative criteria. It is common in patients who underwent aggressive discectomy. Methylprednisolone treatment is effective in recovering the paresthesia finding faster and may show that the radicular injury is in the neuropraxia stage in the early period.
A Narrative Review of Full-Endoscopic Lumbar Discectomy Using Interlaminar Approach
2022, World Neurosurgery
Citation Excerpt :
Three RCTs,5,29,30 15 retrospective studies,10,16-19,22-28,31,32,34 and 5 prospective studies.7,20,21,33,35 Among these studies, 8 studies were completed in China,16-18,24-26,29,34 5 studies in Korea,10,19,21,31,35 4 studies in Germany,5,7,23,30 2 studies in Japan,27,28 2 studies in Taiwan,31,32 1 study in Slovakia,20 and 1 study in Turkey.22 Ten studies covered the herniation type.10,16-18,22,27,29,31,32,34
Lumbar disc herniation (LDH) is a frequently encountered pathologic condition in orthopedic daily practice. Discectomy is considered when patients with LDH experience persistent limb or lumbar pain or neurologic deficits. Various minimally invasive techniques are available for discectomy. Among these techniques, full-endoscopic lumbar discectomy (FED) is one of the least invasive options. During FED, removal of LDH is accomplished using 2 major approaches: transforaminal (TF) or interlaminar (IL). The prototype FED was percutaneous nucelotomy. An endoscope was integrated to percutaneous nucelotomy and TF endoscopic lumbar discectomy (TELD) was first derived. IL endoscopic lumbar discectomy (IELD) was introduced years after TELD. TELD and IELD can compensate for the shortcomings of each other and endoscopic spine surgeons need to acquire both techniques to deal with all type of LDHs. Because of its long history, the TF approach seems to represent the major approach for FED, but the IL approach has numerous benefits in particular types of LDH. The present article focuses on IELD and reviews the history, surgical techniques, indications and contraindications, clinical outcomes, and complications. This review will contribute to improved understanding of IELD as an important technique in full-endoscopic spine surgery.
Transforaminal endoscopic lumbar discectomy with targeted puncture and foraminotomy for very highly migrated disc herniation: A technique note with case series
2022, Heliyon
Citation Excerpt :
Some modified translaminar osseous channel-assisted IELD techniques were introduced for selected VHMDH patients and satisfactory outcomes were obtained [15]. However, all these techniques of IELD were performed under general anesthesia [15, 16, 17]. But a recent study stated that 87% (137 out of 157) of patients had preoperative anxiety about spinal surgery and general anesthesia [18].
Transforaminal endoscopic lumbar discectomy (TELD) has been widely used for lumbar disc herniation. However, in some challenging cases such as very highly migrated disc herniation (VHMDH), traditional TELD is difficult to access the pathology.
From January 2016 to December 2019, 63 patients with single-level VHMDH underwent TELD using targeted puncture and foraminotomy techniques were included. All patients were followed up for 26.5 months on average (range, 24–48 months). Operative time, length of hospital stay, visual analog scale (VAS) score, Oswestry Disability Index (ODI), modified MacNab criteria and surgical complications were evaluated.
The operative time was 40–120 min (56.8 on average). The length of hospitalization was 2.5 days (range, 2–4 d). VAS score decreased significantly from 5.5 ± 1.3 preoperatively to 1.9 ± 1.30 (p < 0.001) 1 day postoperatively, and to 0.9 ± 0.8 (p < 0.001) at the final follow-up. ODI score improved significantly from 23.5 ± 3.2 preoperatively to 13.4 ± 3.0 (p < 0.001) 1 day postoperatively; and 3.1 ± 1.2 (p < 0.001) at the final follow-up. According to the modified MacNab criteria, 40 patients (63.5%) showed excellent results, 20 patients (31.7%) were rated as good, 2 patients (3.2%) were rated as fine, and 1 patient (1.6%) was rated as bad at the final follow-up. No residual fragments, nerve root or cauda equina injury was shown in this series. One recurrent case was resolved by open surgery.
With modified targeted puncture and foraminotomy techniques, VHMDH can be accessed safely and effectively, and satisfactory clinical outcomes can be obtained for these patients.
Comparison of clinical outcomes between unilateral biportal endoscopic discectomy and percutaneous endoscopic interlaminar discectomy for migrated lumbar disc herniation at lower lumbar spine: a retrospective controlled study
2024, Journal of Orthopaedic Surgery and Research
Predicting and analysing of the unfavourable outcomes of early applicated percutaneous endoscopic interlaminar discectomy for lumbar disc herniation: development and validation based nomogram
2024, European Spine Journal

View all citing articles on Scopus

: Conflict of interest statement: This work was supported by Wenzhou Municipal Sci-Tech Bureau Program [Y20170258]. The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

View full text

Original ArticleEarly Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for L4-5 Highly Down-Migrated Disc Herniation: Interlaminar Approach Versus Transforaminal Approach

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Methods

General Information

Discussion

Conclusions

CRediT authorship contribution statement

Surg Neurol

World Neurosurg

Spine J

Clin Neurol Neurosurg

Percutaneous lateral discectomy of the lumbar spine a preliminary report

Clin Orthop Relat Res

Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches

Eur Spine J

Surgical outcome of percutaneous endoscopic interlaminar lumbar discectomy for highly migrated disc herniation

J Spinal Disord Tech

Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study

Spine

Original Article
Early Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for L4-5 Highly Down-Migrated Disc Herniation: Interlaminar Approach Versus Transforaminal Approach