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