Abstract

BackgroundFacetectomy, an important procedure in the in–out and out–in techniques of transforaminal endoscopic lumbar discectomy (TELD), is related to the deterioration of the postoperative biomechanical environment and poor prognosis. Facetectomy may be avoided in TELD with large annuloplasty, but iatrogenic injury of the annulus and a high grade of nucleotomy have been reported as risk factors influencing poor prognosis. These risk factors may be alleviated in TELD with limited foraminoplasty, and the grade of facetectomy in this surgery can be reduced by using an endoscopic dynamic drill.MethodsAn intact lumbo-sacral finite element (FE) model and the corresponding model with adjacent segment degeneration were constructed and validated to evaluate the risk of biomechanical deterioration and related postoperative complications of TELD with large annuloplasty and TELD with limited foraminoplasty. Changes in various biomechanical indicators were then computed to evaluate the risk of postoperative complications in the surgical segment.ResultsCompared with the intact FE models, the model of TELD with limited foraminoplasty demonstrated slight biomechanical deterioration, whereas the model of TELD with large annuloplasty revealed obvious biomechanical deterioration. Degenerative changes in adjacent segments magnified, rather than altered, the overall trends of biomechanical change.ConclusionsTELD with limited foraminoplasty presents potential biomechanical advantages over TELD with large annuloplasty. Iatrogenic injury of the annulus and a high grade of nucleotomy are risk factors for postoperative biomechanical deterioration and complications of the surgical segment.

Highlights

  • Facetectomy, an important procedure in the in–out and out–in techniques of transforaminal endoscopic lumbar discectomy (TELD), is related to the deterioration of the postoperative biomechanical environment and poor prognosis

  • Instability in the surgical segment caused by facetectomy is a risk factor for biomechanical deterioration, which results in degeneration of the surgical functional spinal unit (FSU) and poor long-term prognosis [19,20,21,22, 25]

  • DD in segments adjacent to the surgical segment led to slight increases in intradiscal pressure (IDP) and decreases in facet contact force (FCF) in the surgical segment, which is consistent with published studies [23, 48]

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Summary

Introduction

Facetectomy, an important procedure in the in–out and out–in techniques of transforaminal endoscopic lumbar discectomy (TELD), is related to the deterioration of the postoperative biomechanical environment and poor prognosis. Pathological changes in spinal load distribution may occur after high-grade facetectomy, resulting in injury to the surgical FSU, which is a risk factor for symptom recurrence and disc degeneration [16, 21,22,23]. Instability in the surgical segment caused by facetectomy is a risk factor for biomechanical deterioration, which results in degeneration of the surgical FSU and poor long-term prognosis [19,20,21,22, 25] These deductions are consistent with the findings of our published finite element (FE) numerical studies [26,27,28], which demonstrated that a higher grade facetectomy might be associated with biomechanical deterioration and lumbar instability; these changes may be related to further degeneration and symptom recurrence [27,28,29]. Because axial rotation could enhance the vulnerability of the posterior annulus and the ZJ could restrict lumbar spinal motion under axial rotation, iatrogenic injury of the SAP in TELD may increase the risk of annulus tear, recurrence of related symptoms and acceleration of disc degeneration [17, 18, 24, 30]

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