The effectiveness of the P-DTR method used in the non-invasive treatment of L5-S1 disc herniations

Background: Our country gradually entered an aging society, the incidence of lumbar disc herniation increases year by year, the clinical symptoms such as the pain, seriously affect the elderly's daily life movement, long-term pain will also lead to psychological barriers, seriously affect patient's daily life and work. The purpose of this study was to investigate the clinical efficacy and safety of Gongshi Naoacupuncture combined with Shentongzhuyu Decoction in the treatment of lumbar disc herniation, and to provide a treatment method for the clinical treatment of lumbar disc herniation. Objective: To observe the clinical effect of Gongshi Naoacupuncture combined with Shentongzhuyu Decoction in the treatment of disc herniation. Methods: 120 cases were randomly divided into treatment group (60 cases) and control group (60 cases). Both groups were given Shentongzhuyu decoction, and the observation group was given Gongshi brain needle. The observation period of both groups was 30 days, and the curative effect was evaluated after the treatment. Results: After treatment, VAS score of 2 groups was decreased compared with before treatment (p<0.05), observation group was significantly lower than control group (P<0.05); The score of JOA low back pain scale in 2 groups was higher than before treatment (p<0.05), and the observation group was higher than the control group (P<0.05). The improvement effect (significant efficiency, effective rate) of clinical symptoms in the observation group was better than that in the control group (p<0.05). Conclusion: In the treatment of lumbar intervertebral disc herniation, Gongshi Naoacupuncture combined with Shantong Zhuyu Decoction can significantly improve clinical efficacy, shorten the time of pain relief, significantly reduce the pain symptoms of patients, improve lumbar function, improve the quality of life of patients, with low recurrence rate, remarkable effect and innovation, and solve the dilemma of poor long-term therapeutic effect of lumbar intervertebral disc herniation. With the characteristics of "simple, fast, standard, safe, effective", it is worth trying a kind of treatment method, worthy of clinical promotion and application.

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. 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). 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. 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.

Up to now there have been two contradictory opinions in regard to lumbar facet role in the development of disc degeneration and herniation. To reconfirm the clinical validity of facet arrangement in the development of early disc degeneration and herniation, this study was carried out. For this purpose, the relationship between lumbar unilateral disc protrusion and geometry of the facet joints in the transverse plane was investigated. Method: The facet geometry was measured at the L4 disc level in the 35 protruded disc patients and L5 disc level in the 19 protruded disc patients. The computed tomographic scan sections were made 2[Formula: see text]mm intervals. The discs of L4 and L5 levels in the patients without disc protrusion and patients with spine injury were used as control. Results: 1. The facet angle showed the different individual variance. Among the L[Formula: see text] disc herniation group, the mean facet angle in the protruded and opposite sides and control were [Formula: see text] (29–70[Formula: see text]), [Formula: see text] (29–65[Formula: see text]), and [Formula: see text] (30–65[Formula: see text]). Those values at L5-S1 level were [Formula: see text] (35–79[Formula: see text]), [Formula: see text] (36–79[Formula: see text]), and [Formula: see text] (36–79[Formula: see text]), respectively. 2. Transverse interfacet angle (TIFA) of the L[Formula: see text] protruded disc level and that of control were 97–14[Formula: see text] (59–125[Formula: see text]) and [Formula: see text] (66–127[Formula: see text]). Those of L5-S1 level were [Formula: see text] (70–132[Formula: see text]) and [Formula: see text] (76–151[Formula: see text]). 3. The angle difference between both sides in the case of the facet asymmetry at L[Formula: see text] disc level was [Formula: see text] (0–30[Formula: see text]), and that of the control was [Formula: see text] (0–15[Formula: see text]), and those of L5-S1 level were [Formula: see text] (0–24[Formula: see text]) and [Formula: see text] (0–24[Formula: see text]), respectively. Disc herniation developed toward the more obliquely aligned facet joint side in 19 (54.2%) out of the 35 patients at the L[Formula: see text] disc, while disc herniation at L5-S1 level developed toward the more obliquely aligned facet joint side in 11 (57.9%) out of the 19 patients. 4. Among the L[Formula: see text] disc level, the mean moment arm angles in the disc-protruded side, the opposite side and control were [Formula: see text] (16–40[Formula: see text]), [Formula: see text] (15–35[Formula: see text]), and [Formula: see text] (16–35[Formula: see text]). Those of L5-S1 level each were [Formula: see text] (21–36[Formula: see text]), [Formula: see text] (17–35[Formula: see text]), and [Formula: see text] (16–35[Formula: see text]), respectively. 5. At the L[Formula: see text] level, the mean non-dimensional facet depths in the disc-protruded side, the opposite side, and control were [Formula: see text] (0–0.36[Formula: see text]), [Formula: see text] (0–0.41[Formula: see text]), and [Formula: see text] (0.02–0.28[Formula: see text]). Those facet depths at L5-S1 level were [Formula: see text] (0.02–0.28[Formula: see text]), [Formula: see text] (0.02–0.2[Formula: see text]), and [Formula: see text] (0.02–0.28[Formula: see text]). Conclusion: The five parameters including facet angle showed clinically no significant correlation with the disc herniation.

BackgroundTransforaminal endoscopic discectomy was popular in the treatment of lumbar disc herniation. Previous study focuses on the leg pain of disc herniation, and little study concern the residual leg numbness after surgery. The purposes of this study were to evaluate the clinical outcomes of transforaminal endoscopic discectomy in the treatment of lumbar disc herniation with leg pain and numbness.MethodsPatients with one level lumbar disc herniation who had transforaminal endoscopic lumbar discectomy from June 2016 to July 2019 were categorized into two groups according to the leg numbness. 293 patients initially fulfilled the study criteria, and 27 patients were lost to follow-up. Of the remaining 266 patients available for analysis, 81 cases with leg numbness and pain (A group), and 185 cases with leg pain (B). Endoscopic transforaminal lumbar discectomy was performed, and the clinical outcomes of blood loss, operation times, hospital stay days, pain (Visual Analog Scale, VAS-pain), numbness (VAS-numbness), functional disability (Oswestry Disability Index, ODI), and the disk height and intervertebral foramen height were recorded.ResultsAll patients with pain and numbness pre-operation in group A, complain of leg numbness during or just after walking or standing not diminished after surgery in group A, and no one complain numbness after surgery in group B. The pain index and ODI score were better than preoperational in all patients (P < 0.01), and no significant difference between two groups (P > 0.05). The postoperative disk and foramen height were no significant difference compare to preoperative in all patients (P > 0.05), and no significant difference between two groups (P > 0.05). The leg numbness symptoms last longer in central disc herniation patients (10.4 ± 2.2 months) than in paracentral (6.3 ± 2.1 months) and foraminal disc herniation patients (5.6 ± 2.3 months) after surgery (P < 0.01).ConclusionsBased on the results of this study, transforaminal endoscopic lumbar discectomy was effective and safe procedures in the treatment of disc herniation with leg pain and numbness. The leg numbness symptoms last longer in central disc herniation patients than in paracentral and foraminal disc herniation patients after surgery.

Background:Disc/vertebral degeneration and disc herniation are rare causes of low back pain in childhood. Their relationship with congenital anomalies were reviewed in few studies in literature (1-3).Objectives:To examine the relation between congenital structural malformations in the lumbar spine, early degeneration and lumbar disc herniation in pediatric age group patients with low back pain, and to determine the incidence of congenital structural malformations, disc/vertebral degeneration, and disc herniation.Methods:Four hundred patients with LBP persisting for at least six weeks were included in the study. Demographic characteristics, physical examination findings, and laboratory and imaging results were recorded for all patients. Severity of pain was determined using a visual analog scale (VAS). Lumbosacral X-rays were examined for the presence of lumbosacral transitional vertebrae (LSTV) and spina bifida occulta (SBO). The incidence of disc/vertebral degeneration and disc herniation was investigated at the L4-5 and L5-S1 level in lumbosacral magnetic resonans imaging of patients with and without congenital malformation (LSTV-SBO).Results:The study population consisted of 219 girls and 181 boys aged 10-17 years (mean age 14.9±1.9). Presentation symptoms were low back pain in 90.5% (n= 362), and low back-leg pain in 9.5% (n=38). The mean VAS score was 5.3±1.0. LSTV was determined in 67 (16.8%) patients and SBO in 62 (15.5%). Disc herniation was determined in 68 patients, at the L4-5 level in 26.5% (n=18), at the L5-S1 level in 48.5% (n=33), and at both levels in 25% (n=17). Vertebral degeneration was present at the L4-5 level in 14 (8.6%) patients and at the L5-S1 level in 39 (23.9%), while disc degeneration was present at the L4-5 level in 21 (12.8%) patients and at the L5-S1 level in 31 (19.0%). No significant difference was observed in the incidence of disc/vertebral degeneration and disc herniation in patients with congenital malformation. Disc herniation was significantly more common in patients with disc degeneration (p=0.003, p&lt;0.001). Congenital malformations were not observed in approximately 80% of patients without disc herniation and disc/vertebral degeneration.Conclusion:The presence of congenital malformations does not appear to represent a risk factor for early degeneration and disc herniation in pediatric age group. Congenital malformations, early degeneration, and disc herniation may constitute an underlying pathology in pediatric patients with persistent low back pain.

This study aimed to investigate the effects of IL-8, CRP and TXB2 in the treatment of lumbar disc herniation by combining with percutaneous endoscopic discectomy. For this purpose, 290 patients with disc herniation were selected as the research objects and randomly divided into two groups. The control group was treated with traditional intervertebral fenestration of nucleus pulposus, and the research group was treated with joint process location slip technique combined with percutaneous endoscopic lumbar disc discectomy. The clinical efficacy, functional scores and serological indexes of the two groups were compared, and the prognostic value of IL-8, CRP and TXB2 in the treatment of disc herniation by the combination of the sliding technique of facet location and percutaneous endoscopic discectomy was explored. The results showed that the total effective rate of 95.55% in the study group was higher than 79.31% in the control group, and the difference was significant (P<0.05). The operative time, incision length, length of hospital stay and intraoperative blood loss in the study group were lower than those in the control group (P<0.05). JOA score was higher and ODI score was lower in the two groups after surgery than before surgery, and JOA score in the study group was higher than that in the control group, while the ODI score was lower than that in the control group (P<0.05). Il-8, CRP and MDA in 2 groups increased after the operation, while SOD and TXB2 decreased significantly. Il-8, CRP, TXB2 and SOD in the study group were lower than those in the control group, while MDA was higher than those in the control group (P<0.05). ROC curve indicated that the areas under the curves of IL-8, CRP and TXB2 were 0.725, 0.835 and 0.880, and the areas under the curves, sensitivity and specificity of the combined determination were higher than those of any index (P<0.05). In general, compared with traditional interlaminar fenestration of nucleus pulposus, combined with percutaneous endoscopic lumbar disc discectomy has a significant effect on the treatment of disc herniation, and can reduce the levels of IL-8, CRP and TXB2.

Study Design Comparison outcome treatment of pain syndromes in lumbar degenerative disk disease (DDD) in application two combined minimally invasive methods of treatment in intervertebral disk (IVD) herniations. Objectives To estimate and compare the treatment effectiveness of laser IVD vaporization in combination with dynamic stabilization by percutaneous interspinous implant In-Space. Background Data The method of laser vaporization is based on impact of laser radiation on IVD tissue. The impact of laser radiation impulse lead to the creation of vaporization defect of few square millimeter area and reduction of the intradiscal pressure. The reduction of pressure out of disk causing pain syndrome occurs indirectly. The reduction of disk volume and pressure in it can lead to instability in spinal motion segment and redistribution of loads to facet joints, accelerate development of spondyloarthrosis and lead to appearance of facet syndrom. Height reduction in the posterior column of the lumbar spine accelerate spinal canal stenosis. Pain syndrome recurrences more frequently occur in previous laser vaporization signs of segmental instability. Materials and Methods There were selected patients who were operated (71 females and 55 males) at the age of 28 to 46 with protrusions of IVD and presence of signs of spondyloarthrosis. There were two groups of patients: the first group consisted of 109 patients and underwent laser vaporization of IVD by laser Nd-YAG Dornier; the second group consisted of 17 patients with laser vaporization in combination with percutaneous interspinous stabilization by In-Space (Synthes) implant. In the first group, pathology located on the levels L3-L4 (18 cases), L4-L5 (52 cases) and L5-S1 (39 cases), in the second group on the levels L3-L4 (3 cases), L4-L5 (10 cases), and L5-S1 (4 cases). Relatively less quantity of patients with the level L5-S1 in the second group is caused by selection and limited opportunities of interspinous fixation on this level owing to anatomical peculiarity. Laser vaporization operation of IVD was performed under local anesthesia in the standard regime and takes 25 minutes in the average. The second stage in the second group to the interspinous space from lateral puncture was inserted interspinal stabilizer with 15 minutes duration under local or intravenous anesthesia. All manipulations were performed under X-ray control. Results As a result of treatment, it is managed to gain significant improvement quality of patients life estimated by ODI (23%, from 9.5 to 31%) in discharge for all patients. The results of treatment showed the outcomes as follows: in first group outcomes according to Mac Nab scale areexcellent 59 (54.1%) patients, good 42 (38.5%), satisfactory 8 (7.37%). According to Nurick scale, excellent 61 (64.3%) patients, improvement 19 (17.4%), without dynamic 17 (15.6%), worsening 3 (2.7%). Three patients in the postoperative follow-up had herniation recurrence. In the second group, outcomes according to Mac Nab are as follows: excellent 14 (82.3%), good 3 (17.7%). According to Nurick, excellent 12 (70.5%), improvement 5 (29.5%). Discussion The application of percutaneous dynamic interspinous stabilization in combination with laser vaporization of IVD allowed to improve treatment results of patients with lumbar DDD pain syndrome. The combination of these methods allow to decrease intradiscal pressure, to gain long-term deception of disk, reduction of disk protrusion, and to prevent or eliminate development of segmental instability. The installed implant extend interspinous space, perform expanding of ligaments and restoring foraminal height, reloading of facet joints and occurs restoration of congruence its articulation surfaces. Thus, it is restores natural topographic and anatomic relations in the spinal motion segment by saving its mobility which is confirmed by follow-up X-ray films and clinically neurological results in the long-term follow-up. Conclusion Performing percutaneous dynamic interspinous stabilization after laser vaporization of IVD is an effective method of treatment of pain syndrome in comparison with isolated application of laser vaporization. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared

Prospective longitudinal clinical study. The purpose of our article was to investigate the clinical outcomes with type and level of disc herniation in a young, active population undergoing lumbar microdiscectomy. There are few reported outcomes studies on the relationship between disc herniation level, type of disc herniation, and surgical outcomes of lumbar microdiscectomy in a young, active population. One hundred ninety-seven (197) consecutive single-level lumbar microdiscectomies performed by a single surgeon were prospectively followed over a 3-year period. All patients had failed a period of nonoperative care including physical therapy and/or transforaminal epidural steroid injections. One hundred eighty-three patients (139 males, 44 females) with a mean age of 27.0 years (range 19-46 years) were prospectively followed for a mean of 26 months (range, 12-38 months). Outcomes were assessed using Visual Analog Scale (VAS), Oswestry disability index, patient satisfaction, return to military duty, and need for additional surgery. The type of disc herniation (contained, extruded, or sequestered) and the lumbar level of herniation were also recorded. At final follow-up, 84% (154 of 183) of patients had returned to unrestricted military duty; 16% (29) had been medically discharged. The mean decrease in VAS leg pain score was 4.7 points (from mean preoperative 7.2 to mean postoperative 2.5); 80% (146) reported a decrease of greater than 2 points. The mean Oswestry index improved from 53.6 before surgery to 21.2 at final follow-up. Overall, 85% (156) were satisfied with their surgery. Six patients had recurrent herniations (3%) with 4 of the 6 undergoing additional surgery. Patients with preoperative VAS scores consistent with a preponderance of radicular leg pain versus back pain demonstrated better surgical outcomes in all categories (P < 0.001) When classified by disc herniation type, sequestered discs at all levels demonstrated better Oswestry and VAS scores versus extruded or contained disc herniations. (P < 0.001) Disc herniations at the L5-S1 level had significantly greater improvements in both mean VAS leg and Oswestry outcome scores than disc herniations at the L4-L5 level. (P < 0.001) Preexisting restricted duty status at time of first surgical consultation was associated with poorer outcomes. Smokers had a significantly lower return to full active military duty (P = 0.037). Microdiscectomy for symptomatic lumbar disc herniations in young, active patients with a preponderance of leg pain who have failed nonoperative treatment demonstrated a high success rate based on validated outcome measures, patient satisfaction, and return to active duty. Patients with disc herniations at the L5-S1 level had significantly better outcomes than did those at the L4-L5 level. Patients with sequestered or extruded lumbar disc herniations had significantly better outcomes than did those contained herniations. Patients with contained disc herniations, a predominance of back pain, on restricted duty and smoking should be counseled before surgery of the potential for less satisfaction, poorer outcomes scores, and decreased return to duty rates.

The literature survey was carried to identify the Non Invasive detection and Treatment methods on Tumor Growth in Body System. Techniques and conclusions are given; a table is given listing Non Invasive Treatment methods on tumor growth in body system over the last 22 years.

Chronic low back pain (LBP) is a common condition primarily associated with lumbar disc herniation. Fatty degeneration of the multifidus muscle is also observed in the majority (>80%) of patients with LBP. This retrospective study included 140 patients (72 females and 68 males) with chronic LBP. 3T lumbar magnetic resonance imaging (MRI) T1- and T2-weighted fast spin-echo sequences were used for radiological evaluation. Disc herniations were graded according to the degree of bulging, protrusion, extrusion, and sequestration. Multifidus fatty infiltration was semiquantitatively graded from grade 1 (normal) to grade 4 (severe). Multifidus fatty degeneration was more common in females compared to males at the L4-L5 and L5-S1 levels (p-values <000.1 and <000.1, respectively). There was no correlation between disc herniation at the L4-L5 and L5-S1 levels and fatty degeneration of the multifidus muscle (p values 0.426 and 0.170). There was a statistically significant positive correlation between multifidus fatty degeneration at L4-L5 and L5-S1 levels and increasing age (p<000.1, r-values 0.462 and 0.357, respectively). In contrast, there was no correlation between age and L4-L5 and L5-S1 herniation grades (p values 0.167 and 0.723, respectively). Fatty degeneration grades were generally higher in females and increased with age at L4-L5 and L5-S1 levels in both genders (p<0.001). The frequency and degree of fatty degeneration of the multifidus muscle increasewith age, especially in women, and donot correlate with the presence of a herniated disc.

Objective– This study was done to assess the spectrum of pathology of lumbar degenerative disc disease via MRI, to correlate MRI findings with the symptomatology and assessment of relevance of MRI findings in young adult patients with low back pain.Methods: A retrospective hospital based study was done of 232 patients who underwent lumbar spine MRI for low back pain symptom complex with exclusion of acute spinal infection, recent trauma, tumors, spinal dysraphism and metabolic conditions from the study. The MRI findings were interpreted independently and subsequently correlated with clinical history and examination findings from patients’ records.Results26 (11.2%) of the 232 patients in the study group had completely normal MRI findings. 2 patients had zygapophyseal joint arthropathy only with no evident diskal abnormality on MRI. Multiple contiguous level disc disease was noted in 138 (59.5%) patients, multiple level disc disease with skipped segments was noted in 14(6%) patients, and 52 (22.4%) patients had single level disc involvement. Disc degeneration on MRI was most frequent at L4-L5 level (79.3% ) followed by L5-S1 level (68.9%), L3-L4 level (32.8%), L2-L3 level (16.3%) and L1-L2 level (9.5%). Disc herniations were most frequent at L4-L5, L5-S1 and L3-L4 levels in decreasing order of frequency. Nerve root compromise was noted most frequently at L4-L5 level (56.9%), followed by L5-S1(41.4%) and L3-L4 (19%) levels. Annular tear was most frequent in L4-L5 intervertebral disc (36.2 % cases), followed by L5-S1 ( 32.8%) , L3-L4 (8.6%) and L2-L3 (3.4%) respectively. Vertebral end plate changes were most common at L5-S1 and L4-L5 vertebral levels with Modic Type II changes (12.5% ) and Type I changes (3.45%). Significant associated findings i.e. transitional vertebra, spondylolysis with anterolistheis of L5 vertebra, Scheuermann disease, Chiari 1 type malformation, thoracic cord syrinx, block L4-L5 vertebra and old healed vertebral pathology not involving lumbar spine were noted in 59 (25.4%) patients.ConclusionThis study shows utility of MRI in depicting objective evidence of lumbar degenerative disc disease in symptomatic young adult patients with clinical suspicion of disease. Foraminal/subarticular disc protrusions/extrusions and significant nerve root compromise on MRI are more likely in clinical setting of radicular pain. Presence of transitional vertebra/ Scheuermann disease, lumbar vertebral neural arch defects, old infective/traumatic pathology in other segments of spine should be investigated in presence of young lumbar degenerative disc disease.

Objective. To determine the timing and to identify predictive factors of resorption of lumbar intervertebral disc herniation.Material and Methods. This study is retrospective cohort and is devoted to the study of two groups of patients: Group 1 with herniated disc resorption and Group 2 with no resorption. All patients underwent MRI of the lumbar spine at the onset of initial symptoms, and the second study was conducted during the second visit. Based on the MRI results, the following parameters were assessed: the degree of intervertebral disc degeneration according to the Pfirrmann classification, the degree of facet joint degeneration according to the Grogan classification, the type of hernia, the degree of migration of the hernial fragment according to the Komori classification, Modic changes, the state of the endplates according to the Rajasekaran classification, the presence of retrolisthesis and the presence of resorption of the hernial fragment in dynamics. The Syngo.via workstation was used to measure the volume of the hernial fragment. Resorption of a disc herniation was considered to be a decrease in its volume by more than 50 % of the initial value with mandatory relief of radicular pain syndrome. The identification of resorption predictors was performed by building logistic regression models. Single-factor models were used to identify individual predictors associated with the target event. For continuous indicators, the ROC analysis identified the maximum cut-point values according to the Youden’s index.Results. Group 1 included 141 patients, and Group 2 (comparison) – 93. Statistically significant differences between groups were found in several parameters. The average age of patients was 6 years younger; the interval between MRI studies was on average 2 months longer; and the protrusive type hernias were more in Group 2 than in Group 1. Gender, body mass index, the presence of retrolisthesis and smoking habit did not differ significantly between the groups. In Group 2, there were more cases of hernia at the L5–S1 level, which is associated with a higher incidence of hernia at this level. Using logistic regression models, it was revealed that hernia volume, hernia type according to the Komori classification, body mass index and Modic changes are significant factors for hernia resorption. A hernia volume of more than 1.1 cm3, no Modic change, hernia types II and III according to Komori, and body mass index of less than 30.24 increase the chances of disc herniation resorption.Conclusion. The average time to resorption of herniated lumbar disc is 5.5 months. Factors that predict the resorption include types II and III of hernia according to the Komori classification (correspond to sequestered herniation), the absence of Modic changes, hernial fragment volume larger than 1.1 cm3, and body mass index less than 30.24.

Percutaneous endoscopic transforaminal discectomy is often used as a minimally invasive procedure for lumbar disc herniation. However, a transforaminal approach posts limitations at the L5-S1 level owing to anatomic constraints, such as a high iliac crest or small intervertebral foramen and especially for migrated large intracanalicular disc herniations. We discuss the procedure and clinical results of percutaneous endoscopic interlaminar discectomy using a rigid working channel endoscope at the L5-S1 level and the relevant surgical anatomy. We performed percutaneous endoscopic discectomy through the interlaminar approach in 67 patients who satisfied our inclusion criteria during the period from March 2002 to November 2002. All procedures were performed under local anesthesia. Under fluoroscopic guidance, we performed discography using indigocarmine mixed with radio-opaque dye. The 6-mm working channel endoscope was then introduced into the epidural space. Herniated disc material was removed using forceps and laser under clear endoscopic visualization. We retrospectively evaluated the 65 cases with more than 1.5 years of follow-up. The patients were evaluated using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). VAS for leg pain (preoperative mean, 7.89; postoperative mean, 1.58) and ODI (preoperative mean, 57.43; postoperative mean, 11.52) showed statistically significant (P = 0.00) improvement in their values at the last follow-up examination compared with preoperative scores. Of the study group, 90.8% individuals showed favorable result. The mean hospital stay was 12 hours. The average time to return to work was 6.79 weeks. Complications included two cases of dural injury with cerebrospinal fluid leakage, nine cases of dysesthesia that were transient, and one case of recurrence. Two patients required conversion to open procedure at the initial operation. There was no evidence of infection in any patients. Percutaneous endoscopic interlaminar discectomy is a safe, effective, and minimally invasive procedure for the treatment of intracanalicular disc herniations at the L5-S1 level in properly selected cases, especially when the transforaminal approach is not possible because of anatomic constraints.

Background: Minimally invasive approaches to intra/extraforaminal lumbar disc herniations offer the benefit of less bone removal and reduced nerve root manipulation at the L5-S1 level. Moreover, the potential to better preserve stability.Methods: Here, we summarized the efficacy of the contralateral approach to intraforaminal/extraforaminal lumbar disc herniations particularly focusing on the L5-S1 level. Variables studied included the level of these disc herniations, their locations within the foramina, and the anatomy of the facet joints.Results: A major “pro” for the contralateral interlaminar procedure at the L5-S1 level is that it does not require facet joint removal, or with a spondylotic facet, <30% joint excision, to directly visualize the intraforaminal/ extraforaminal nerve root. It, therefore, reduces the risk of creating iatrogenic instability, while offering a higher certitude of adequate nerve root visualization, decompression, and safer disc removal.Conclusion: The contralateral interlaminar approach is more suitable for all types of intra/extraforaminal disc herniations at the L5/S1 level. The most specific benefit of this approach is its avoidance of disruption/significant removal (i.e., <30%) of the facet joint to adequately expose the foraminal L5 nerve root, and more safely remove the intra/extraforaminal disc herniation.

Sacral Epidural Laser Discectomy (SELD) which is an effective and minimally invasive procedure for the direct visualization and therapeutic treatment of pain due to spinal disorders. The aim of this study is to share the effect of SELD on clinical findings and pain. 43 patients who had not undergone back surgery and were found to have lumbar intervertebral disc herniation at L4-5 or L5-S1 level without any indication for back surgery, and who underwent SELD for the treatment patients with low back and/or radicular pain were evaluated. Physical examination findings (the straight leg raising test (SLR) <45 degrees positive(+), SLR >45 degrees negative(-) test were accepted) and visual pain scale (VAS) values were evaluated at admission, on the same day of post-op, 1st and 6th months. Disc herniation was observed at L4-5 level in 27 patients (62.79%) and at L5-S1 level in 16 patients (37.21%). 31 patients (72.09%) benefited from SELD treatment, while surgery was recommended for 10 patients (23.26%). With SELD procedure no permanent complication was observed. The clinical response of SELD according to the lumbar disc level, a more significant improvement was found in both physical examination and VAS scores in patients with disc herniation at the L5-S1 level (p<0.001). There was no statistically significant relationship between the SLR (+) side and the outcome. SELD is a more effective option, especially in patients with good physical examination findings at admission and mild-to-moderate soft disc herniation at the L5-S1 level.