Cauda Equina Research Articles

Prevalence of Transitional Vertebra in Lumbar Disc Herniation in Bangabandhu Sheikh Mujib Medical University

Background: Lumbosacral transitional vertebrae (LSTV) occur as a congenital anomaly in the segmentation of lumbosacral spine that occur during intrauterine life. LSTV includes lumbarization and sacralization of the lumbosacral region. A transitional vertebra(TV) may have varying formations, the common feature being an atypical lumbosacral articulation between transverse process of the most inferior lumbar vertebra and the sacrum. There has been a lot of discussion regarding the prevalence of LSTV in lumbar disc herniation(LDH). Most of the studies showed increased prevalence while other studies showed TV is an incidental finding and there is no increased prevalence in LDH. LDH is a quiet common ailment encountered in neurosurgical practice. Numerous causes have been attributed to it. LSTV might have great importance in patients who clinically seem to have LDH where it’s presence in plain X-ray might provide a supportive evidence for diagnosis and it can help to counsel the patient. We will be able to recommend a plain x-ray of lumbosacral spine first, having history and clinical findings suggestive of LDH and can save the cost of MRI investigation until decision for operation. Beside this LSTV is an important entity for spinal surgeons , radiologists and also for those who do interventional procedures in the spine. For this reason the prevalence of TV in LDH should be known. This study was not carried out in our country yet. So this study will enrich our demographic information and will also help the spinal surgeons to counsel the patients about their congenital spinal morphological variation and different facts related with this. Objectives: General objective of this study is to observe the prevalence of LSTV in patients with LDH. Specific objective of this study was to identify the diathroidal joint or fusion between transverse process of last lumbar vertebra and ala of sacrum, to count the vertebral number from C2 to S1 in whole spine screening film, to identify the transitional vertebra as sacralization or lumbarization or absence of TV, to predict the future possibility of development of LDH from plain X-ray of lumbosacral spine. Methods: This study was a cross sectional type of observational study and was conducted in Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU). The patients (N=45) who fulfilled the selection criteria was enrolled in this study. Patient’s data were recorded in a predetermined data sheet. Patients were informed in details about the study, its merits and demerits in easy and understandable language and then informed consent was taken. Also assurance was given that all the information and records would be kept confidential and the study result would help the neurosurgeons to counsel the patients with LSTV about future possibility of development of LDH from plain X-ray of lumbosacral spine. This study was not responsible for any additional harm to the patient and study had no potential risk to the patient and no experimental drugs were used in this study. Results: A total of 45 patients of LDH were studied to see the prevalence of lumbosacral TV in LDH. Based on history and clinical findings, 100% of patients presented with low back pain, 100% of patients presented with sciatica, and 62.2% presented with gait difficulty and 02.2% of patients presented with cauda equina syndrome. Mean age of patients having LDH herniation was 38.08 ± 10.15 years. LSTV was found in 31.11% of patients with LDH. In this study, LSTV was diagnosed by plain X ray of Lumbosacral spine (A/P view) and supplemented with MRI of L/S spine with screening of whole spine (in most cases). Diagnosis of transitional vertebra was done by researcher and was further confirmed by guide and faculty members of BSMMU. In relation to gender, prevalence of LSTV in male was 25.9% and in female was 38.9% which indicated higher prevalence of TV in female but this is not statistically significant (p value 0.356).Incidence of disc herniation in patients with TV was at the space above the transition in 85.7% of cases. The most likely explanation for this is that the motion segment cephalad to the LSTV has to bear additional stresses by virtue of it being juxtaposed to a relatively non-mobile segment Conclusion: This study reveals that the prevalence of LSTV in LDH is 31.11% which is near the upper limit of its prevalence(according to literature). Association of TV with LDH can not be obtained as a control group of patient without LDH was not considered. So further study should be carried out incorporating large number of patients with control group with long study period to generalize the findings to target population. Bang. J Neurosurgery 2023; 12(2): 76-85

Factors influencing the outcome in patients with cauda equina syndrome

Factors influencing the outcome in patients with cauda equina syndrome

Less Invasive Triangular Osteosynthesis in the Management of AO Type-B Unstable Sacral Fractures

Objective: This prospective cohort study investigated the clinical and radiological efficacy of triangular osteosynthesis (TO) in the management of AO type-B unstable sacral fractures.Methods: All patients with unstable AO type-B sacral fractures were included in this study. They were evaluated clinically and radiologically and underwent TO. Pre- and postoperative clinical parameters included the visual analogue score (VAS) for back pain, Oswestry Disability Index (ODI), and Gibbon classification. Radiological parameters included x-rays and multislice 3-dimensional computed tomography scans of the pelvis and the Tornetta and Matta criteria for fracture reduction.Results: This study included 30 patients (17 males and 13 females; mean age, 31.63±9.65 years). The reported causes of trauma were a fall from height in 17 patients, road traffic accident in 11 patients, and hard objects falling onto the pelvis in 2 patients. According to the AO spine sacral fracture classification system, 8 cases were type B2 and 22 were type B3. At the last postoperative follow-up, the mean VAS improved from 7.77±1.19 preoperatively to 3.97±1.59 (p<0.001), the mean ODI was 15.27±3.34, and the Gibbon classification of cauda equina injury improved from 2.87±0.97 preoperatively to 1.27±0.52 (p<0.001). According to Tornetta and Matta criteria for fracture reduction, the results were excellent (<4 mm) in 73.3% of patients, good (4–10 mm) in 20%, and fair (10–20 mm) in 6.7%. All patients experienced complete fracture healing.Conclusion: TO is a less invasive, safe, and effective option for the management of unstable AO type-B sacral fractures with good clinical and radiological outcomes.

Spinal Intradural Epidermoid Cyst with Dermal Sinus in a 2 – Year Old Child: A Rare Case Report

Introduction: Spinal epidermoid accounts for < 1% of all primary cord tumor. This rare benign lesion may be congenital or acquired. Invagination of epidermal elements into the neural tube during embryonic period leads to the development of epidermoid cyst. Case Presentation: A 2 year old girl presented with a spontaneous intergluteal swelling with dermal sinus and lower limbs weakness. The lumber MR demonstrated an intradural lesion from L3 to L5 levels that compressed cauda equine or nerve roots. MR findings were compatible with an epidermoid cyst with dermal sinus without any coexistent spinal dysraphism. The patient underwent microsurgical laminectomy from L3 to L5, tumor was resected and sent for histopathological examination. A pearly white tumor was found and histopathology revealed an epidermoid tumor. Post-operative Magnetic Resonance Imaging (MRI) finding was total removal. Conclusion: Diagnosis of spinal epidermoid cyst is often delayed due to its obscure presentation. Here, we presented spinal lumber intradural epidermoid cyst with dermal sinus which was treated successfully with microsurgical total resection with preservation of spinal stability and neurological function. Post-operative follow up with MRI is helpful.

Primary intradural Extraosseous Ewing’s sarcoma of the cauda equina: A case report and literature review

Intradural Extraosseous Ewing sarcoma (IEES) is an infrequent occurrence. We report a case of a 66-year-old male who presented with a 2-month history of low back pain and bilateral S1 sciatica, with acute sphincter dysfunction. Imaging studies revealed an intradural extramedullary lesion in the cauda equina spanning from level L4 to S1. The patient underwent partial removal of the intradural lesion. Histopathological examination showed the presence of small round cells, which were consistent with Ewing Sarcoma. The patient was then treated with targeted radiation therapy and chemotherapy.The rarity of IEES in this specific location underscores the significance of evaluating and managing patients with intradural spinal tumors with careful consideration of this diagnosis. To further investigate this condition, we conducted a thorough review of the literature on IEES involving the lumbar spine and cauda equina. Our analysis revealed that patients with this condition frequently exhibit rapidly progressive neurological symptoms likely attributed to hemorrhagic transformation. This characteristic may serve as a distinguishing factor from other lesion types, particularly benign ones. Our study provides a comprehensive summary that can offer direction for clinical management in comparable uncommon and novel cases.

Inadvertent administration of intravenous anaesthesia induction agents via the intracerebroventricular, neuraxial or peripheral nerve route - A narrative review.

Intravenous (IV) medication administration error remains a major concern during the perioperative period. This review examines inadvertent IV anaesthesia induction agent administration via high-risk routes. Using Medline and Google Scholar, the author searched published reports of inadvertent administration via neuraxial (intrathecal, epidural), peripheral nerve or plexus or intracerebroventricular (ICV) route. The author applied the Human Factors Analysis and Classification System (HFACS) framework to identify systemic and human factors. Among 14 patients involved, thiopentone was administered via the epidural route in six patients. Four errors involved the routes of ICV (propofol and etomidate one each) or lumbar intrathecal (propofol infusion and etomidate bolus). Intrathecal thiopentone was associated with cauda equina syndrome in one patient. HFACS identified suboptimal handling of external ventricular and lumbar drains and deficiencies in the transition of care. Organisational policy to improve the handling of neuraxial devices, use of technological tools and improvements in identified deficiencies in preconditions before drug preparation and administration may minimise future risks of inadvertent IV induction agent administration.

Improved Susceptibility Detection at 3T MRI Permits the Diagnosis of a Rare Case of Superficial Siderosis at the Cauda Equina (P8-4.014)

Improved Susceptibility Detection at 3T MRI Permits the Diagnosis of a Rare Case of Superficial Siderosis at the Cauda Equina (P8-4.014)

A Case of Anti-Glial Fibrillary Acidic Protein (GFAP) Antibody-associated Arachnoiditis Presenting as Cauda Equina Syndrome (P5-14.008)

A Case of Anti-Glial Fibrillary Acidic Protein (GFAP) Antibody-associated Arachnoiditis Presenting as Cauda Equina Syndrome (P5-14.008)

Hundreds of body parts are named after hair: is anatomical terminology supercilious or simply super silly?

Relatively more-apparent body parts are often used to name relatively less-apparent body parts. To explore this etymological phenomenon, this report assesses anatomical terminology derived from some of the most apparent structures of the human body-hairs. Hair-related anatomical terminology involves varied etymons, roots, and derivatives: calvus "bald," cilia "eyelashes," glaber "hairless," pilus "hair," pubes (historically referring to the developing beard), pudendum "modesty" (referring to hair growth that covers genitalia), tempus "time" (referring to the location where hair commonly grays, thus showing a person's age), and tragus "goat" (referring to the tuft of hair that resembles the beard of a goat). Also including lanugo, vibrissae, hirci, flocculus, and cauda equina, a systematic review of Terminologia Anatomica and Terminologia Neuroanatomica revealed 285 unique non-duplicate hair-related terms. Several anatomical terms allude to particular age groups or sexes, but are used indiscriminately (e.g., tragus alludes to the older male ear, though may describe the fetal female ear). Likewise, human-centric anatomical terminology influences non-human anatomical terminology- a turtle has a "temporal bone" only because some humans develop gray hair on the sides of their heads as they age. Accordingly, etymological recursion is common: The human ear has a tragus, named after the goat, and the goat ear has a tragus, named after the human tragus, that was named after the goat. The use of Latin as the foundation of anatomical and medical terminology may appear seriously supercilious; however, it is often simply super silly. After all, hundreds of body parts are formally named after hair.

Migratory schwannoma of the cauda equina with a change in radicular pattern: illustrative case.

Intradural spinal tumors are an uncommon entity with a variety of pathologies and symptom patterns. Few cases reports in the literature have described tumor migration within the spinal canal. A 38-year-old male presented with bilateral upper lumbar radicular symptoms of anterior thigh pain, with an enhancing tumor of the cauda equina initially located at L1-2. He declined surgery initially, and at a follow-up 3 years later, his symptoms were unchanged but the tumor was now located at T12-L1. He again declined surgery, but 3 months later, he had a significant change in his pain distribution, which was now along his posterolateral right leg to his foot with associated dorsiflexion and extensor hallicus longus weakness. At this time, the tumor had migrated to L2-3. He underwent laminectomy and tumor resection with resolution of his radicular symptoms and improvement in his strength back to baseline by the 1-month follow-up. Pathology was consistent with a World Health Organization grade I schwannoma. Migratory schwannoma is a rare entity but should be considered when radicular symptoms acutely change in the setting of a known intradural tumor. Repeat imaging should be performed to avoid wrong-level surgery. Intraoperative imaging can also be used for tumor localization.

Laminectomy for acute transverse sacral fractures with compression of the cauda equina: A neurosurgical perspective

IntroductionOptimal management of transverse sacral fractures (TSF) remains inconclusive. These injuries may present with neurological deficits including cauda equina syndrome. We present our series of laminectomy for acute TSF with cauda equina compression. MethodsThis was a retrospective chart review of all patients that underwent sacral laminectomy for treatment of cauda equina compression in acute TSF at our institution between 2007 through 2023. ResultsA total of 9 patients (5 male and 4 female) underwent sacral laminectomy to decompress the cauda equina in the setting of acute high impact trauma. Surgeries were done early within a mean time of 5.9 days. All but one patient had symptomatic cauda equina syndrome. In one instance surgery was applied due to significant canal stenosis present on imaging in a patient with diminished mental status not allowing proper neurological examination. Torn sacral nerve roots were repaired directly when possible. All patients regained their neurological function related to the sacral cauda equina on follow up. The rate of surgical site infection (SSI) was 33%. ConclusionAcute early sacral laminectomy and nerve root repair as needed was effective in recovering bowel and bladder function in patients after high impact trauma and TSF with cauda equina compression. A high SSI rate may be reduced by delaying surgery past 1 week from trauma, but little data exists at this time for clear recommendations.

A prospective review of Cauda Equina Syndrome referrals received by an on-call orthopaedic department at a major trauma unit.

Cauda Equina Syndrome (CES) is one of the genuine orthopaedic emergencies. Diagnosis of acute CES is challenging and may be missed, resulting in considerable medicolegal claims. In Ireland, nearly €21 million in compensation has been paid out over a 10-year period due to the diagnosis being missed. As a result, defensive practices have resulted in an increased number of referrals for CES to the on-call orthopaedic service in a major trauma unit. A prospective data-capturing exercise was carried out of all referrals for acute CES to the orthopaedic on-call department in a tertiary-level university-affiliated teaching hospital between August and November 2023. Qualitative data was captured including referral source, referring clinician grade, in-hours or out-of-hours referral, MRI on referral, red flags as identified by the referring team, red flags as identified by the orthopaedic team, and outcome. Forty referrals for CES were made over the duration of this audit. Seventeen (42.5%) referrals were made in-hours, and 23 (57.5%) were referred out-of-hours. Only five (12.5%) of these referrals had an MRI done at the time of the referral. No patients were transferred for an out-of-hours MRI to another hospital. Only five (12.5%) patients required surgical decompression-none of these patients required an out-of-hours emergent decompression. There is a lack of understanding as to what exactly is being referred-resulting in a referral volume which is over ten times the expected number of CES cases being made to our unit. The lack of out-of-hours MRI access poses a significant concern for patient outcomes.

Primary Intradural Chordoma along the Cauda Equina

Chordoma is a rare malignancy originating from remnants of the primitive notochord along the midline craniospinal axis, usually seen as an osseous lesion of the skull base, spinal column, and sacrum. Several cases of intracranial intradural chordomas have been reported; however, we present a case of primary intradural chordoma along the cauda equina, which, on literature review, has not been previously described. Although this is an uncommon location for a chordoma, it should be considered in the differential diagnosis of an intradural lumbar mass because chordoma has a high recurrence rate following surgery and may influence a surgeon’s approach to the lesion.

Comparative Analysis of Learning Curve, Complexity, Psychological Stress, and Work Relative Value Units for CPT 62380 Endoscopic Lumbar Spinal Decompression vs Traditional Lumbar Spine Surgeries: A Paired Rasch Survey Study.

Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT) code 62380. However, no work relative value units (RVUs) are currently assigned to the procedure. An international team of endoscopic spine surgeons conducted a study, endorsed by several spine societies, analyzing the learning curve, difficulty, psychological intensity, and estimated work RVUs of endoscopic lumbar spinal decompression compared with other common lumbar spine surgeries. A survey comparing CPT 62380 to 10 other comparator CPT codes reflective of common spine surgeries was developed to assess the work RVUs in terms of learning curve, difficulty, psychological intensity, and work effort using a paired Rasch method. The survey was sent to 542 spine specialists. Of 322 respondents, 150 completed the survey for a 43.1% completion rate. Rasch analysis of the submitted responses statistically corroborated common knowledge that the learning curve with lumbar endoscopic spinal surgery is steeper and more complex than with traditional translaminar lumbar decompression surgeries. It also showed that the psychological stress and mental and work effort with the lumbar endoscopic decompression surgery were perceived to be higher by responding spine surgeons compared with posterior comparator decompression and fusion surgeries and even posterior interbody and posterolateral fusion surgeries. The regression analysis of work effort vs procedural difficulty showed the real-world evaluation of the lumbar endoscopic decompression surgery described in CPT code 62380 with a calculated work RVU of 18.2464. The Rasch analysis suggested the valuation for the endoscopic lumbar decompression surgery should be higher than for standard lumbar surgeries: 111.1% of the laminectomy with exploration and/or decompression of spinal cord and/or cauda equina (CPT 63005), 118.71% of the laminectomy code (CPT 63047), which includes foraminotomy and facetectomy, 152.1% of the hemilaminectomy code (CPT 63030), and 259.55% of the interlaminar or interspinous process stabilization/distraction without decompression code (CPT 22869). This research methodology was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the Mexican Society of Spinal Surgeons (AMCICO), the International Society For Minimally Invasive Spine Surgery (ISMISS), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Surgery (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS). This study provides an updated reimbursement recommendation for endoscopic spine surgery. Level 3.

Successful surgical treatment of a sacral hemangioma causing cauda equina dysfunction: a case description.

Successful surgical treatment of a sacral hemangioma causing cauda equina dysfunction: a case description.

Double Level Non-Contiguous Traumatic Lumbar Disc Herniation Presenting With Cauda Equina Syndrome: A Case Report and Literature Review.

A 52-year-old man presented with cauda equina syndrome after a motorcycle accident. Magnetic resonance imaging revealed traumatic disc herniation, at L2-L3 and L5-S1 levels without bony injury. He was managed successfully by wide laminectomy and microdiscectomy at both levels with complete neurological recovery at 2-month follow-up. With a reported incidence of 0.4%, traumatic disc herniation in the lumbar region is an uncommon occurrence that may resemble a spinal epidural hematoma in acute trauma. Although MRI may not reliably differentiate spinal epidural hematoma from disc herniation, urgent surgical intervention may be required in profound neurological deficits.

Utility of Sensate Pedicled Medial Thigh Perforator Flaps in Treating Recurrent Ischial Ulcers in Individuals with Cauda Equina Lesions and Spinal Dysraphism – A Retrospective Analysis

Abstract Background: Ischial pressure ulcers pose a significant challenge due to their high recurrence rates. It is imperative to provide or establish a reliable, well-vascularized soft-tissue cover over the ischial area to prevent recurrences. The objective of the study was to study the utility and complication rates associated with pedicled medial thigh perforator (P-MTP) sensate flap procedures in managing recurrent ischial ulcers and perineal lesions. Methods: A retrospective cohort study was conducted at Christian Medical College, Vellore, a tertiary care center in South India. This study involved 30 patients with ischial pressure sores. Of these, 13 patients underwent P-MTP flaps, while 17 underwent alternative surgeries for ulcer closure (January 2014–June 2020). Results: Among 13 patients who underwent P-MTP sensate flaps, 1 major complication (full-thickness flap necrosis) necessitated flap revision, while 6 minor complications occurred in the postoperative period. Three patients (23.08%) reported late recurrence of ulcers at the same postoperative site. In contrast, among the 17 patients who underwent the other (alternative) methods of surgical closure, 3 patients had wound dehiscence in the postoperative period. Four patients reported recurrence of ulcer at the postoperative site within 6 months and another four after 6 months of surgical closure. The surgical outcomes in sensate flap surgeries (P-MTP flaps) were comparable to other approaches for surgical closure. Sensation in the P-MTP flap transposed over the ischial region remained intact in all 13 patients at 6-month follow-up. Conclusion: The P-MTP sensate flap is a feasible and reliable treatment strategy for regional soft-tissue reconstruction in ischial and perineal lesions with postoperative complications comparable to other surgical methods for ischial ulcer closure. The sensate flap surgeries offer the additional benefit of maintaining intact sensation over the pressure injury vulnerable ischial region.

Full endoscopic resection of large bilateral synovial cysts in lumbar spine.

Synovial spinal cysts cause radiculopathy and back pain, with rare reports of cauda equina syndrome. Hypermobility and instability are cornerstones for synovial cyst formation. The incidence is around 5%, and data for bilateral cysts are lacking. Surgery is indicated after conservative measures fail. Recurrence is common and is potentially due to joint violation and destabilization from open surgery. This could be prevented via ultra-minimally invasive approaches. The authors present full endoscopic removal of bilateral synovial cysts in a patient with grade 1 stable spondylolisthesis and include a 360° view for confirmation of complete decompression. Postoperatively, the patient reported immediate pain relief. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23208.

Compensatory upregulation of MT2A alleviates neurogenic intermittent claudication through inhibiting activated p38 MAPK-mediated neuronal apoptosis.

Neurogenic intermittent claudication (NIC), a classic symptom of lumbar spinal stenosis (LSS), is associated with neuronal apoptosis. To explore the novel therapeutic target of NIC treatment, we constructed the rat model of NIC by cauda equina compression (CEC) method and collected dorsal root ganglion (DRG) tissues, a region responsible for sensory and motor function, for mRNA sequencing. Bioinformatic analysis of mRNA sequencing indicated that upregulated metallothionein 2A (MT2A), an apoptosis-regulating gene belonging to the metallothionein family, might participate in NIC progression. Activated p38 MAPK mediated motor dysfunction following LSS and it was also found in DRG tissues of rats with NIC. Therefore, we supposed that MT2A might affect NIC progression by regulating p38 MAPK pathway. Then the rat model of NIC was used to explore the exact role of MT2A. Rats at day 7 post-CEC exhibited poorer motor function and had two-fold MT2A expression in DRG tissues compared with rats with sham operation. Co-localization analysis showed that MT2A was highly expressed in neurons, but not in microglia or astrocytes. Subsequently, neurons isolated from DRG tissues of rats were exposed to hypoxia condition (3% O2, 92% N2, 5% CO2) to induce cell damage. Gain of MT2A function in neurons was performed by lentivirus-mediated overexpression. MT2A overexpression inhibited apoptosis by inactivating p38 MAPK in hypoxia-exposed neurons. Our findings indicated that high MT2A expression was related to NIC progression, and MT2A overexpression protected against NIC through inhibiting activated p38 MAPK-mediated neuronal apoptosis in DRG tissues.

Preliminary Outcomes of Patients with Lumbar Disc Herniation Undergoing Unilateral Biportal Endoscopic Spine Surgery: A Single-Center Retrospective Study in Vietnam

Objective: Unilateral biportal endoscopic (UBE) treatment for lumbar disc herniation (LDH) is an advanced surgical procedure that has recently gained popularity. Numerous reports from developed countries have demonstrated the effectiveness of this minimally invasive technique. We evaluated the initial outcomes of UBE at a healthcare facility with limited resources.Methods: Clinical and radiographic data of 82 patients with LDH treated between July 2022 and June 2023 using UBE discectomy techniques, including the ipsilateral interlaminar approach, contralateral sublaminar approach, and paraspinal approach, were reviewed. Outcomes were analyzed in terms of the modified MacNab criteria, Japanese Orthopaedic Association (JOA) score, and visual analogue scale (VAS), with a mean follow-up of 3.1 months.Results: At the final follow-up, the mean VAS for low back pain improved from 4.5±1.0 to 1.2±0.4 and the VAS for leg pain improved from 7.8±0.9 to 1.6±0.5. The mean JOA score improved from 13.5±2.4 to 24.2±2.1. The modified MacNab criteria were excellent in 56 patients (68.3%), good in 22 (26.9%), and fair in 4 (4.8%). In total, 106 levels of LDH were treated. L4–5 disc herniation was performed in 55 patients (51.9%), L5–S1 in 36 (34.0%), L3–4 in 8 (7.5%), L2–3 in 6 (5.7%), and L1–2 in 1 (0.9%). The ipsilateral interlaminar approach was performed in 93 patients (87.7%), the contralateral sublaminar approach in 7 (6.6%), and the paraspinal approach in 6 (5.7%). Operative time significantly improved after performing 20 cases. In the early stage (1–20 cases), the operation time per level was 102.0±28.2 min, while in the next stage (21–82 cases) it was 78.1±20.4 minutes. No serious complications, including cauda equine syndrome or root palsy, were observed. Three patients had dural tears (2.8%), and 1 had epidural hematoma (0.9%).Conclusion: UBE discectomy may be performed safely and effectively for the treatment of LDH in limited-resource settings.