Foraminal Disc Herniation Research Articles

Contralateral Sublaminar Approach in Lumbar Spine With Unilateral Biportal Endoscopy

Unilateral biportal endoscopy (UBE) can be used to treat common lumbar pathologies, such as synovial facet cysts, foraminal disc herniations, and foraminal stenosis via a contralateral sublaminar approach. Due to the ultra-minimally invasive technique, UBE can reduce damage to anatomical structures, thereby reducing postoperative pain and allowing faster recovery. The patient is placed prone on a Wilson frame or bolsters. Fluoroscopy is used to identify the midline and medial pedicle line in the anterior-posterior projection. Spinal needles can aid to identifying portals’ trajectory in the lateral fluoroscopic projection. The procedure is performed via 2 separate portal incisions. The endoscope is introduced through the viewing portal and the surgical instruments through the working portal. Soft tissue dissector is used to create a working area over the spinous process-lamina junction. Bony shaving and drilling start at the target area and continue medially underneath the base of the spinous process until the midline and contralateral ligamentum flavum are identified. Contralateral ligamentum flavum is excised, exposing thecontralateral thecal sac, traversing nerve root, and lateral recess. The contralateral disc space, annulus, and superior articulating process are then identified and the offending pathology can be addressed under direct visualization. Meticulous hemostasis and close attention to outflow should be maintained to reduce the risk of complications. The steps of this procedure closely resemble those of traditional microscopic “over-the-top” techniques, including the surgical instruments used through the working portal. In this video, authors present the surgical technique of the contralateral sublaminar approach in the lumbar spine with UBE.

Biportal Endoscopic Posterior Cervical Foraminotomy for Adjacent 2-Level Foraminal Lesions Using a Single Approach (Sliding Technique).

Endoscopic posterior cervical foraminotomy (PCF) using uniportal or biportal endoscopic approach has been performed for cervical foraminal stenosis or foraminal disc herniation. Two-level PCF is possible using a single biportal endoscopic approach. The purpose of this study was to present a technique of biportal endoscopic PCF for contiguous 2-level foraminal lesions using a single approach and its clinical results. Patients who received 2-level PCF using a single biportal endoscopic approach were enrolled in this study. We analyzed their clinical data including age, sex, complications, and Neck Disability Index (NDI), and visual analogue scale (VAS) of neck and arm. Postoperative magnetic resonance image was taken on the first postoperative day to determine whether there was sufficient decompression. We successfully performed biportal endoscopic PCF for adjacent 2-level foraminal lesions using a single approach (sliding technique) in all 12 patients. There were cervical foraminal disc herniation with foraminal stenosis (5 cases) and 2-level foraminal stenosis (7 cases). Preoperative mean NDI and VAS of arm and neck significantly decreased at 12 months after surgery. Postoperative clinical outcomes were excellent in 5 patients, good in 6 patients, and fair in 1 patient. There was no major complication. Two-level PCF could be performed using a single approach biportal endoscopic surgery with only 2 skin incisions. Clinical outcomes are favorable. This sliding PCF technique using biportal endoscopic approach might be an alternative surgical treatment for contiguous 2-level cervical foraminal pathologic lesions.

Full Endoscopic Thoracic Discectomy: Is the Interlaminar Approach an Alternative to the Transforaminal Approach? A Technical Note.

Various approaches are used for decompressive surgeries in the thoracic spine depending on the location and consistency of the pathology, always avoiding manipulation of the thoracic spinal cord. Recently, there has been an effort to achieve adequate results and reduce morbidity with minimally invasive surgeries. Good outcomes and the advantages of full endoscopic spine surgery (FESS) have been proven for surgerical correction of herniated discs and stenoses in the lumbar and cervical spine. Similar evidence has recently been described for the thoracic spine, but it has not previously been reported in Brazil. Although the transforaminal approach is already established for the thoracic spine, the newly described interlaminar approach is equally efficient, and both techniques must be considered when treating thoracic spine diseases. The objective of the present article was to present the full endoscopic interlaminar and transforaminal techniques in patients with symptomatic disc herniation of the thoracic spine, discuss the rationality for implementing FESS in thoracic spine, and discuss the rationality in choosing between both approaches. Two patients were submitted to thoracic FESS. A transforaminal approach was chosen for a T10-T11 foraminal disc herniation; an interlaminar approach was selected for a paramedian T7-T8 disc extrusion. Data regarding operating time, intraoperative images, hospital stay, visual analog scales before and after FESS, course of recovery, and surgery satisfaction were evaluated. The patients had eventless surgeries, improved from preoperative pain without morbidity. Both were satisfied and recovered well. Hospital stay was less than 6 hours after surgery. Transforaminal and interlaminar FESS for thoracic disc herniation are safe, efficient, and minimally invasive alternatives. Despite being an innovative technique with evident advantages, it should be carefully considered along with conventional technique for the treatment of thoracic spine diseases, since its clinical relevance is yet to be determined.

Preoperative and postoperative ultrasound elastography findings of the sciatic nerve in patients with unilateral lumbar foraminal disc herniation: a pre-test and post-test design.

The aim of this study was to compare preoperative and postoperative findings of the sciatic nerve by using B-mode ultrasound, strain elastography (SE), and shear wave elastography (SWE) in patients with unilateral lumbar foraminal disc herniation. In this prospective study group, patients with complaints of foraminal disc herniation due to one level (L4-5 or L5-S1) were included. Preoperative and postoperative (one month after surgery) B-mode ultrasound, SE, and SWE findings of the affected sciatic nerve in patients who underwent unilateral spinal decompression surgery were compared. Evaluations were performed on the axial plane from the gluteal region using a convex probe of 5-9L MHz. The reference method used to assess nerve root compression was 1.5-T Magnetic Resonance Imaging (MRI). A total of 20 patients (9 males, 11 females) with a mean age of 46.2±13.1 years were included. The cross-sectional area (CSA), diameter, SWE values of the sciatic nerve were significantly higher in the affected side compared to those of the non-affected side (all for p<0.05). Blue and blue-green were the most common color codes in the affected side while green and green-yellow-red were the most common color codes in the non-affected side. The CSA, diameter, and SWE values of the sciatic nerve decreased after the surgery in the affected side (all for p<0.05), nonetheless. those did not differ in the non-affected side (all for p>0.05). Lumbar decompression surgery decreases the sciatic nerve diameter, CSA, and stiffness of the sciatic nerve.

Two Cases of Iatrogenic Lumbar Foraminal Disc Herniations

Objective We report two cases of iatrogenic deterioration of lumbar foraminal disc herniations following lumbar disc injections. Summary of Background Data. Complications associated with discography were reported. However, only a few reports have thus far referred to the iatrogenic deterioration of lumbar foraminal disc herniations. Cases 60-year-old and 74-year-old men were treated with MR images of L4-5 foraminal disc herniations without fragment in the spinal canal. The patients underwent discography and disc block for its diagnosis and treatment. After disc injections, both patients complained of deterioration of L4 radiculopathy. Results On disco-CT or reexamined MR images after disc injections, herniated fragment was migrated from neural foramen to cranial central spinal canal with was not shown in previous MR images. The herniated fragments were extirpated by means of osteoplastic laminoplasty or transforaminal lumbar interbody fusion with facetectomy. The herniated fragments were migrated from neural foramen to cranial central spinal canal. Conclusions The injection of liquid medicine into the nucleus led the intradiscal pressure increased, and the disc fragment might prolapsed through the raptured region of annulus fibrosus and migrated to cranial central spinal canal by anatomical reason. The disc injection may have a risk for deterioration of foraminal disc herniation. Our report is instructive for the management of discography for the diagnosis of foraminal disc herniations.

Postoperative outcome of robot-assisted transforaminal lumbar interbody fusion: A pilot study

Introduction:Transforaminal lumbar interbody fusion (TLIF) surgery is well established for the treatment of discopathy, foraminal disc herniation, and recurrent disc herniation. At the Amiens university medical center, we have been using a robot-assisted technique for performing the TLIF. The purpose of this study is to evaluate the radiological and clinical outcome, specifically pain, of patients having undergone robot-assisted TLIF.Materials and Methods:We performed a retrospective analysis of prospectively collected data of patients having undergone minimally invasive (MI) robot-assisted TLIF between November 2014 and July 2018 in a French university medical center. In clinical consultations at 6 weeks, 12 months, and 24 months posttreatment, patients were assessed for back and leg pain (on a visual analog scale), breached screws, and sagittal parameters.Results:A total of 136 pedicle screws were inserted with robot guidance into 32 patients. Four of the patients required laminectomy before fusion. No pedicle breach occurred for 94% of the screws, and no joint violation was observed for 90%. Lordosis was improved in 78% of the cases.Conclusions:The robot provides valuable assistance during MI arthrodesis; it facilitates the surgical procedure by preplanning the trajectory, providing instantaneous navigation and tracking, and thus assure the accuracy of screw positioning.

Surgical Techniques Ensuring Success in Posterior Endoscopic Cervical Foraminotomy and Discectomy at C6-7 in Patients with Prominent Shoulders and Short Necks

Introduction: There is a steep learning curve for a successful posterior endoscopic cervical foraminotomy and discectomy (PECFD), an important surgery for cervical foraminal or lateral disc herniation, and cervical radiculopathy due to a small operation field. PECFD becomes even more challenging in patients who have prominent shoulders and/or short necks with C6–7-disc herniation, because of the difficulty to localize C6–7 vertebral structure under fluoroscopy. The study objective is to prove that the PECFD can be performed safely and successfully to C6–7-disc herniation on patients with prominent shoulders and/or short necks following our novel surgical techniques under fluoroscopic guidance. Materials and Methods: PECFD was performed on a patient who had an extruded foraminal disc herniation at C6–7 on the left with left arm pain and weakness. Due to his prominent shoulders and a short neck, the C6–7 anatomic site was not visible under traditional anterior-posterior (AP) and lateral fluoroscopic views. The authors inserted a reference needle to C4–5 facets between C4 and C5 pedicles under AP and lateral fluoroscopic views. Following the reference needle, the C6–7 facets were easily located with an oblique fluoroscopic view. A large endoscopic cannula was used initially for adequate resection of C6–7 facets, followed by a small cannula for nerve root handling with minimal pressure and discectomy. Results: The novel surgical techniques resulted in a complete resection of the C6–7-disc herniation and resolution of the patient’s radiculopathy with no postoperative complications. Conclusion: PECFD can be safely and successfully applied for C6–7-disc herniation in patients with prominent shoulders and/or short necks using our novel surgical techniques.

Conservative Management of a Foraminal Lumbar Disc Herniation

A 39-year-old college professor presented to physical therapy via direct access, with a 2-month history of progressive lower back and right buttock pain. Following examination, the patient self-referred to a physiatrist, who ordered magnetic resonance imaging of the lumbar spine. Magnetic resonance imaging revealed a moderate, broad-based right foraminal disc herniation at L5-S1 encroaching on the right L5 nerve root exit. JOSPT Cases 2021;1(1):49–50. doi:10.2519/josptcases.2021.9776

MRI predictors of revision surgery after primary lumbar discectomy

The prognostic significance of preoperative MRI findings in patients undergoing discectomy is incompletely understood. Identifying the radiological predictors of revision surgery on pre-operative MRI can guide management decisions and potentially prevent multiple surgeries. We included 181 patients who underwent primary lumbar discectomy between 2010 and 2014. All patients were contacted via a short telephone interview to determine if they had revision surgery within 5 years of their index surgery. Preoperative MRI of the lumbosacral spine was evaluated for various radiological factors including type of disc herniation, anatomical location of herniation, direction of herniation, degree of disc degeneration, end plate changes and presence of listhesis. Other potential confounders including age, gender, smoking status and index level of surgery were also recorded. Multivariate model of all radiological predictors and confounders were developed and a step-wise approach was used to remove insignificant variables in order to develop final significant multivariate model. P value of <0.05 was considered statistically significant. Patients with retrolisthesis were found to be 2.7 times more likely than the patients without listhesis to require revision surgery (p = 0.019). Patients with foraminal disc herniation were 3.45 times more likely than the patients with paramedian disc herniation to require revision surgery (p = 0.026). Other MRI predictors failed to achieve statistical significance. Based on the data presented patients with retrolisthesis and/or foraminal disc herniation should be counselled on the relatively higher risk of revision surgery when proceeding with discectomy, or alternative options should be considered.

Minimally Invasive Navigated Foraminal Discectomy via Contralateral Approach Using a 3-Dimensional 4K High-Definition Exoscope: 2-Dimensional Operative Video.

This surgical video is the first to demonstrate a novel minimally invasive technique of utilization of surgically navigated foraminal discectomy using a 3-dimensional 4k high-definition exoscope (Sony Olympus). Typical approaches for foraminal disc herniations may involve violation of the facet resulting in subsequent destabilization requiring fusion.1 Although minimally invasive facet-sparing contralateral techniques have previously been described,2 there is continued limitations stemming from rudimentary localization with standard fluoroscopy and impaired visualization with the bulky traditional operative microscope.3 We demonstrate that high-quality real-time navigation is possible using standard Iso-C intraoperative fluoroscopy for 3-dimensional reconstructions, allowing for intraoperative routing. Navigation is particularly advantageous for adjustments in the trajectory of the tubular retractor and for confirmation of complete foraminal decompression. Visualization from the 4k high-definition exoscope also allows for an unparalleled view of the narrow operative corridor and allows for participation from the operative team. Informed consent was obtained from the patient for the surgery in its entirety.

Posterior Endoscopic Cervical Decompression: Review and Technical Note.

Endoscopic spine surgery for the treatment of degenerative spinal diseases from lumbar to cervical spine has accelerated over the past 2 decades. Posterior endoscopic cervical discectomy (PECD) has been described as a safe, effective, and minimally invasive procedure for cervical radiculopathy or even part of the myelopathy. This procedure also has been validated with comparable outcomes to open and microscopic surgery. Radiculopathy due to foraminal disc herniation or foraminal stenosis should be the optimum indications of this procedure. Intraoperative 3-dimensional navigation can help surgeons to get quick and great quality guidance for endoscopic surgeons. In this review, we will focus on the technical details and evidence-based results of PECD which is a promising procedure for cervical radiculopathy with the advantages of a minimally invasive method.

Residual leg numbness after endoscopic discectomy treatment of lumbar 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.

The minimally invasive paramedian approach for foraminal disc herniation

Foraminal disc herniation presents with an operative challenge, as it often requires facetectomy, which can result in segmental instability. The intraforaminal approach includes partial pars resection and medial facetectomy and allows for direct visualization of the nerve roots and herniated disc in the foramen without violating the joint, with good clinical outcomes. Herein, we describe a retrospective series of patients that underwent minimally invasive paramedian approach with hemilaminectomy, partial medial pars resection, medial facetectomy for foraminal disc herniation. Demographics and clinical outcomes were obtained from medical records. Improvement in functional outcomes was evaluated using the pre and post-operative Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). A total of 23 patients were included in this study. The average age was 56.47 ± 9.4 yrs and body mass index was 31.92 ± 7.7 kg/m2. 47.8% of cases were L4-5 FDH. The estimated blood loss was 31.32 ± 19.8 ml. The average length of hospital stay was 1.11 ± 0.3 days. All patients were discharged home. Overall, there was a significant improvement in the VAS (pre-op: 8.21 ± 2.1; post-op: 2.59 ± 2.7; p-value: <0.0001) and ODI (pre-op: 57.16 ± 13.2; post-op: 21.47 ± 9.9; p-value: <0.0001). The minimally invasive paramedian approach provides satisfactory outcomes as a safe strategy in the treatment of foraminal disc herniation. Herein, there was a significant improvement in pain and functional outcomes, minimal blood loss and decreased hospital stay.

Minimally invasive endoscopic foraminal decompression for adult degenerative scoliosis: clinical case study and literature review

Objective. To demonstrate opportunities of minimally invasive surgery in the treatment of deformities in patients with degenerative disease of the spine. Material and Methods. The clinical case of a 53-year-old female patient with adult degenerative scoliosis accompanied by foraminal stenosis and foraminal disc herniation at the L4–L5 level on the left with L5 root compression was considered. The clinical picture of the disease was carefully analyzed for compliance with the criteria for possibility of minimally invasive intervention as opposed to reconstructive surgery using instrumentation. The nature of the pain syndrome and its intensity according to VAS were determined, preoperative CT and MRI studies were carried out, and functional radiographs to detect signs of instability and the whole spine radiographs to calculate sagittal and coronal balance parameters were taken. A retrospective dynamic assessment of radiological data throughout the disease course was carried out to determine the dynamics of the deformity development. Postoperative follow-up was performed during 6 months. Pain syndrome was assessed according to VAS, and quality of life – according to Oswestry questionnaire. Postoperative CT and MRI studies were performed, and spinal radiographs were taken to calculate sagittal and coronal balance parameters. PubMed data and a number of meta-analyzes were considered to substantiate the choice of treatment. Results. Six months after surgery, the patient does not complain, is physically active, fully resumed work. She has not pain syndrome (VAS score 0), the Oswestry index is 8 points, neurological and static-dynamic statuses are without negative dynamics. The parameters of coronal and sagittal balance are stable. Conclusion. Endoscopic foraminal decompression may be the method of choice in the treatment of patients with adult degenerative scoliosis with a dominant clinical picture of monoradicular syndrome and compensated sagittal balance.

“Less is better”—always true?

The aim of the study is to try to explain what an overtreatment is and which ones are the possible risks related to an excess of simplification in the medical practice, through the description of an emblematic clinical case. In the present article, we report the case of a female patient aged 57 who complained about lower back pain and crural neuralgia and had a lumbar and sacral magnetic resonance imaging performed in the Department of Neuroradiology in Bari showing suspicious repetitive bone lesions; therefore, the patient underwent several medical procedures and laboratory exams which ended with a surgical removal of a left L3-L4 foraminal disc herniation and a bone biopsy. When it was finally possible to exclude any other diseases including thyroid neoplasms, a "reassuring" osteoporosis diagnosis has been made since the lesions were likely to be degenerative and the patient underwent menopause 7years ago. However, the multiplicity of the lesions of the vertebrae and of the pelvic bones as well as their signal could not be ignored, so that a close magnetic resonance imaging follow-up has been recommended. The present case is therefore a good example of overtreatment which may lead to delicate questions, investigating any possible mistakes in the diagnosis procedure as well as the role that defensive medicine is playing nowadays on medical procedures and the economic impact that all this can have on our healthcare system. In the end, we may ask ourselves: is "less" better or is "more" always "more?"

Comparative study between transforaminal epidural selective nerve root block versus interlaminar epidural in the treatment of lumbar radicular leg pain

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Sciatic neuralgia is a result of nerve root oedema because of the inflammatory, immunological and mechanical factors. Steroid injections play an important role in the management of sciatic radiculopathy. Steroids act by reducing the oedema around the nerve roots and decreasing pain. Locally administered steroids have the advantage of reduced dosage and targeted delivery around the nerve roots. This forms the basis of epidural steroid injections. This can be given around the nerve root in the transforaminal space or in the interlaminar space. There is a paucity of literature comparing the two techniques of epidural steroid injections. We have done a randomized comparative trial, to compare the effectiveness of the two modalities of injection in the management of a single level unilateral foraminal disc herniation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Patients were randomized in two groups Group A: Transforaminal epidural (SNRB) and Group B: interlaminar epidural. Same dose of steroid was used in each group.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Immediate post injection, 2 week and 1 month transforaminal epidural (SNRB) was better compare to interlaminar epidural however at the end of 3 months the difference was not significant (p=0.08).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Both transforaminal and interlaminar epidural injection are effective form of treatment in mild to moderate grade of disc disease. Both the technique provide short lasting relief in the symptoms associated with disc pathology, however pain management is better in transforaminal group compared to interlaminar group. Thus these techniques can be considered for delaying surgery and providing intermitant relief. &lt;/p&gt;

Posterolateral Endoscopic Lumbar Decompression Rotate-to-Retract Technique for Foraminal Disc Herniation: A Technical Report.

Background and Study Aim Foraminal disc herniations present the unique surgical challenge for exiting nerve root retraction and decompression. The aim of current study is to describe an innovative maneuver and evaluate its usefulness for endoscopic decompression of foraminal disc herniations. Material and Methods A retrospective review was performed including cases of foraminal disc herniations who underwent endoscopic discectomy utilizing the rotate-to-retract technique. Data on patient demographics and improvement in VAS/ODI scores were collected and analyzed statistically. Results There were ten patients (three male; seven female) in the final analysis. Seven procedures were done at the L4-L5 level, two were done at the L5-S1 level, and one was done at the L3-L4 level. The average VAS scores improved from preoperatively 7.5 to postoperatively 4.4 (p= 0.001). The mean preoperative ODI was 67.8 and improved to 26.6 postoperatively (p< 0.001). None of the cases reported any neurological or dural complication. Conclusion Foraminal disc herniations can be safely and adequately addressed endoscopically with the use of rotate-to-retract technique.

Anatomical Features of Neural Foramen at T12â€"L1 Level for Endoscopic Transforaminal Approach of Paramedian and Foraminal Disc Herniations: An Anatomical Study on Fresh Human Cadavers.

To explore the anatomic features of the neural foramen in particularly at the T12-L1 level in order to assess reveal the safety and efficiency of the endoscopic transforaminal approach for paramedian and foraminal disc herniations at this level. The study included 15 fresh human cadavers. The soft tissues were removed at the T12-L1 level and bony tissues, were exposed including the transverse processes. The bilateral facets and pars interarticulares at this level were resected revealing the foraminal anatomy and exiting roots. The anatomical structures constituting the triangular safe working zone (TSWZ) were explored. The nerve root length, nerve root width, nerve root angle, TSWZ height, and base of TSWZ base, nerve root width, nerve root angle and disc height were recorded. The root length is the hypotenuse of the TSWZ between the axilla of the exiting root and the lateral margin of the pedicle, and the mean root length was 14.94 ± 2.45 mm. The dural height is the interval between the axilla of the exiting nerve root axilla and the superior end plate of the caudal vertebra, and the mean of the dural height was 10.95 ± 1.74 mm. The base of TSWZ is the distance between the lateral margin of the dural sac and the medial margin of the exiting root, and the mean measurement for the base measurement was 11.83 ± 2.26 mm. According to the results data from our cadaveric study, we believe that Kambin’s triangular working zone is a safe area to consider for the endoscopic transforaminal approach at the T12-L1 level, especially for paramedian and foraminal disc herniations.

Transforaminal Epidural Steroid Injection in the Treatment of Pain in Foraminal and Paramedian Lumbar Disc Herniations.

To compare the effect of fluoroscopically guided transforaminal epidural steroid injections on radicular pain in foraminal and paramedian lumbar disc herniations. This study included patients who did not benefit from previous medical treatments or are not suitable for surgery. Transforaminal epidural steroid injections for the treatment of foraminal and paramedian lumbar disc herniation were performed in 370 and 1262 patients, respectively. Every group’s preprocedural visual analogue scale (VAS) and 12-week postprocedural VAS scores were recorded, and statistical analysis was performed. The complications noted were also recorded. The preprocedural and postprocedural mean VAS scores for radicular pain in foraminal disc herniation were 67.11 ± 4.28 and 34.78 ± 3.64, respectively. However, the preprocedural and postprocedural mean VAS scores in paramedian disc herniation were 62.16 ± 6.65 and 19.07 ± 4.50, respectively. Statistical analysis of the varying preprocedural and postprocedural VAS scores showed that transforaminal epidural steroid injections were more effective for paramedian disc herniation than for foraminal disc herniation (p < 0.05). Transforaminal epidural steroid injections were more effective for paramedian lumbar disc herniation than for foraminal disc herniation, 12 weeks after the procedure.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM What's New in MIS: 37. Transforaminal percutaneous endoscopic lumbar discectomy for upward migration of upper lumbar foraminal discherniation: clinical and radiological outcomes and technical considerations

PURPOSE Upper lumbar disc herniations occur from the L1-2 to L3-4 level. Compared with lower lumbar disc herniation, conventional open microdiscectomy for upward migration of upper lumbar foraminal disc herniation is associated with a higher risk of isthmic injury and wide facetectomy, which can consequently result in postoperative back pain and segmental instability. To date, there are no published studies on the feasibility of percutaneous endoscopic lumbar discectomy (PELD) for upward migrated foraminal disc herniation of upper lumbar; hence, the purpose of this study was to assess the clinical and radiologicoutcomes and the technical pitfalls of PELD for upper lumbar foraminal disc herniation with upward migration. METHODS Twenty-five patients with upward migrated foraminal disc herniation at the L1-2, L2-3, and L3-4 levels who were treated by PELD under epidural anesthesia were enrolled in this study. The clinical outcomes were assessed using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) of pain, and any complications related to the operation were analyzed. Moreover, the radiological outcomes were investigated using postoperative magnetic resonance imaging (MRI) and plain radiography. According to the preoperative sagittal magnetic resonance images, disc upward migration was classified into three zones (A, B, and C) according to the pedicle and vertebral endplates. Zones A and B were defined as the area from the lower margin of the pedicle to the lower endplate, with zone B comprising the upper half and zone A, the lower half. Zone C was defined as the area above the lower margin of the pedicle. We compared the postoperative results according to these disc migration zones. RESULTS All patients were followed for more than 2 years. The mean age was 51.1±14.9 years. Disc migrations were localized in zones A, B, and C in 13, six and six patients, respectively. After PELD, the ODI and VAS score significantly decreased from 69.8±6.5 and 8.1±0.7 to 17.5±4.4 and 2.0±0.7, respectively regardless of the disc migration zones. In 23(92%) out of the 25 patients, the ruptured disc particles were completely removed, as confirmed by postoperative MRI. In zone C, which was defined as disc migration above the lower margin of pedicle, a small remnant disc particle was detected in two patients. However, even in these two patients, the symptoms were improved after PELD. Early recurrence of the herniated disc occurred at the operated segment in one patient with a zone C migration disc. In all patients, the disc height and lordosis were well maintained at the latest follow-up. There were no significant complications related to PELD, except transient numbness and a tingling sensation in the leg in three patients. CONCLUSIONS PELD is a safe and effective treatment option for upward migrated foraminal disc herniation of the upper lumbar area. From anatomical aspect, it is associated with a relatively wide foramen as well as a lower incidence of spinal stenosis. In addition, our results suggest that PELD may prevent complications related to general endotracheal anesthesia and iatrogenic isthmic fracture, violation of facet joint and cauda equina injury. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.