Migrated Lumbar Disc Herniation Research Articles

Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis.

The surgical resection of very highly migrated lumbar disc herniation (VHM-LDH) is technically challenging owing to the absence of technical guidelines. Hence, in the present study, we introduced the transforaminal endoscopic lumbar discectomy (TELD) with two-segment foraminoplasty to manage VHM-LDH and evaluated its radiographic and midterm clinical outcomes. The present study is a retrospective analysis of 33 consecutive patients with VHM-LDH who underwent TELD with two-segment foraminoplasty. The foraminoplasty was performed on two adjacent vertebrae on the basis of the migration direction of disc fragments to fully expose the disc fragments and completely decompress the impinged nerve root. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. Additionally, imageological observations were evaluated immediately after the procedure via magnetic resonance image and computerized tomography. Clinical outcomes were evaluated by calculating the visual analog scale (VAS) score and Oswestry Disability Index (ODI). The MacNab criterion was reviewed to assess the patients' opinions on treatment satisfaction. The resection rate of bony structures were quantitatively evaluated on postoperative image. The segmental stability was radiologically evaluated at least a year after the surgery. Additionally, surgery-related and postoperative complications were evaluated. The average age of the patients was 56.87 ± 7.77 years, with a mean follow-up of 20.95 ± 2.09 months. The pain was relieved in all patients immediately after the surgery. The VAS score and ODI decreased significantly at each postoperative follow-up compared with those observed before the surgery (P < 0.05). The mean operation duration, blood loss, and hospital stay were 56.17 ± 16.21min, 10.57 ± 6.92 mL, and 3.12 ± 1.23 days, respectively. No residual disc fragments, iatrogenic pedicle fractures, and segmental instability were observed in the postoperative images. For both up- and down- migrated herniation in the upper lumbar region, the upper limit value of resection percentage for the cranial SAP, caudal SAP, and pedicle was 33%, 30%, and 34%, respectively; while those in the lower lumbar region was 42%, 36%, and 46%, respectively. At the last follow-up, the satisfaction rate of the patients regarding the surgery was 97%. Surgery-related complications including dural tear, nerve root injury, epidural hematoma, iatrogenic pedicle fractures, and segmental instability were not observed. One patient (3%) suffered from the recurrence of LDH 10 months after the initial surgery and underwent revision surgery. The TELD with two-segment foraminoplasty is safe and effective for VHM-LDH management. Proper patient selection and efficient endoscopic skills are required for applying this technique to obtain satisfactory outcomes.

Comparison of clinical outcomes between unilateral biportal endoscopic discectomy and percutaneous endoscopic interlaminar discectomy for migrated lumbar disc herniation at lower lumbar spine: a retrospective controlled study

BackgroundBoth Unilateral Biportal Endoscopic Discectomy (UBED) and Percutaneous Endoscopic Interlaminar Discectomy (PEID) have resulted in favorable clinical outcomes in the management of LDH. The aim of this study is to comprehensively compare the efficacy of UBED and PEID in treating migrated LDH in the lower lumbar spine, with a specific focus on high-grade migrated LDH.Methods96 patients who underwent UBED (31 cases) and PEID (65 cases) procedures were enrolled in the study. All patients received a minimum follow-up period of 6 months. Clinical outcomes of the patients were assessed with incision length, operation time, total hemoglobin loss, hospital stay, intraoperative fluoroscopy times, visual analogue scale (VAS) for lower back and leg pain, Oswestry disability index (ODI), modified MacNab criteria, complications, area of lamina loss and increased intervertebral height.ResultsThe VAS scores for lower back and leg pain and ODI significantly decreased in both groups after the operation. Preoperatively, at 1 day, 1 month, and 6 months after the procedure, the VAS and ODI scores exhibited no significant differences between the two groups. There was no significant difference in terms of modified MacNab criteria, area of lamina loss, and increased intervertebral height. The UBED group had a longer incision length, operation time and postoperative hospital stay, and fewer intraoperative fluoroscopy times than to the PEID group. Complications were noted in both groups throughout the follow-up period, but there was no significant difference in the rate of complications. Moreover, there were no notable differences in clinical outcomes between the two groups in the high-grade migrated LDH.ConclusionsBoth UBED and PEID could achieve favorable clinical outcomes for treating migrated LDH at the lower lumbar spine. Despite the longer operative time and postoperative hospital stay associated with the UBED group, UBED remains safe and innovative for treating migrated LDH at the lower lumbar spine.

One-hole split endoscope technique for migrated lumbar disc herniation: a single-centre, retrospective study of a novel technique

BackgroundLumbar disc herniation (LDH) is one of the most common diseases of the spine, and migrated LDH is a more serious type, associated with nerve root function injury or abnormality. Regarding the increasing surgery adoption of treating migrated LDH, we aimed to investigate the clinical efficacy and safety of discectomy with a novel technique–one-hole split endoscope (OSE) technique.MethodsThis was a retrospective analysis of migrated LDH treated between December 2020 and September 2021. Hospitalization time, operative duration, intraoperative blood loss, number of fluoroscopy exposures, incision length, postoperative facet preservation rate, number of excellent–good cases, lower back and leg visual analogue score (VAS), Oswestry Disability Index (ODI) and surgical complications were compared between high-grade migration group (82 cases) and low-grade migration group (148 cases). The Macnab criteria was used to evaluate the clinical outcome. The Shapiro‒Wilk test was used to test measurement data, and the χ2 test was used to test counting data.ResultsThere was no significant difference in hospitalization time, operative duration, intraoperative blood loss, number of fluoroscopy exposures, incision length or postoperative facet preservation rate between the two groups by independent sample t test or nonparametric test. At any time point, the lower back and leg VAS and ODI of the two groups were significantly improved compared to those before the operation, but there was no significant difference between the two groups at the same time point by two-way repeated measures ANOVA. There were two cases of postoperative nerve root stimulation symptoms in the high-grade migration group and three cases in the low-grade migration group. There was one patient reoperated in the high-grade migration group. There was no significant difference in number of excellent–good cases between the two groups. The overall excellent–good rate was 89.6%.ConclusionThe OSE technique has the advantages of less trauma, faster recovery, complete removal of the nucleus pulposus and a satisfactory early clinical efficacy in the treatment of migrated LDH.

Full Endoscopic Translaminar Approach Using 7 mm Working Endoscope for High Up Migrated Disc Herniation with Severely Collapsed Disc Space: Technical Note

The clear indication for the transforaminal approach is simple or low migrated lumbar disc herniation (LDH). The incidence of migration of the disc fragment in LDH varies from 35% to 72%. The high up migrated disc herniation into MacNab’s hidden zone remains technical challenge. We provide a technical note of seldomly performed full endoscopic translaminar approach with its potential indications. A 52 years male patient presented with low back pain with left lower limb radiculopathy for 2 months. Visual analogue scale for back and leg was 2 and 8, respectively. MRI examination revealed high up migrated disc herniation with collapsed disc space at L4-5. Dynamic radiograph was not showing any instability. Based on the preoperative surgical planning working cannula was docked over left L4 lamina perpendicular to horizontal plane. With the help of 3.5 mm endoscopic burr translaminar keyhole was drilled in a concentric manner. The distance between lateral margin of pars and keyhole was intermediately inspected for preservation of adequate bone in pars interarticularis. Though the translaminar key hole subluxated tip of SAP, up-migrated disc fragment was removed. The VAS score of leg reduced significantly from 8 to 2 in immediate postoperative period. At the end of 6 months follow up period patients leg symptoms completely improved with minimal back pain. We measured the width of remaining pars postoperatively and found to be 5 mm. The full endoscopic translaminar approach is valid alternative approach for the high up migrated HNP.

Independent reliability and availability analyses of modified classification for migrated lumbar disc herniation

Study designRetrospective cohort study.ObjectiveThe purpose of this study was to evaluate the reliability of modified classification system of migrated nucleus pulposus and its clinical application value.MethodsWe retrieved 1000 lumbar MRI of different patients in Hangzhou Hospital of Traditional Chinese Medicine from January 2016 to December 2019 for interpretation, and screened 105 migrated lumbar MRI for inclusion in the study. Three spinal surgeons made classification according to the modified classification method. Two weeks later, the sorting data of the patients were shuffled and the classification was judged by three doctors again. The consistency and repeatability of the improved classification were evaluated by Kappa coefficient. The general data of the included patients were collected. The patients were followed up for 2 years, and the risk factors of surgical treatment of patients with migrated lumbar disc herniation were analyzed. The treatment plan, surgical approach, operation time, VAS score, ODI score and other relevant data of the included patients were collected to evaluate the guiding effect of the classification system on clinical practice.ResultsIn this study, the incidence of migrated lumbar disc herniation was about 10.5%, and most of the patients were male. Patients with higher BMI are more likely to develop this disease. Our study confirmed that the modified classification has moderate to high confidence. During the 2-year follow-up period, 66 patients (62.9%) were treated conservatively, and the patients with conservative treatment were mainly A2 and B2 type (59.1%). Thirty-nine patients (37.1%) underwent surgical treatment. The patients recovered well after operation, and the low back pain and ODI index were significantly improved at 1 year after operation (P < 0.05). We suggest that type A1 and B1 migrated nucleus pulposus can be removed by posterior approach. For type A2, B2, C1, C2, the lateral approach is recommended to remove the nucleus pulposus directly. Logistic regression and ROC analysis showed that disease duration (≥ 1 year) and BMI (≥ 24) maybe were risk factors for surgical treatment of patients with migrated lumbar disc herniation.ConclusionThe modified classification has good reliability. In the current study, the experience level of spine surgeons does not affect the reliability of the classification system. Our study confirmed that this classification has a good reference value for guiding the treatment plan and the choice of surgical approach.

Full Endoscopic Transpedicular Technique in the Treatment of High Grade Down Migrated Herniated Disc: An Evaluation of Clinical Outcomes at 12 Months Follow-Up

High-grade migrated lumbar disc herniation (LDH) such as up-migrated and down-migrated discs are challenging pathologies to treat. High-grade migrated discs are usually sequestered and situated adjacent to the medial pedicle wall. This can be easily addressed if the pedicle is used as an access route. The authors present a retrospective case series of high-grade migrated LDH treated using a full endoscopic transforaminal approach. This is a retrospective case series. The clinical outcomes in the patients were evaluated according to improvement in the symptoms as suggested by improvement in Visual Analog Score (VAS) and Oswestry Disability Index (ODI) scores in the immediate postoperative period and at the final follow-up. The radiological outcomes were evaluated using postoperative magnetic resonance imaging and computed tomography scans. After the data were collected and tabulated, descriptive statistics were used for continuous variables. The t test was used to determine the significance of changes in the VAS and ODI scores. Statistical significance was set at P<0.05. Five patients underwent discectomy using the transpedicular technique, and the mean preoperative VAS scores for the back and leg were 7.2±0.83 and 8.4±0.54, respectively. The mean VAS scores at the final follow-up for the back was 0.2±0.4 and 0 for the leg (P < 0.05). The mean preoperative ODI score was 72±8.3, which improved to 6±4.69 at the final follow-up (P < 0.05). All patients had a hospital stay of 1day. The full endoscopic transpedicular approach is a good option for treating highly migrated LDH. Surgical planning, including pedicle morphometry and the angle of the approach, should be undertaken preoperatively for the best results.

Unilateral biportal endoscopic discectomy for high-grade migrated lumbar disc herniation

To investigate the effectiveness of the unilateral biportal endoscopy (UBE) technique in the treatment of high-grade migrated lumbar disc herniation (LDH). Between January 2020 and February 2021, 23 cases of high-grade migrated LDH were treated with discectomy via UBE. There were 14 males and 9 females, with a mean age of 48.7 years (range, 32-76 years). All patients had low back and leg pain. The disease duration ranged from 2 months to 7 years (median, 13 months). Lesion segments were L 3, 4 in 2 cases, L 4, 5 in 15 cases, and L 5, S 1 in 6 cases. The operation time, intraoperative blood loss, the time when the patients started to move off the floor, and postoperative complications were recorded. The effectiveness was evaluated using the visual analogue scale (VAS) score, the modified Oswestry disability index (ODI), and the modified MacNab criteria. All operations were completed successfully, and no complication such as dural tear, epidural hematoma, nerve injury, or vascular injury occurred. The operation time ranged from 53 to 96 minutes, with an average of 71.0 minutes. The intraoperative blood loss ranged from 32 to 56 mL, with an average of 39.3 mL. All patients were removed the drainage tube and wore a lumbar brace to move off the floor around 1 to 2 days after operation. All patients were followed up 3-12 months after operation, with an average of 5.7 months. The VAS scores of low back pain and leg pain and the modified ODI at all postoperative time points were lower than those before operation, and the differences were significant ( P<0.05). The differences were significant ( P<0.05) when comparing the above indexes between the time points after operation. At last follow-up, the effectiveness was evaluated according to the modified MacNab criteria, and 17 cases were excellent, 4 cases were good, and 2 cases were fair, with an excellent and good rate of 91.3%. There was no recurrence of LDH during follow-up. Discectomy via UBE is an effective method for the treatment of high-grade migrated LDH because of its flexibility, clear view, and wide range of intraoperative exploration, which can effectively reduce the risk of residual nucleus pulposus after operation.

Unilateral Biportal Endoscopic Translaminar Keyhole Approach to Treat High-grade Up-migrated Lumbar Disc Herniation: Technical Note

The incidence of lumbar disc fragment migration is approximately 35%–72% of which 34% are high-grade up-migrated discs. Translaminar keyhole approach is a minimally invasive and true tissue sparing technique which has been applied to approach migrated disc herniation. The unilateral biportal endoscopic approach is an emerging technique among endoscopic spine surgery that combines the advantages of microscopic surgery with endoscopic surgery. In this technical report we demonstrate the surgical technique of performing the translaminar keyhole approach with unilateral biportal endoscopic spine surgery to treat high-grade up-migrated discs. As far as we know, this is the first technical report of unilateral biportal endoscopy with translaminar keyhole approach to treat high-grade up migrated lumbar disc herniation.

Targeted fully endoscopic visualized laminar trepanning approach under local anaesthesia for resection of highly migrated lumbar disc herniation.

To introduce a new fully endoscopic visualized laminar trepanning approach with a periendoscopic trephine under local anesthesia for resection of highly migrated lumbar disc herniation (LDH) and report the clinical outcomes of oneyear follow-up. Twenty-one patients with highly migrated LDH who underwent percutaneous endoscopic lumbar discectomy via the laminar trepanning approach from June 2019 to August 2020 were retrospectively reviewed. Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms-Pain Interference (PI) and Physical Function (PF) were selected as outcome measures. The operating duration and complication were documented. The average age of the 21 patients (15 males, 6 females) was 37.8 ± 6.0years (29-52years). Disc migration originated from L4/5 in 19 patients, L5/S1 in two patients. The mean operative duration was 54.1 ± 9.0minutes (42-79min). All patients were followed up to 12months after the operation. PROMIS PI T-scores decreased significantly from pre-operatively mean 68.6 ± 2.4 to 54.4 ± 1.9 (P < 0.001) and 47.1 ± 4.3 (P < 0.001) at sixweeks and 12months, respectively. PROMIS PF T-scores improved significantly from pre-operatively mean 26.7 ± 4.7 to 44.3 ± 4.2(P < 0.001) and 58.4 ± 4.0 (P < 0.001) at sixweeks and 12months, respectively. No complications and disc herniation recurrences occurred. The targeted full endoscopic laminar trepanning under local anesthesia with a visualized periendoscopic trephine offers a safe, efficient and cost-effective option for the resection of highly migrated LDH.

Full-endoscopic foraminoplasty for highly down-migrated lumbar disc herniation

Background and study aimsMultiple surgical approaches have been studied and accepted for the removal of highly downward migrated lumbar disc herniation (LDH). Here, we investigated the efficacy and safety of full-endoscopic foraminoplasty for highly downward migrated LDH.Patients and methodsThirty-seven patients with highly down-migrated LDH treated by the full-endoscopic foraminoplasty between January 2018 and January 2020 were retrospectively investigated. Clinical parameters were evaluated preoperatively and 1, 6, and 12 months postoperatively, using pre- and post-operative Oswestry Disability Index (ODI) scores for functional improvement, visual analog scale (VAS) for leg and back pain, and modified MacNab criteria for patients satisfactory.ResultsThirty-seven patients with highly downward migrated LDH were successfully removed via the transforaminal full-endoscopic discectomy. The average VAS back and leg pain scores were significantly reduced from 7.41 ± 1.17 and 8.68 ± 1.06 before operation to 3.14 ± 0.89 and 2.70 ± 0.46 at postoperative 1 month, and 1.76 ± 0.59 and 0.92 ± 0.28 at postoperative 12 months, respectively (P < 0.05). The average ODI scores were reduced from 92.86 ± 6.41 to 15.30 ± 4.43 at postoperative 1 month, and 9.81 ± 3.24 at postoperative 12 months (P < 0.05). Based on the modifed MacNab criteria, 36 out of 37 patients (97.30%) were rated as excellent or good outcomes.ConclusionThe full-endoscopic foraminoplasty can be used successfully for surgical removal of high grade down-migrated LDH, and it could serve as an efficient alternative technique for patients with highly downward migrated LDH.

A New Grading System for Migrated Lumbar Disc Herniation on Sagittal Magnetic Resonance Imaging: An Agreement Study

Understanding the degree of disc migration is essential in order to diagnose, treat, and assess the prognosis of migrated lumbar disc herniation (LDH). Based on anatomical configuration, we developed a simple six-level grading system for migrated lumbar disc herniation. We aimed to evaluate whether the new grading system was reliable and could replace the previous grading system. We selected 101 cases from our database. Two independent raters evaluated the magnetic resonance images using each grading system. Interobserver, intraobserver, and inter-grading system agreements were assessed using kappa statistics. The most common migration pattern was low-grade inferior migration. Interobserver agreements between the two readers showed substantial agreement in the first and second assessments (k = 0.753 and 0.756, respectively). The intraobserver agreement of reader 1 revealed substantial agreement (k = 0.733), while that of reader 2 revealed almost perfect agreement (k = 0.829). The strengths of the agreements of the new grading system were higher than those of the Lee-Kim grading system. The two grading systems agreed almost perfectly for most measurements. The new grading system was reliable and feasible to determine migrated LDH grade. It allowed for a more intuitive, objective measurement and helped select surgical options.

Transforaminal Endoscopic Lumbar Discectomy with Foraminoplasty for Down-migrated Disc Herniation: A Single-center Observational Study

Objective: Full-endoscopic lumbar discectomy has evolved to be an alternative for the treatment of lumbar disc herniation. Regarding the techniques, the transforaminal approach remains the primary access. The indications of transforaminal endoscopic lumbar discectomy (TELD) have expanded following the evolution of the techniques, especially TELD with foraminoplasty. This study is to evaluate the efficacy of the TELD with foraminoplasty for downward migrated lumbar disc herniation.Methods: The authors conducted a retrospective study with prospectively collected data in a single center. The study enrolled patients with downward migrated lumbar disc herniation undergoing TELD with foraminoplasty from May 2009 to June 2018. All procedures were performed under local anesthesia. Patients' demographics, clinical outcomes, and satisfaction with surgery were recorded. Results: There were 126 patients included in the current study. The mean age was 50.7±17.4 years old. The leg pain and functional outcome scores significantly improved after the operation. There was no neurological deficit or iatrogenic instability requiring fusion surgery. The operation time was within 2 hours in most cases (92%). Thirteen patients reported minor complications, but symptoms were self-limited or responded to conservative treatment. The operation satisfied 94.4% of patients. Seven cases underwent revision surgery within six months due to recurrence.Conclusion: TELD with foraminoplasty under local anesthesia can be an alternative for downward migrated lumbar disc herniation. Nerve root irritation can be detected without intraoperative neurophysiological monitoring when the patient is awake during the procedures. The clinical outcomes were favorable and the risk of complication was low with the current technique.

Quantitative Evaluation of the Trauma of CT Navigation PELD and OD in the Treatment of HLDH: A Randomized, Controlled Study

More evidence is required to support that computerized tomography navigation percutaneous spinal endoscopy in the treatment of highly migrated lumbar disc herniation is a more minimally invasive surgery than open discectomy . To quantitatively evaluate the efficacy and minimal invasiveness of computerized tomography navigation percutaneous spinal endoscopy and open discectomy in highly migrated lumbar disc herniation. A prospective randomized study. First Affiliated Hospital of Gannan Medical College. From August 2016 to February 2020, 68 patients with highly migrated lumbar disc herniation had undergone discectomy. Thirty-five of them randomly received computerized tomography (CT) navigation percutaneous spinal endoscopy at the pain department (CT navigation percutaneous spinal endoscopy group), and 33 patients received open discectomy at the orthopedics department (open discectomy group). The Visual Analog Scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and modified MacNab criteria were applied to evaluate the clinical situations pre- and post-operation. The serum concentrations of IL-6, TNF-alpha, creatine phosphokina (CPK), and C-reactive protein (CRP) in the 2 groups were quantitatively measured. The postoperative VAS scores of the back and lower extremity were lower than those pre-operation in both groups, while the VAS score of back pain in the open discectomy group was significantly higher than that in the CT navigation percutaneous spinal endoscopy group at one week post-operation (P < 0.01). The postoperative JOA scores were significantly higher than those pre-operation in both groups. The serum concentrations of IL-6, TNF-alpha, CPK, and CRP in the open discectomy group were higher than those in the computerized tomography navigation percutaneous spinal endoscopy group postoperatively (P < 0.01). This is a single-center randomized study and with the limitation of the sample size. CT navigation percutaneous spinal endoscopy is a more minimally invasive surgery than open discectomy.Certificate number for the medical institution conducting the clinical trials for humans in China: 934.

Surgical Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion for Highly Migrated Lumbar Disc Herniation.

ObjectiveTo describe minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for highly migrated lumbar disc herniation (LDH) and assess its clinical outcomes.Patients and MethodsThis research retrospectively assessed 25 patients who were diagnosed with one-segmental highly migrated LDH and underwent MIS-TLIF in Peking University First Hospital from June 2015 to September 2019. Demographic data, perioperative parameters, complications, recurrence, and surgical outcomes were assessed.ResultsTwelve males and 13 females, with a mean age of 56.68 years old, were involved and the follow-up period was at least one year. The mean operation time was 222.16 minutes, the mean intraoperative hemorrhage was 250.00 mL, and the mean post-operative hospitalization was 5.76 days. The improvements in visual analog scale (VAS) and Oswestry disability index (ODI) were statistically significant. In addition, based on the MacNab criteria, 22 patients (88.0%) acquired satisfactory (good or excellent) results. One patient underwent post-operative epidural hematoma and recovered after evacuation of the hematoma. No recurrence was found.ConclusionMIS-TLIF is safe and effective and it can provide satisfactory clinical outcomes for highly migrated LDH.

How I do it? Full endoscopic transforaminal approach for lumbar disc herniation that migrated bilaterally to four corners.

Despite of the evolution of endoscopic surgery, the literature on technique uniportal transforaminal endoscopic lumbar discectomy (TELD) for bilateral lesions is scarce. Unilateral TELD was performed in a patient with bilateral superior and inferior migrated, broad-based disc herniation presenting with an impaired neurological state. The key surgical steps focus on free mobility in Kambin triangle with the mobile outside-in technique and accessibility to contralateral lesions with an extensive annular resection procedure. TELD can be a surgical option for treating bilateral multiple direction migrated lumbar disc herniation with benefits of minimal neural retraction and facet joint preservation.

Functional outcomes of full-endoscopic spine surgery for high-grade migrated lumbar disc herniation: a prospective registry-based cohort study with more than 5\u2009years of follow-up

BackgroundFull-endoscopic lumbar discectomy (FELD) is an alternative to posterior open surgery to treat a high-grade migrated herniated disc. However, because of the complexity of the surgery, success is dependent on the surgeon’s skill. Therefore, patients are frequently treated using open discectomy. Anatomical constraints and technical difficulties can lead to the incomplete removal of high-grade migrated discs.MethodsWe retrospectively reviewed patients who had undergone FELD performed by a single surgeon between January 2010 and January 2014 from a prospective spine registry in an institute. Perioperative records and data of the Oswestry Disability Index, visual analog scale scores (preoperatively and 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and 5 years after the operation), and MacNab criteria were collected.ResultsOf 58 patients with a follow-up duration of > 5 years, (41 and 17 patients had undergone transforaminal endoscopic lumbar discectomy [TELD] and interlaminar endoscopic lumbar discectomy [IELD], respectively), the satisfaction rate was 87.8% (five unsatisfactory cases) for TELD and 100% for IELD. The overall percentage of patients with good to excellent results according to modified MacNab criteria was 91.3% (53/58 patients). Two patients had residual discs. Two patients needed an open discectomy due to recurrent disc herniation. One IELD patient received spinal fusion surgery due to segmental instability after 5 years.ConclusionFELD has a high success rate for the management of high-grade migrated herniated discs. In patients with high-grade disc migration from L1 to L5, TELD is effective and safe. However, for L4–L5 and L5–S1 high-grade upward and downward disc migration, IELD is the favorable option and provides high patient satisfaction.

The Trans-Superior Articular Process Approach Utilizing Visual Trephine: A More Time-Saving and Effective Percutaneous Endoscopic Transforaminal Lumbar Discectomy for Migrated Lumbar Disc Herniation.

To introduce, and to evaluate the efficacy of the trans-superior articular process (trans-SAP) approach utilizing visual trephine in percutaneous endoscopic transforaminal lumbar discectomy (PETLD) for migrated lumbar disc herniation. This study included 98 patients, 50 patients were in trans-SAP PETLD group and 48 patients were in conventional PETLD group. Visual analogue scale (VAS), Oswestry disability index (ODI), gender, age, blood loss, operation time, the frequency of X-ray fluoroscopy and the percentage of highly migrated herniation were evaluated and compared between the trans-SAP PETLD and conventional PETLD group. In both trans-SAP PETLD and conventional PETLD group, VAS and ODI were decreased at postoperative 1 day and 3 months compared with preoperative (p < 0.001). What's more, the VAS and ODI of postoperative 3 months were lower than postoperative 1 day (p < 0.001). There was no difference in gender, age, blood loss after the operation, and VAS during operation between trans-SAP group and conventional group (p > 0.05). The blood loss during the operation of trans-SAP group was higher (p < 0.05), but the operation time and frequency of X-ray fluoroscopy were lower than conventional group (p < 0.001). Last, trans-SAP group had a higher percentage of highly migrated herniation (p < 0.001). Both the conventional way and trans-SAP approach can achieve excellent surgical results. But, in trans-SAP group, the operation time is shorter, and X-ray fluoroscopy is less. PETLD with visual trephine has more advantages in highly migrated herniation and maybe easier to be mastered by young surgeons.

ANALYSIS OF THE RELIABILITY OF THE LEE CLASSIFICATION FOR LUMBAR DISC HERNIATIONS

ABSTRACT Objective To evaluate the intra- and interobserver reliability of the Lee et al. classification for migrated lumbar disc herniations. Methods In 2018, Ahn Y. et al. demonstrated the accuracy of this classification for radiologists. However, magnetic resonance images are often interpreted by orthopedists. Thus, a cross-sectional study was conducted by evaluating the magnetic resonance images of 82 patients diagnosed with lumbar disc herniation. The images were evaluated by 4 physicians, 3 of whom were spinal orthopedic specialists and 1 of whom was a radiologist. The intra- and interobserver analysis was conducted using the percentage of concordance and the Kappa method. Results The report of the classifications used by the four observers had a higher proportion of “zone 3” and “zone 4” type classifications in both evaluation moments. The most affected anatomical levels were L5-S1 (48.2%) and L4-L5 (41.4%). The intra- and interobserver concordance, when comparing both moments evaluation of the complementary examinations of the participants involved, was classified as moderate and very good. Conclusions Lee’s classification presented moderate to very good intra- and interobserver reliability for the evaluation of migrated lumbar disc herniation. Level of evidence II; Retrospective Study.

Biportal endoscopic discectomy for high-grade migrated lumbar disc herniation.

Although endoscopic procedures for lumbar disc herniation have improved greatly and offer many advantages, the indications are limited mostly to nonmigrated or low-grade migrated disc herniation. Endoscopic application in migrated disc herniation cases is still challenging and technically demanding. The goal in this study was to determine the feasibility of biportal endoscopic discectomy for removal of high-grade migrated disc herniation. A retrospective review was performed in 262 patients who had undergone biportal endoscopic discectomy after the diagnosis of lumbar herniated disc. According to preoperative MRI findings, disc herniation was classified into 5 zones based on the direction and distance from the disc space. Patients were divided into 2 groups-a high-grade migration group and a low-grade migration group. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI), visual analog scale (VAS), and modified Macnab criteria, and those outcomes and operation time were compared between the 2 groups. There were 10 patients with "high-grade up," 8 with "low-grade up," 98 with disc-level, 102 with "low-grade down," and 44 with "high-grade down" herniation, thereby yielding 54 patients in the high-grade group and 208 in the low-grade group. Demographic data for the 2 groups showed no significant difference. There was no significant difference between the 2 groups in ODI, VAS, and modified Macnab criteria. Operation time between the 2 groups was not significantly different (60.74 vs 65.63 minutes, p > 0.05). Biportal endoscopic discectomy can be effective for high-grade migrated lumbar disc herniation with no prolonged operation time and satisfactory clinical outcomes.

Percutaneous Endoscopic Transforaminal Decompression in the Treatment of Patients with Migrated Lumbar Disc Herniation: A Retrospective Study

We aimed to discuss the surgical strategies, safety and clinical efficacy of percutaneous endoscopic transforaminal decompression for the treatment of patients with migrated lumbar disc herniation. This is a retrospective study. From May 2014 to April 2017, a total of 56 patients (32 men and 24 women) with migrated lumbar disc herniation were operated on by percutaneous endoscopic decompression via transforaminal approach. All enrolled patients had clinical symptoms with radiculopathy, and were identified as single-level, soft herniated disc by computed tomography and magnetic resonance imaging. Clinical efficacy were evaluated chiefly by leg pain visual analogue scale score, Oswestry disability index score, and modified MacNab criteria. Patients were all successfully treated by percutaneous endoscopic transforaminal decompression, with an mean operation time of 63 ± 12 minutes. The patients were followed up for a mean duration of 15 ± 2.7 months (range 12-18 months). The leg pain visual analogue scale score was dropped from 8.2 ± 1.9 preoperatively to 2.4 ± 1.5, 2.2 ± 1.3, and 1.8 ± 1.1 at 1, 6, and 12 months after the operation, respectively. Similarly, the Oswestry disability index score was also decreased from 62.4 ± 8.2 preoperatively to 18.4 ± 6.2, 12.6 ± 5.1, and 9.2 ± 3.4 at 1, 6, and 12 months postoperatively. There were 38 excellent cases, 13 good cases, and 5 fair cases by the assessment method of modified MacNab criteria at 12 months after the operation, with an excellent and good rate of 91.07%. Two cases were complicated with low extremity numbness, which were recovered by conservative treatment in 3 weeks. No persistent neurological deficit or infection occurred in this group postoperatively. We consider that percutaneous endoscopic decompression via transforaminal approach provided a safe, effective and minimally invasive alternative for the treatment of patients with migrated lumbar disc herniation.