Transforaminal Percutaneous Endoscopic Lumbar Discectomy Research Articles

Letter to the Editor Regarding: “Coronavirus Neurosurgical/Head and Neck Drape to Prevent Aerosolization of Coronavirus Disease 2019 (COVID-19): The Lenox Hill Hospital/Northwell Health Solution”

Transforaminal percutaneous endoscopic lumbar discectomy (TPELD) has become an alternative and minimally invasive surgical technique for soft lumbar disc herniation. However, the learning curve has been relatively long and difficult. In the present study, we have summarized the characteristics of the learning curve of TPELD, including the number of cases required to achieve technical proficiency, and discussed the strategies to improve the learning curve.The PubMed, Embase, Cochrane Library, and KoreaMed databases were searched for reports describing the learning curve for TPELD. Clinical studies involving human patients and evaluating the learning curve of TPELD with quantitative data were included. A strict quality assessment was completed, and descriptive statistics were calculated.Of the 6884 screened titles and abstracts, 10 full-text reports, including 958 cases, were included in the analysis. All were cohort studies, which were grouped into early and late groups according to surgeon experience with TPELD. The most commonly used cutoff to differentiate between these groups was 20 (mean, 24.70 ± 18.99 cases; range, 10–72 cases). The most widely used measure was the operative time. Although most studies had reported better results in the operative time or pain scores in the late group, only 1 study had proposed a bona fide learning curve.We found insufficient evidence to support a cutoff point of 20 or other numbers of cases for determining when the learning curve has reached a plateau. Therefore, these numbers should be interpreted with great care, and high-quality prospective studies evaluating the actual learning curve are required.

Unrecognized Dural Tear During Transforaminal Percutaneous Endoscopic Lumbar Discectomy

Journal of Minimally Invasive Spine Surgery & Technique (JMISST) is the official journal of the Korean Minimally Invasive Spine Surgery Society (KOMISS) for the publication of research results about minimally invasive spinal surgery (MISS), including studies in spinal endoscopic surgery, minimally invasive procedure for degenerative spine disease, pain intervention, and minimally invasive surgery for spinal fusion or spine trauma, neuroscience, neurology, molecular biology and biomechanics etc. Articles with helpful information for MISS such as reports of rare cases or technical review of special devices or equipment are also available

71. Can the novel lumboiliac triangle technique based on biplane oblique fluoroscopy facilitate transforaminal percutaneous endoscopic lumbar discectomy for patients with L5-S1 disc herniation combined with high iliac crest? A case-control study of 100 patients

BACKGROUND CONTEXT Percutaneous endoscopic lumbar discectomy (PELD) via the transforaminal approach is difficult at L5-S1 in patients presenting with high iliac crests (HIC). The conventional wisdom is that measurement using lumbar radiography, CT or MRI is necessary. PURPOSE To introduce a lumbo-iliac triangular (LI-Tri) technique based on biplane oblique fluoroscopy and verify whether it facilitates transforaminal PELD for patients with L5-S1 LDH combined with HIC. STUDY DESIGN/SETTING Retrospective case-control study. PATIENT SAMPLE The definition of HIC is derived from Choi's degree system, classifying the relationship between the location of the highest point of the iliac crest and the adjacent bony structures such as the L5 pedicle, and the L4 inferior and S1 superior endplates. In our patient selection, the highest point of the iliac crest above the mid-point of the L5 pedicle (Type>5) was regarded as ‘HIC.’ Between January 2016 and December 2016, 100 patients with LDH combined with HIC were treated with PELD via a unilateral transforaminal approach in two tertiary spine centers. Inclusion criteria were as follows: (1) clinical symptoms and signs of unilateral neurological deficit including radiculopathy, paresthesia, motor weakness that did not respond to conservative treatments including medication, physiotherapy, and nerve root blocks for 6 weeks; (2) symptoms corresponding to preoperative MRI and/or CT scans. Exclusion criteria were as follows: (1) definite segmental instability (anterior or posterior displacement>3 mm or the angle change of the endplate>15 ° on the dynamic radiography); (2) severe central canal stenosis (less than 10 mm) on preoperative MRI or CT; (3) cauda equina syndrome; (4) highly migrated nucleus pulposus beyond the low rims of adjacent pedicles; and (5) suspected infection or malignant diseases. OUTCOME MEASURES Besides the mean operative duration, clinical outcome evaluation included the Oswestry Disability Index (ODI) score and visual analog scale (VAS) score without the usage of analgesic to truly reflect the intensity of back and leg pain. Relevant complications, including intraoperative conversion from conventional puncture to LI-Tri technique, postoperative dysthesias and motor weakness were also recorded. METHODS The LI-Tri technique was used in the first 50 patients (applied group) with L5-S1 disc herniation. The other 50 patients were classified as non-applied group, in which the conventional puncture process was performed. The puncture location was considered unsatisfactory after 20 puncture attempts, regarded as a difficult puncture. If this occurred in the non-applied group, the LI-Tri technique was introduced into the puncture process, as with the applied group. Three senior surgeons with experience of over 500 transforaminal PELD cases performed the surgeries. The intervals of follow-up were scheduled at 1 day, 1, 3, 6, 12 and 24 months after surgery. Postoperative MRI or CT examinations were recommended, especially for patients without satisfactory symptom relief. RESULTS No significant difference was observed with respect to demographic information (P .05, respectively). With the exception of the back pain VAS and ODI at 1 day postoperatively, no significant difference was observed in the three parameters at other time-points postoperatively between two groups (P>.05, respectively). CONCLUSIONS For patients with L5-S1 LDH combined with HIC treated by transforaminal PELD, the LI-Tri technique is simple and effective in preoperative evaluations, locating the skin entry point and guiding the puncture trajectory. Compared to the conventional technique, it shows advantages in terms of reducing intraoperative surgical duration and promoting fast postoperative recovery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Percutaneous Endoscopic Transforaminal Lumbar Discectomy via Eccentric Trepan foraminoplasty Technology for Unilateral Stenosed Serve Root Canals.

ObjectiveTo evaluate the clinical outcomes of percutaneous lumbar foraminoplasty for unilateral stenosed nerve root canals.MethodsThe article is a retrospective analysis. From May 2016 to April 2017, 32 patients with lumbar spinal stenosis syndrome (unilateral stenosed nerve root canals) were treated with percutaneous endoscopic transforaminal lumbar discectomy (PETLD). The study included 15 men and 17 women, with an average age of 53.8 ± 15.4 years, ranging from 24 to 78 years. The indexes used for preoperative and postoperative 1 day, 3 months, and final follow up were the visual analogue scale (VAS) for lumbar and leg, the Oswestry disability index (ODI), and the modified Macnab criteria. All patients were followed up for an average 6 months after the operation.ResultsThe average operative time was 75.82 ± 10.58 min, the average blood loss was 15.83 ± 3.75 mL, and the average hospital stay after surgery was 6.2 ± 4.6 days. The VAS score (leg) decreased from 6.94 ± 0.50 preoperatively to 1.16 ± 0.45 at the final follow up (P < 0.05) and ODI were obviously improved, from preoperative evaluation of 80.19 ± 5.55 to 9.44 ± 1.16 at the final follow up (P < 0.05). However, the postoperative VAS score (lumbar) did not show an improvement, reducing from 1.78 ± 0.49 preoperatively to 1.62 ± 0.55 at the final follow‐up (P > 0.05). According to the modified Macnab criteria, the outcome showed that the excellent and good rate was 90.6%. There were three patients with hip soreness, and nerve root symptoms were relieved.ConclusionPercutaneous endoscopic transforaminal lumbar discectomy has a satisfactory clinical effect in the treatment of lumbar spinal stenosis syndrome, especially for unilateral stenosed nerve root canals, and in decompressing the lateral recess and relieving the nerve root symptoms.

Cauda Equina Syndrome: A Review of 15 Patients Who Underwent Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD) Under Local Anaesthesia.

Introduction:To analyse the results of Cauda Equina Syndrome (CES) operated by Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD).Material and Methods:The study is a retrospective series of 15 patients operated by PTELD. Bladder dysfunction was classified as incomplete CES (CESI) and complete CES retention (CESR). Bladder / motor recovery rate and its timing, Oswestry Disability Index (ODI), Visual Analogue Score (VAS), patient satisfaction index, and sexual dysfunction were used to measure the outcome objectively. Additionally, in CESR patients, post-void residual (PVR) urine was measured by sonography. Complications and technical problems were noted.Results:There were ten patients of CESI and five patients of CESR. The average follow-up was 20.33(12.05) months. Bladder symptoms recovery was 100%, and motor recovery was 80%. VAS for back pain recovered to 0.53(0.52) from 8(2.39). VAS for leg pain recovered to 0.13(0.35) from 9.20(1.32). ODI improved to 6.07(2.85) from 77.52(13.20). The time to the recovery of bladder function was 1.47(1.55) days. All CESR patient’s abnormal PVR urine was normalised at five weeks post-operative. No complications were reported. However, five technical executional problems occurred.Conclusion:PTELD can be considered for CES treatment due to its substantial and quick recovery advantages. However, more evidence support is needed to make it a practice recommendation.

Transforaminal percutaneous endoscopic lumbar discectomy combined with anchorage technique of pedicle for the treatment of high prolapse free lumbar disc herniation

To investigate the clinical effects of percutaneous spinal endoscopy (percutaneous endoscopy) in the treatment of high prolapse free lumbar disc herniation. From May 2016 to June 2018, 24 patients with highly prolapse free lumbar disc herniation were enrolled in this study, including 11 males and 13 females, ranging in age from 48 to 72 years old, with an average of (59.5±7.2) years old. There were 1 case of L2, 3, 5 cases of L3, 4, 18 cases of L4, 5. The course of disease ranged from 8 to 26 months, with an average of (16.2±6.3) months. All the patients were subjected to local infiltration anesthesia. The clinical outcomes were evaluated by visual analog scale (VAS) for leg pain, low backpain and Oswestry Disability Index (ODI) at preoperative, first day after operation and 6 month after surgery. All data were statisticed by SPSS 22.0. All the patients were followed up, and the duration ranged from 12 to 24 months, with a mean of (17.5±5.3) months. The average operation time was(69.8±14.2) minutes. One patient had cerebrospinal fluid leakage, which improved after supine rest. VAS scores of lower back pain were 6.36±1.27, 3.94±1.03, 1.62±0.87, 0.44±0.27, 0.37±0.29. VAS scores of leg pain were 8.28±1.74, 3.16±1.24, 2.83±1.13, 0.83±0.31, 0.46±0.31, and the differences were statistically significant (P<0.05). The ODI were (48.79±9.83)%, (36.51±11.24)%, (21.05±6.35)%, (9.83±4.62)% and (7.24±4.72)% 1 day before and 1 weeks, 3 months, 6 months and 1 year after the operation, respectively. One year after the operation, the modified Macnab evaluation system was used to evaluate the clinical efficacy of the patients, 19 patients got an excellent result, 3 good, 2 fair and 0 poor. Percutaneous endoscopic pedicle anchoring technique for the treatment of high prolapse free lumbar disc herniation can effectively improve the clinical symptoms of patients, and has the advantages of less trauma, less bleeding, rapid recovery, complete removal of the nucleus pulposus, and less pain of patients, etc., its clinical efficacy is accurate, operability is strong, it is worth promoting in the clinical use.

Can the Novel Lumbo-Iliac Triangle Technique Based on Biplane Oblique Fluoroscopy Facilitate Transforaminal Percutaneous Endoscopic Lumbar Discectomy for Patients with L5-S1 Disc Herniation Combined with High Iliac Crest? A Case-Control Study of 100 Patients

Background: Percutaneous endoscopic lumbar discectomy (PELD) via the transforaminal approach is difficult at L5-S1 in patients presenting with high iliac crests (HIC). The conventional wisdom is that measurement using lumbar radiography, computed tomography (CT), or magnetic resonance imaging (MRI) is necessary. Objectives: The objective of this study was to introduce a lumbo-iliac triangular (LI-Tri) technique based on biplane oblique fluoroscopy and verify whether it facilitated transforaminal PELD for patients with L5-S1 lumbar disc herniation (LDH) combined with HIC. Study Design: A retrospective analysis. Setting: All data were from Honghui Hospital in Xi’an. Methods: One hundred patients with L5-S1 LDH combined with HIC were treated with PELD. The LI-Tri technique was used in the first 50 patients (applied group). The other 50 patients were classified as the nonapplied group, in which the conventional technique was performed. Clinical outcome evaluation included Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores. The intervals of follow-up were scheduled at 1 day and 1, 3, 6, 12, and 24 months postoperatively. Results: No significant difference was observed with respect to demographic information (P &lt; .05, respectively). There were 8 patients in the nonapplied group with difficult punctures. Together with the remaining 50 patients, the puncture was successful with the LI-Tri technique. The mean operative duration was shorter in the applied group (55 vs 70 min, P &lt; .01). Compared to the preoperative data, only the back pain VAS and ODI in the nonapplied group were nonsignificantly lower at one day postoperatively (P &gt; .05, respectively). With the exception of the back pain VAS and ODI at one day postoperatively, no significant differences were observed in the 3 parameters at other time points postoperatively between 2 groups (P &gt; .05, respectively). Limitations: The study is limited by its retrospective, nonrandomized controlled design. Conclusions: For patients with L5-S1 LDH combined with HIC treated by transforaminal PELD, the LI-Tri technique is simple and effective in preoperative evaluations, locating the skin entry point and guiding the puncture trajectory. Compared to the conventional technique, it shows advantages in terms of reducing intraoperative surgical duration and promoting fast postoperative recovery. Key words: Endoscopic discectomy, iliac crest, L5-S1 disc, PELD, percutaneous, transforaminal.

Two cases of retroperitoneal hematoma after transforaminal percutaneous endoscopic lumbar discectomy

IntroductionTransforaminal percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive spinal procedure for soft disc herniation of the lumbar spine. It is considered relatively safe and is commonly used. However, hemorrhagic complications can occur. Herein, we report two cases of severe retroperitoneal bleeding after transforaminal PELD. Case reportsTwo patients underwent PELD at the L4-5 level, and the preoperative symptoms improved. However, a few hours after the surgery, the patients complained of severe abdominal pain. Radiologic evaluation showed a large retroperitoneal hematoma compressing the abdominal organs. ResultsThe patients did not undergo an open hematoma evacuation but received intensive care. After 9–14 days of intensive care, they recovered and were discharged. ConclusionRetroperitoneal hematoma may occur after PELD due to segmental artery perforation. The spinal needle should be manipulated carefully. Even for large hematomas, conservative treatment is possible in select patients.

Clinical efficacy of transforaminal percutaneous endoscopic lumbar discectomy combined with ozone therapy for the treatment of lumbar disc herniation: comparison with fenestration discectomy. A prospective study

AbstractThe aim of this prospective study was to investigate the clinical efficacy of the transforaminal percutaneous endoscopic lumbar discectomy (PELD), combined with ozone in the treatment of lumbar disc herniation, and to compare its short-term efficacy with fenestration. The study included 109 adult patients admitted to our hospital from January 2015 to December 2016 that met the inclusion criteria. All patients were randomly divided into two groups: the combination group and the fenestration group. The visual analogue scale (VAS) was used to measure postoperative pain of the surgical wound and waist and leg. The JOA score was used to measure recovery status, and the Oswestry disability index (ODI) was used to determine lumbar dysfunction. The operation time and hospitalization time in the combined group were significantly shortened, and the average blood loss and the average amount of intervertebral disc resection were also significantly lower than those in the fenestration group. At all-time points, the VAS score of postoperative pain in the combined group was significantly lower than that in the control group. VAS and ODI scores were significantly decreased and JOA scores were significantly higher in the combined group. The treatment rate in the combined group was significantly higher than that in the open window group. However, there was no a significant difference in the incidence of complications between the two groups. PELD combined with ozone therapy can significantly improve the therapeutic effects and shorten the recovery time of patients with lumbar disc herniation, but does not affect the incidence of postoperative complications.ResumenSe evaluo la eficacia clinica de la discectomia lumbar endoscopica percutanea (PELD) combinada con ozonoterapia en el tratamiento de la hernia de disco lumbar, y se comparo su eficacia a corto plazo con la fenestracion. El estudio incluyo a 109 pacientes adultos, divididos aleatoriamente en: un grupo de combinacion, en el que los pacientes recibieron PELD y tratamiento con ozono y un grupo tratado mediante fenestracion. La escala analogica visual (VAS) se utilizo para medir el dolor postoperatorio de la herida quirurgica y el de la cintura y la pierna. La escala JOA se uso para medir el estado de recuperacion, y el indice de discapacidad de Oswestry (ODI) para determinar la disfuncion lumbar. Los tiempos de operacion y de hospitalizacion en el grupo combinado se redujeron significativamente, y los promedios de perdida de sangre y la cantidad de reseccion del disco intervertebral tambien fueron significativamente mas bajas que las del grupo de fenestracion. La puntuacion VAS de dolor postoperatorio en el grupo combinado fue significativamente menor que en el grupo control. Los puntajes VAS y ODI disminuyeron significativamente y los puntajes JOA fueron significativamente mas altos en el grupo combinado. La tasa de tratamiento en el grupo combinado fue significativamente mayor que la del grupo de ventana abierta. Sin embargo, no hubo diferencias significativas en la incidencia de complicaciones entre los dos grupos. La PELD combinada con la ozonoterapia puede mejorar significativamente el efecto terapeutico y acortar el tiempo de recuperacion de los pacientes con hernia de disco lumbar, pero no afecta la incidencia de complicaciones postoperatorias.

Ultrasound guidance for transforaminal percutaneous endoscopic lumbar discectomy may prevent radiation exposure: A case report.

BACKGROUNDPercutaneous endoscopic lumbar discectomy (PELD) has become a mature and mainstream minimally invasive surgical technique for treating lumbar disc herniation (LDH). Repeated fluoroscopy, with more than 30 shots on average, is inevitable to ensure its accuracy and safety. However, exposure to X-rays may pose a threat to human health. We herein report a case of ultrasound (US)-assisted PELD in two levels of LDH to explore a new possibility that can reduce the radiation dose during puncture and cannulation in PELD.CASE SUMMARYA 38-year-old man with low back pain and left leg pain for more than 7 years came to our clinic, his symptoms had aggravated for 1 month, and he was diagnosed with L3-4 and L4-5 disc herniations. He received US-guided PELD with good results: His straight leg elevation increased from 40 to 90 degrees after PELD, and his visual analog scale (VAS) and Oswestry Disability Index scores both significantly decreased immediately and 6 mo after PELD. With the guidance of US, he received only two shots of fluoroscopy (fluoroscopic time: 4.4 s; radiation dose: 3.98 mGy). To our knowledge, this is the first case of US-guided puncture and cannulation of PELD for LDH at two levels.CONCLUSIONUS could be used to guide PELD and has the potential to largely reduce radiation than traditional X-ray guidance.

Ultrasound-guided transforaminal percutaneous endoscopic lumbar discectomy: a new guidance method that reduces radiation doses.

The purpose of this study is to establish a new method to reduce the radiation dose during puncture and cannulation in percutaneous endoscopic lumbar discectomy (PELD). Sixty patients with lumbar disk herniation undergoing PELD were prospectively enrolled and randomly divided into an ultrasound (US) guidance group and an X-ray guidance group. The puncture, cannulation, and total operation times; number of fluoroscopy shots; and radiation dose were recorded in both groups. The factors influencing the operation were analyzed. The clinical effect of PELD was evaluated using the straight leg elevation test, visual analog scale (VAS) and Oswestry disability index (ODI). The researchers who collected and analyzed the data were blinded to the group assignments. The puncture, cannulation and operation times in the US group were comparable to those in the X-ray group. The patients in the US group received 2.13 ± 0.35 fluoroscopy shots and a radiation dose of 5.34 ± 0.63 (mSV), which were significantly lower than the values in the X-ray group (7.57 shots ± 2.99 shots and 18.25 mSV± 10.52 mSV) (P < 0.001). In the US group, the puncture time was significantly longer at the L5-S1 level, in patients with a BMI greater than 28kg/m2 and in patients with a high iliac crest. The US and X-ray groups had comparable VAS and ODI scores 1h and 3months after PELD, and the VAS scores were significantly lower after PELD (all P < 0.001). No complications were observed in either group. US guidance is a new method that reduces the radiation dose required during puncture and cannulation in PELD. These slides can be retrieved under Electronic Supplementary Material.

Radiation Exposure Reduction in Ultrasound-Guided Transforaminal Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation: A Randomized Controlled Trial

Transforaminal percutaneous endoscopic lumbar discectomy (TF-PELD) is a minimally invasive technique with high radiation exposure. The purpose of this study was to compare radiation exposure of ultrasound-guided TF-PELD with fluoroscopy-guided TF-PELD. In this prospective randomized controlled clinical trial, 60 patients with lumbar disc herniation were enrolled and randomly assigned to 2 groups (30 cases in each group): the ultrasound-guided group or the fluoroscopy-guided group. The radiation exposure, fluoroscopy time, and visual analog scale score were recorded. The number of possible operations per year within the yearly occupational exposure limit (OEL) was calculated. We also recorded the adverse events to evaluate the safety of ultrasound-guided TF-PELD. In 30 patients from the ultrasound-guided group, the lumbar disc structure was clearly visible under ultrasound guidance. The effective dose to surgeons and radiation dose to patients were 1.7 ± 0.4 and 25.2 ± 4.9 μSv in the ultrasound-guided group and 9.0 ± 2.5 and 127.4 ± 27.1 μSv in the fluoroscopy-guided group (P < 0.05), respectively. The fluoroscopy time was 2.6 ± 0.5 seconds in the ultrasound-guided group and 127.3 ± 29.5 seconds in the fluoroscopy-guided group (P < 0.05). A surgeon with shielding devices could treat 5556 cases per year in the fluoroscopy-guided group before exceeding the OEL for whole-body radiation, whereas they could treat 29,412 cases in the ultrasound-guided group. No difference between groups was detected in postoperative visual analog scale score (P > 0.58). No serious adverse event was found in any patient. Ultrasound-guided TF-PELD could decrease radiation exposure to surgeons and patients, without serious adverse events. It seems to be an acceptable alternative to fluoroscopy-guided TF-PELD.

Comparison of Transforaminal Percutaneous Endoscopic Lumbar Discectomy with and without Foraminoplasty for Lumbar Disc Herniation: A 2-Year Follow-Up.

Background Both transforaminal percutaneous endoscopic lumbar discectomy with foraminoplasty (TF PELF) and transforaminal percutaneous endoscopic lumbar discectomy without foraminoplasty (TF PELD) were developed for lumbar disc herniation (LDH) patients. However, the safety and effectiveness between the TF PELF and TF PELD have not been investigated. Methods Of the included 140 LDH patients, 62 patients received TF PELF (PELF group) and 78 patients received TF PELD (PELD group). The operation time, the duration of staying at the hospital, and complication incidences were recorded. All patients were followed up for 2 years, where low back and leg visual analogue scale (VAS) pain ratings and Oswestry Disability Index (ODI) were compared between the 2 groups before and after surgery. Modified Macnab criterion was estimated for all patients at postoperative 2 years. Results There were no significant difference of the operation time, number of days staying at the hospital, and the incidence of complications between the 2 groups (P > 0.05). Two cases in the PELF group and 1 case in the PELD group received a second surgery due to unrelieved symptoms postoperatively. Low back and leg VAS and ODI scores decreased in both groups after operation (P < 0.01), respectively, but were not significant between the 2 groups over time (P > 0.05). Six patients in the PELF group and 3 patients in the PELD group did not continue the follow-up; thus, only 131 patients completed Macnab evaluation. The satisfactory rate was reported as 80.4% in the PELF group and 90.7% in the PELD group (P > 0.05). Conclusions This study suggested that the safety and effectiveness of TF PELF are comparable to TF PELD for LDH patients.

Real-time Ultrasound Volume Navigation Guided Transforaminal Percutaneous Endoscopic Lumbar Discectomy in Anatomic Variation: A Case Report

Real-time Ultrasound Volume Navigation Guided Transforaminal Percutaneous Endoscopic Lumbar Discectomy in Anatomic Variation: A Case Report

Foraminoplasty at the Tip or Base of the Superior Articular Process for Lateral Recess Stenosis in Percutaneous Endoscopic Lumbar Discectomy: A Multicenter, Retrospective, Controlled Study with 2-Year Follow-Up

Objective To compare the clinical efficacy and complications which obtained foraminoplasty at the tip or base of the superior articular process (SAP) for the patients with lateral recess stenosis treated by percutaneous endoscopic lumbar discectomy (PELD). Methods Between January 2015 and January 2016, 156 patients of lumbar disc herniation accompanying with lateral recess stenosis were treated with PELD in five tertiary hospitals and fulfilled the 2-year follow-up. Among them, 78 patients obtained a foraminoplasty at the tip of SAP (group A), and foraminoplasty at the base of SAP was performed in the other 78 cases (group B). Clinical efficacy was evaluated using the visual analog scale (VAS) score for back and leg pain, Oswestry Disability Index (ODI), and 36-item Short-Form Health Survey (SF-36) score. The intervals of follow-up were scheduled at 1 month, 3 months, 6 months, 1 year, and 2 years after surgery. Results Mean operative duration is shorter in group B (55 versus 61 min, P = 0.047). Only one case belonged to group A could not tolerate the neural irritation and required conversion to an open procedure. During the surgery, no dura tears, cauda equina syndrome, or infections were observed. 5 patients experienced transient dysesthesia located at the exiting nerve in group A, while no cases complained dysesthesia in group B. 2 cases who suffered temporary motor weakness all belonged to group A. A total of 5 cases obtained a revision surgery after recurrence in the follow-up, in which 3 patients belonged to group A. Compared to the preoperative data, significant improvements in VAS scores of low back pain and sciatica, ODI, and SF-36 PCS and MC were observed in the follow-up, respectively (P < 0.05, respectively). However, no statistical difference was observed at all time-points after surgery between these two groups (P > 0.05, respectively). Conclusions For the patients of LDH accompanying with lateral recess stenosis, compared with the routine foraminoplasty at the tip of SAP, our modified foraminoplastic technique does not only change place of foraminoplasty to the base of SAP but also simplified puncture process in transforaminal PELD. Although there was no significant difference in symptom relief, the modified foraminoplasty showed the advantages in decreasing the incidence of postoperative neural dysfunction and reducing operation time.

Analysis of Clinical Results of Three Different Routes of Percutaneous Endoscopic Transforaminal Lumbar Discectomy for Lumbar Herniated Disk

Objective: Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) can be performed by using foraminal, intervertebral, and suprapedicular routes. The aim of this study was to assess clinical results of three different routes of PETLD.Methods: One hundred and eleven patients who underwent PETLD between January 2016 and October 2016 were included in this study. PETLD was performed using the foraminal (group A), intervertebral (group B), and suprapedicular (group C) routes in 32, 46, and 33 patients, respectively. Outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and MacNab criteria.Results: Seventy-one men and 40 were women (mean age 53.33 ± 14.12 years). The mean follow-up period was 6.44 ± 3.26 months. The preoperative VAS score decreased significantly (P &lt; 0.01) in all 3 groups, but the postoperative VAS score was higher for the foraminal route than the intervertebral (P&lt;0.001) and suprapedicular routes (P&lt; 0.001). Excellent outcome grade according to MacNab criteria was less in foraminal route (18.7%) than in intervertebral (52.2%) and suprapedicular (56.7%) routes. ODI improved significantly (P&lt; 0.01) in all 3 groups.Conclusion: All 3 routes of PETLD resulted in good to excellent clinical results. Nevertheless, the postoperative VAS score was higher for the foraminal route than the intervertebral and suprapedicular routes, probably because of the neurologic characteristics of the disk location. The surgeon should consider this problem to alleviate pain postoperatively and to better counsel the patient before surgery.

A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations.

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are two techniques for the introduction of a working cannula with respect to disc-outside-in and inside-out. The aim of this prospective study is to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse. A total of 184 consecutive patients with unilateral lower limb radiculopathy due to lumbar disc prolapse were operated on with the mobile outside-in technique of PETLD. Their clinical outcomes were evaluated based on the type of disc prolapse they had, a visual analog scale (VAS) leg pain score, the Oswestry Disability Index (ODI), and the Macnab criteria. The completeness of the decompression was documented with a postoperative magnetic resonance imaging. The mean age of the patients was 50 ± 16 years and the male/female ratio was 2:1. The mean follow-up was 19 ± 6 months. A total of 190 lumbar levels were operated on (L1-L2: n = 4, L2-L3: n = 17, L3-L4: n = 27, L4-5: n = 123, and L5-S1: n = 19). Divided into types, the patient distribution was central: n = 14, paracentral: n = 74, foraminal: n = 28, far lateral: n = 13, superior-migrated: n = 8, inferior migrated: n = 38, and high canal compromise: n = 9. The mean operative time was 35 ± 12 (25 - 56) min and the mean hospital stay was 1.2 ± 0.5 (1-3) days. The VAS score for leg pain improved from 7.5 ± 1 to 1.7 ± 0.9. The ODI improved from 70 ± 8.3 to 23 ± 5. According to the Macnab criteria, 75 patients (40.8%) had excellent results, 104 patients (56.5%) had good results, and 5 patients (2.7%) had fair results. Recurrence (including early and late) was seen in 15 out of the 190 levels that were operated on (7.89%). This article presents a novel outside-in approach that relies on a precise landing within the foramen in a mobile manner and does not solely depend upon the enlargement of the foramen. It is more versatile in application and useful in the management of all types of disc prolapse, even in severe canal compromise and high migration.

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.

Percutaneous Endoscopic Lumbar Discectomy for All Types of Lumbar Disc Herniations (LDH) Including Severely Difficult and Extremely Difficult LDH Cases

Lumbar disc herniation (LDH) is being treated with limited indication by percutaneous full endoscopic lumbar discectomy. However, microscopic lumbar discectomy (MLD) is still considered as a gold standard. With the advances in spinal endoscopic instruments and surgical techniques, all LDHs have now become operable with percutaneous full endoscopic lumbar discectomy procedure. We report the results of percutaneous full endoscopic lumbar discectomy (PELD) for all patients diagnosed with LDH, including severely difficult and extremely difficult LDH cases who visited our clinic with leg pain and lower back pain. Retrospective study of consecutive prospective patients. Spine center, Nanoori Suwon Hospital, Suwon, Korea. Electronic medical records of 98 consecutive patients (104 levels) who underwent surgery from October 2015 to May 2016, by PELD for different LDHs either by percutaneous endoscopic transforaminal lumbar discectomy (PETLD) or percutaneous endoscopic interlaminar lumbar discectomy (PEILD) approach were reviewed retrospectively. The L5-S1 level was accessed with PEILD approach and the other levels were accessed with PETLD approach. Outcomes were analyzed utilizing the visual analog scale (VAS), Oswestry disability index (ODI), Mac Nab Criteria and endoscopic surgical success grade/score. There were 75 (72.1%) men and 29 (27.9%) women patients with a mean age of 48.12 ± 15.88 years. Follow-up range from a minimum of 10 to 15 months (mean 12.77 ± 1.84 months). Most of the LDHs were located at L4-5 level. There were 76% severely difficult and extremely difficult cases. PETLD was the choice of approach in most of the cases (78 cases, 75%). VAS decreased significantly. ODI improved from preoperative 54.67 ± 7.52 to 24.50 ± 6.45 at last follow-up. 96.1% good to excellent result was obtained as per Mac Nab criteria. 98.1% of patients were managed with a successful to completely successful grade according to the endoscopic surgical success grading/scoring. Two cases (1.9%) developed transient motor weakness. Retrospective analysis of consecutive prospective patients. With more than 96% success (98.1% as per endoscopic success grading/scoring) all kinds of LDHs, including severely difficult and extremely difficult LDHs, are accessible by the PELD (PETLD and PEILD) technique. PELD can now be considered an alternative to microscopic lumbar discectomy (MLD) in the treatment of all kinds of disc herniations with the added benefits of keyhole surgery even for severely difficult and extremely difficult LDH cases. Lumbar disc herniation (LDH), percutaneous endoscopic lumbar discectomy (PELD), percutaneous endoscopic transforaminal lumbar discectomy (PETLD), percutaneous endoscopic interlaminar discectomy (PEILD), evolution of PELD, difficult LDH, highly migrated LDH, high canal compromised LDH, revision LDH, LDH with discal cyst, calcified LDH.

Biomechanics changes of lumbar spine caused by foraminotomy via percutaneous transforaminal endoscopic lumbar discectomy

Objective: To analyze the biomechanics changes of lumbar spine caused by foraminotomy via percutaneous transforaminal endoscopic lumbar discectomy using the finite element method. Methods: Three healthy adult males (aged 35.6 to 42.3 years) without spinal diseases were enrolled in this study and 3D-CT scans were carried out to obtain the parameters of lumbar spine. Mimics software was applied to build a 3D finite element model of lumbar spine. Graded resections (1/4, 2/4, 3/4 and 4/4) of the left superior articular process of L(5) were done via percutaneous transforaminal endoscopic lumbar discectomy. Then, the pressure of the L(4/5) right facets, the pressure of the L(4/5) intervertebral disc and the motion of lumbar spine were recorded after simulating the normal flexion and extension, lateral flexion and rotation of the lumbar spine model during different resections. The data were compared among groups with analysis of variance. Results: Comparing with the normal group, after 1/4 resection of the left superior articular process of L(5), the pressure of the L(4/5) right facets showed significant differences during left lateral flexion and rotation of lumbar spine (q=8.823, 8.248, both P<0.05); and the pressure of L(4/5) intervertebral disc also changed significantly during extension and right rotation of lumbar spine (q=6.918, 6.438, both P<0.05); the motion of lumbar spine showed obvious differences during right lateral flexion and rotation (q=6.845, 7.772, 13.58, all P<0.05). Comparing with the normal group, after 2/4 resection of the left superior articular process of L(5), the pressure of the L(4/5) right facets presented significant differences during all conditions (q=5.670-17.830, all P<0.05); the pressure of L(4/5) intervertebral disc changed significantly during flexion, extension, lateral flexion and right rotation (q=5.260, 17.150, 5.727, 8.890, 15.660, all P<0.05); the motion of lumbar spine also existed differences during extension, lateral flexion and rotation (q=9.106, 5.431, 12.060, 11.160, 17.260, all P<0.05). However, after 3/4 resections, the pressure of the L(4/5) right facets, the pressure of the L(4/5) intervertebral disc and the motion of lumbar spine presented differences during all conditions when compared with those in normal group (q=6.303-25.48, all P<0.05). After 4/4 resections, the pressure of the L(4/5) right facets and the pressure of the L(4/5) intervertebral disc and the motion of lumbar spine showed significant differences during all conditions when compared with those in normal group (q=8.065-45.70, all P<0.05). Conclusions: The biomechanics and the stability of lumbar spine changed partly after 1/4 resection of the superior articular process and obviously after more than 2/4 is resected. The superior articular process should be paid more attention during foraminotomy via percutaneous transforaminal endoscopic lumbar discectomy.