Transforaminal Full-endoscopic Lumbar Discectomy Research Articles

Comparison of Percutaneous Endoscopic Transforaminal Discectomy, Chemonucleolysis, Microdiscectomy, and Microendoscopic Discectomy for Symptomatic Lumbar Disc Herniation: One-year Follow-up Clinical Results and Disc Degeneration.

This study compared the 1-year clinical outcomes and disc degeneration rates after transforaminal full-endoscopic lumbar discectomy (TF-FED), condoliase injection, open discectomy (OD), and microendoscopic discectomy (MED) for lumbar disc herniation (LDH). In total, 279 patients with LDH were divided into four treatment groups: TF-FED, OD, MED, and condoliase injection. Outcomes were evaluated on the basis of the complication rate, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), visual analog scale (VAS) scores, and the modified MacNab criteria. Surgical and hospital costs were assessed. Disc degeneration and endplate bone marrow edema were evaluated using magnetic resonance images. The mean postoperative JOABPEQ, VAS, or modified MacNab scores among the four groups had no significant differences. Additionally, the nerve injury or reoperation rate among the TF-FED, OD, and MED groups had no significant difference. However, the reoperation rate with condoliase injection was high because of residual disc herniation. Surgical and hospital costs were lower with condoliase injection and higher with OD and MED than those with TF-FED. With TF-FED and condoliase injection, the Pfirrmann grade progressed, and the disc height was significantly smaller than that with OD and MED. Endplate bone marrow edema was more common with condoliase injection and TF-FED. All groups had good outcomes. TF-FED and condoliase injection may reduce the burden of surgery because they can be performed under local anesthesia with little blood loss and low medical costs but tend to be associated with disc degeneration and endplate bone marrow edema. A randomized controlled study with a larger sample is needed.

Risk Factor for Additional Intravenous Medication during Transforaminal Full-endoscopic Lumbar Discectomy under Local Anesthesia.

Transforaminal full-endoscopic lumbar discectomy (TELD) can be performed under local anesthesia. However, there have been no reports on risk factors for a change in vital signs or the need for additional medications to maintain adequate analgesia during this procedure. The purpose of this study was to identify risk factors for additional intravenous medication during TELD under local anesthesia. The following factors were retrospectively evaluated in 113 consecutive patients who underwent TELD under local anesthesia at our institution: demographic characteristics, radiological features at the intervertebral disc level, distance between the superior articular process and the exiting nerve root, height of the intervertebral disc, height of the bulging disc, height of the intervertebral foramen, and distance from the insertion site to the spinous process on magnetic resonance imaging (MRI) and computed tomography (CT) scans of the lumbar spine. Logistic regression analysis was performed to determine factors associated with the need for additional drugs. In all, 23 cases (20.4%) required additional intraoperative medications because of hypertension, hypotension, bradycardia, or pain. Logistic regression analysis revealed that age (partial regression coefficient 0.05, p = 0.02) and bulging disc height (partial regression coefficient −0.7, p = 0.003) influenced the need for additional drugs. There were significant associations of need for additional intravenous medication with older age (>62 years) and a smaller bulging disc height (<8.2 mm). Patients with these factors require close monitoring for changes in vital signs or increasing pain when performing TELD under local anesthesia and may need additional intravenous medication.

Posterolateral Transforaminal Full-Endoscopic Lumbar Discectomy for Foraminal or Extraforaminal Lumbar Disc Herniations

Surgical procedures via the posterior median or paramedian approach for lateral lumbar disc herniation require significant bone resection to reach the herniation. In contrast, posterolateral transforaminal full-endoscopic lumbar discectomy (FELD) allows direct access to the lateral disc herniation. This study aimed to determine the efficacy and safety of this procedure. A total of 118 patients who underwent posterolateral transforaminal FELD were retrospectively examined. Data on surgical time, perioperative complications, and reoperation rate were reviewed from the medical records. Clinical evaluations were completed in 78 patients using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and numeric rating scale (NRS) for low back pain, lower limb pain, and lower limb numbness obtained at baseline and during a follow-up of more than 12 months. The mean operative time was 33.9 min. Postoperative transient dysesthesia occurred in 11 of 118 patients (9.3%). No other complications were observed. Reoperation was performed in nine patients (5.9%). All domains of JOABPEQ and NRS significantly improved during the follow-up period. The effectiveness rates of the JOABPEQ for measuring low back pain, lumbar function, walking ability, social life function, and mental health were 70.4%, 46.5%, 62.0%, 59.2%, and 32.4%, respectively. Using the Macnab criteria, excellent or good results were achieved in 52 patients (73%). Successful clinical results were obtained with a few complications and improvements inthe domains of JOABPEQ and NRS. Posterolateral transforaminal FELD for lateral lumbar disc herniations is an effective and safe surgical option with minimal invasiveness and sufficient decompression.

腰部脊柱管狭窄を合併した腰椎椎間板ヘルニア症例に対する全脊椎内視鏡治療．後方除圧併用でのヘルニア摘出術（FEL）と前方除圧術（FELD TF）の比較

腰部脊柱管狭窄を合併した腰椎椎間板ヘルニア症例に対する全脊椎内視鏡治療．後方除圧併用でのヘルニア摘出術（FEL）と前方除圧術（FELD TF）の比較

Suprapedicular Retrocorporeal Technique of Transforaminal Full-Endoscopic Lumbar Discectomy for Highly Downward-Migrated Disc Herniation

Anatomical barriers (e.g., pedicles, narrow foramina) can hinder direct access to, and removal of, disc fragments that have migrated far downward. Using transforaminal full-endoscopic lumbar discectomy (FELD), we devised a modified technique, the suprapedicular retrocorporeal approach, for herniations in which the disc has migrated to the axilla of the traversing nerve roots. In the present report, we have described our preliminary results. Soft, highly downward-migrated disc herniation was treated with transforaminal FELD through the suprapedicular retrocorporeal approach in 22 patients from June 2017 to May 2019. The clinical outcomes were evaluated, including the preoperative and postoperative visual analog scale scores for the back and leg, Oswestry disability index, and MacNab criteria for surgical success. The affected discs were at L4-L5 in 14 patients, L3-L4 in 6 patients, and L5-S1 in 2 patients. In each case, the affected disc was successfully removed using the suprapedicular retrocorporeal approach. The mean follow-up was 18.1 ± 5.7 months. The mean visual analog scale scores for back and leg pain improved significantly (P < 0.05 for both). The mean Oswestry disability index had decreased from 62.5 ± 14.2 preoperatively to 10.5 ± 5.9 postoperatively (P < 0.05). Using the MacNab criteria, 13 patients reported excellent outcomes and 9, good outcomes. No complications or recurrence developed during follow-up. The suprapedicular retrocorporeal technique is a feasible and effective surgical option in transforaminal FELD for the treatment of herniation in which the disc has migrated to the axilla of the traversing nerve roots.

Comparing Oblique Lumbar Interbody Fusion with Lateral Screw Fixation and Transforaminal Full-Endoscopic Lumbar Discectomy (OLIF-TELD) and Posterior Lumbar Interbody Fusion (PLIF) for the Treatment of Adjacent Segment Disease.

Background A potential long-term complication of lumbar fusion is the development of adjacent segment disease (ASD), which may require surgical intervention and adversely affect outcomes. A high incidence of recurrent ASD was reported in patients who underwent the second (repeat) PLIF for symptomatic ASD. Herein, a feasible method, oblique lumbar interbody fusion combined with transforaminal endoscopic lumbar discectomy (OLIF-TELD) for dealing with adjacent lumbar disc herniation with upward or downward migration after lumbar spinal fusion, was proposed. Methods A total of 19 patients who underwent revision surgery at ASD were consecutively enrolled. Clinical efficacy analysis included operative time, intraoperative bleeding, visual analogue scale (VAS) score, Oswestry dysfunction index (ODI) score, and Japanese orthopaedic association (JOA) assessment treatment score. Results Among them, 11 patients were treated in a new surgical strategy, which is OLIF-TELD, and 8 patients underwent PLIF. There was no statistically significant difference between the two groups in terms of age, gender, and preoperative scores of VAS, ODI, and JOA. The operative duration was shorter, and intraoperative bleeding was less in the OLIF-TELD group compared with the PLIF group. PLIF had the greatest blood loss, and the OLIF-TELD group had lower VAS scores than the PLIF group postoperatively. The symptoms of all patients improved postoperatively with statistical significance. Conclusion OLIF with lateral screw fixation combined with TELD may be an alternative surgical method for the treatment of adjacent lumbar disc herniation with upward or downward migration after lumbar fusion surgery.

Is Full Endoscopic Lumbar Discectomy Less Invasive Than Conventional Surgery? A Randomized MRI Study

In the present randomized prospective study, we compared the surgical invasiveness using a quantitative volumetric analysis of postoperative paravertebral muscle signal intensity changes between transforaminal full endoscopic lumbar discectomy (FELD) and open discectomy (OD). We prospectively collected the data from 50 patients with a single-level lumbar foraminal herniation, invalidating radicular pain, and adequate imaging studies available (postoperative magnetic resonance imaging [MRI] <24 hours). These patients had been randomly assigned to FELD (n= 25) or OD (n= 25). Data were collected on age, sex, leg and back pain, complications, and follow-up time. Muscle segmentations were performed manually using 3DSlicer software on postoperative isovolumetric T1-weighted contrast-enhanced and T2-weighted short tau inversion recovery MRI scans. Both sequences were processed using multiplanar reconstruction in orthogonal planes. The clinical and demographic characteristics and volumetric data were then compared between the 2 groups. We found a higher mean volume of paravertebral muscle signal alterations among the OD-treated patients in both T2-weighted short tau inversion recovery MRI (P ≤ 0.001) and T1-weighted contrast-enhanced MRI (P≤ 0.001) scans than among the FELD-treated patients. No differences were found between the median preoperative and postoperative leg pain between the 2 groups (P=1.000). The median scores for postoperative back pain were significantly lower for the FELD group (P ≤ 0.001), as was the median interval from surgery to autonomous mobilization (P= 0.001). We found a significant difference in signal intensity of the paravertebral muscles between the FELD and OD groups, reflective of the minor surgical invasiveness of endoscopic discectomy. FELD resulted in less trauma to the paraspinal muscles, possibly also reducing inflammatory cytokine release and, therefore, is a valuable tool for spinal surgeons.

P35. Transforaminal full-endoscopic lumbar discectomy at the L5-S1 disc level: anatomical considerations and operability

BACKGROUND CONTEXT Transforaminal full-endoscopic lumbar discectomy (TELD) is a minimally invasive procedure for the surgical treatment of lumbar disc herniation (LDH). It can be performed under local anesthesia and requires a skin incision of only 8 mm, with minimal disruption of the spinal structures including ligaments and muscles. However, performing TELD for the lower lumbar spine is associated with some anatomical problems, such as interference with the iliac crest. This study sought to assess the operability of TELD at the L5-S1 disc level. PURPOSE The purpose of this study is to assess a three-dimensional relationship between the trajectory of TELD and the iliac crest, and the operability of TELD at the L5-S1 disc level compared with the L4-L5 disc level using CT images. STUDY DESIGN/SETTING This is a retrospective study using 323 multiplanar abdominal computed tomography (CT) scans. PATIENT SAMPLE We retrospectively reviewed multiplanar abdominal CT scans of 323 consecutive patients (203 male and 120 female) in our hospital from April 2009 to March 2013. The mean age was 66.5 (range 15-89) years old. OUTCOME MEASURES The operability of the TELD at the L5-S1 disc level was the outcome measure. METHODS We defined the tangent line in the iliac crest and the superior articular process of the caudal spine as the trajectory line of TELD, and evaluated the maximum inclination angle of the trajectory of the TELD (α angle) at the L4–L5 and the L5-S1 disc levels. Assuming the use of an oblique viewing endoscope at 25°, we defined α angle≥65° as the operability of TELD. RESULTS (1) The relationship between the iliac crest and disc level: The trajectory of the TELD interfered with the iliac crest at L4-L5 in 40.2% (right) and 54.5% (left) of the subjects, and at L5-S1 in 99.7% and 100% of the subjects. (2) The maximum inclination angle of the trajectory of TELD: the α angles were 84.3° and 82.3° at the L4-L5, and 56.8° and 55.2° at L5-S1. (3) Operability of TELD: At L4-L5, TELD could be performed in 94.4% and 90.4% of the subjects. In contrast, at L5-S1 the procedure could be performed in 24.1% and 19.2% of the subjects (male: 15.8% and 10.8%, female: 38.3% and 33.3%). CONCLUSIONS From the results of this study, the trajectory of TELD can be limited by the surrounding anatomical structure. The maximum inclination angle indicates that TELD for the central type of LDH at the L5-S1 disc level is more technically demanding than TELD at the L4-L5 disc level because of the interference of the iliac crest. However, in the clinical setting, such anatomical particularities can be overcome by using a hand-down technique with the possible addition of a foraminoplasty when we perform TELD at the L5-S1 disc level. Because the maximum inclination angle is defined by the iliac crest and ventrolateral aspect of the superior articular process, it makes sense that we remove the superior articular process partially. After widening the neural foramen after foraminoplasty, the working cannula could easily and safely pass through the foramen without touching the exiting nerve root, and be close to the herniated disc. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Transforaminal full-endoscopic lumbar discectomy under local anesthesia in awake and aware conditions: the inside-out and outside-in techniques.

Transforaminal full-endoscopic lumbar discectomy (TELD) under local anesthesia was first introduced in Japan in 2003. Initially referred to as percutaneous endoscopic discectomy, in 2018, a consensus was reached worldwide and the preferred term is now TELD. The procedure requires only an 8-mm skin incision and causes minimal damage to the paravertebral muscles. Thus, it is the least invasive disc surgery. In this review, we introduce two types of the TELD surgery. Initially, TELD was performed as the "inside-out" technique but was associated with reports of postoperative dysesthesia due to exiting nerve injury. Recently, the "outside-in" technique after foraminoplasty was proposed for safer insertion of the cannula into the disc. Foraminoplasty can widen the narrow foramen, thereby allowing the 8-mm cannula to pass through easily and safely, and thus injury to the exiting nerve root can be theoretically avoided. We described two types of the TELD in this review. Surgeons should be familiar with the inside-out and outside-in techniques for TELD; therefore, we can select appropriate technique for each case.

Transforaminal full-endoscopic lumbar discectomy in obese patients.

Obese patients are at risk of complications such as slower wound healing and increased infection rates after spinal surgery. Transforaminal full-endoscopic lumbar discectomy (ELD) has advantages over conventional microdiscectomy because it decreases perioperative complications and increases favorable clinical outcomes. No clinical studies have reported ELD in obese patients. The purpose of this study is to evaluate the clinical outcomes of transforaminal ELD in obese patients. Obesity is defined as a body mass index (BMI) of more than 30 kg/m2. Our study included 21 obese patients and 27 normal BMI patients treated by posterolateral transforaminal ELD for radiating pain caused by a single-level lumbar disc herniation with more than 2 years of follow-up. Clinical chart reviews and telephone surveys were conducted. Clinical and functional outcomes using VAS and ODI, perioperative complications, and reherniation were evaluated. Overall clinical and functional outcomes were improved during postoperative follow-up evaluation. There were no immediate perioperative complications, such as infection or durotomy in both groups. In obese group, three patients had late reherniations. Of these, 2 patients had tolerable pain and showed good recovery with conservative treatment; 1 patient who had undergone ELD for recurrent disc herniation underwent open microdiscectomy. In control group, two patients had early reherniation and underwent open microdiscectomy and one patient with late reherniation showed good recovery with conservative treatment. In select cases, ELD is an effective, safe, and minimally invasive technique for obese patients. It decreases perioperative morbidity and allows for both early mobilization and early return to work. level 3b.