Transforaminal Percutaneous Endoscopic Lumbar Discectomy Research Articles

Postoperative spondylodiscitis following transforaminal percutaneous endoscopic lumbar discectomy: clinical characteristics and preventive strategies

Introduction. We aimed to demonstrate the unique clinical characteristics and outcomes of spondylodiscitis after transforaminal percutaneous endoscopic lumbar discectomy (PELD), and we also discuss about adequate preventive methods of this unexpected complication. Methods. The medical records of 9821 consecutive cases treated with PELD between January 2001 and December 2009 were reviewed. All cases of postoperative infection were identified. The clinical course, infection type, laboratory results and treatment options for each case were available from their records. Results. Of the 9821 patients, 12 (0.12%) were identified as having postoperative infections, and in all these cases, the infection manifested as spondylodiscitis. Four patients were treated with only antibiotic therapy; two patients were treated with surgical debridement; and the remaining six patients who were unresponsive to the initial therapies finally required lumbar interbody fusion with posterior instrumentation surgery. The mean Oswestry Disability Index (ODI) improved from 60.4% ± 19.4% to 29.3% ± 15.4%. Based on the modified MacNab criteria, 7 of the 12 patients (58.3%) showed an excellent or good outcome. Conclusion. Postoperative spondylodiscitis following PELD is relatively rare. However, its clinical progression could be more rapid and more serious than that after open surgery. Therefore, thorough preventive strategies for postoperative spondylodiscitis are mandatory.

Prevention of Development of Postoperative Dysesthesia in Transforaminal Percutaneous Endoscopic Lumbar Discectomy for Intracanalicular Lumbar Disc Herniation: Floating Retraction Technique

Transforaminal percutaneous endoscopic lumbar discectomy (PELD) has become a routine surgical procedure because it is minimally invasive. Perioperative complications such as dural injury, infection, nerve root irritation and recurrence can occur not only with PELD, but also with conventional open microsurgery. In contrast, post-operative dysesthesia (POD) due to existing dorsal root ganglion (DRG) injury is a unique complication of PELD. When POD occurs, even if the traversing root has been successfully decompressed, it hinders swift recovery and delays the return to daily routines. Thus, prevention of POD is the key to successful and widespread use of PELD. From January 2006 to December 2008, 154 patients underwent percutaneous endoscopic discectomy by floating retraction technique at 160 disc levels under local anesthesia. This approach towards the superomedial border of the lower pedicle and the cannula can be placed by gentle retraction of the root with perineural fat instead of direct compression of dorsal root ganglion. The clinical outcomes were assessed using the Visual Analogue Scale (VAS, 0-10 point) for radicular pain and low back pain, and using the Oswestry Disability Index (ODI) for functional status. Perioperative complications and recurrence were reviewed. The mean age was 45 years, the mean operative time was 36 min and the mean follow-up period was 3.4 years. The mean hospital stay for endoscopic discectomy was 1.8 days. No patient underwent repeated PELD or convert microsurgery by incomplete removal of the ruptured particle. All patients experienced early relief of symptoms, as determined by VAS and ODI. No patient developed POD. 1 patient experienced dural injury. There was 1 case of discitis. The recurrence rate was 1.95% (3 patients). Transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation is a safe and effective procedure. The floating retraction technique is recommended to avoid development of POD.

Percutaneous Endoscopic Lumbar Discectomy via Contralateral Approach

Technical case report. The authors report a new percutaneous endoscopic lumbar discectomy (PELD) technique for the treatment of lumbar disc herniation via a contralateral approach. When there are highly down-migrated lumbar disc herniation along just medial to pedicle and narrow ipsilateral intervertebral foramen, the conventional PELD is not easily accessible via ipsilateral transforaminal route. Five patients manifested gluteal and leg pain because of a soft disc herniation at the L4-L5 level. Transforaminal PELD via a contralateral approach was performed to remove the herniated fragment, achieving complete decompression of the nerve root. The symptom was relieved and the patient was discharged the next day. When a conventional transforaminal PELD is difficult because of some anatomical reasons, PELD via a contralateral route could be a good alternative option in selected cases.

Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration

Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration

Postoperative retroperitoneal hematoma following transforaminal percutaneous endoscopic lumbar discectomy

The purpose of this study was to demonstrate the clinical characteristics of postoperative retroperitoneal hematoma (RPH) following transforaminal percutaneous endoscopic lumbar discectomy (PELD) and to discuss how to prevent the complication of unintended hemorrhage. The medical records of 412 consecutive patients treated with transforaminal PELD between January 2005 and May 2007 were reviewed. A total of 4 patients (0.97%) experienced symptomatic postoperative RPH. The clinical outcomes were evaluated using the visual analog scale and the Oswestry Disability Index. The common symptom in all patients with a hematoma was inguinal pain. The mean hematoma volume was 527.9 ml (range 53.3-1274.1 ml). Two patients with massive diffuse-type RPHs compressing the intraabdominal structures required open hematoma evacuation performed by general surgeons, and the other 2 patients with small, localized RPHs of < 100 ml were treated conservatively. The mean follow-up period was 21.3 months (range 13-29 months). The mean visual analog scale score for radicular leg pain improved from 7.6 to 1.8 and that for back pain improved from 4.3 to 2. The mean Oswestry Disability Index improved from 58.8 to 9.1%. The preoperative symptoms improved after the second treatment without significant neurological sequelae in all patients. Although transforaminal PELD is a minimally invasive and safe procedure, the possibility of RPH should be kept in mind. Adequate technical and anatomical considerations are important to avoid this unusual hemorrhagic complication, especially in the patient with underlying medical problems or previous operative scarring. A high index of suspicion and early detection is also important to avoid the progression of the hematoma.

Percutaneous Endoscopic Lumbar Discectomy by Transiliac Approach

Case report. The authors report a new percutaneous endoscopic lumbar discectomy (PELD) technique for the treatment of lumbar disc herniation with a high iliac crest via a transiliac approach. When the iliac crest is high, the L4-L5 and L5-S1 disc spaces are located deep in the pelvis, so they are not easily accessible via a suprailiac route. A 51-year-old man manifested left gluteal and leg pain due to an up-migrated soft disc herniation at the L4-L5 level. Transforaminal PELD via a transiliac approach was performed to remove the herniated fragment, achieving complete decompression of the nerve root. The symptom was relieved and the patient was discharged the next day. When a conventional transforaminal PELD is impossible due to the presence of a high iliac crest, PELD via a transiliac route could be a alternative option in selected cases.

Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration

Compared with lower lumbar disc herniations, upper lumbar disc herniations at L1-L2 and L2-L3 have specific characteristics that result in different surgical outcomes after conventional open discectomy. There are no published studies on the feasibility of percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation. The purpose of this study was to assess the clinical outcome, prognostic factors and the technical pitfalls of PELD for upper lumbar disc herniation. Forty-five patients with a soft disc herniation at L1-L2 or L2-L3 underwent percutaneous endoscopic discectomy. Posterolateral transforaminal endoscopic laser-assisted disc removal was performed under local anesthesia. Clinical outcomes was assessed using the Prolo scale. The prognostic factors associated with outcome were then analyzed. The mean follow-up was 38.8 months (range, 25-52 months). The outcome of the 45 patients was excellent in 21 (46.7%), good in 14 patients (31.1%), fair in six patients (13.3%), and poor in four patients (8.9%). Four patients with a poor outcome underwent further open surgery. Mean scores on a visual analog scale decreased from 8.38 to 2.36 (P < 0.0001). Age less than 45 years and a lateral disc herniation were independently associated with an excellent outcome (P < 0.05). Patient selection and an anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic discectomy for upper lumbar disc herniation.

Percutaneous Endoscopic Approach for Highly Migrated Intracanal Disc Herniations by Foraminoplastic Technique Using Rigid Working Channel Endoscope

A retrospective analysis of 59 patients operated for excision of soft highly migrated intracanal lumbar disc herniations by percutaneous endoscopic foraminoplasty. To describe a safe and effective percutaneous endoscopic technique for removal of migrated herniations and report the results on the basis of modified MacNab criteria. Migrated herniations pose a great challenge even for experienced endoscopic surgeons. These herniations are hidden from the endoscopic view by anatomic barriers like hypertrophied facet, inferior pedicle and foraminal ligaments rendering percutaneous endoscopic transforaminal lumbar discectomy (PELD) by conventional approach, difficult with high failure rate. Foraminoplasty, which means enlargement of foramen by undercutting ventral part of superior-facet, upper border of inferior pedicle along with ablation of foraminal ligament, can help us to address this issue. Fifty-nine patients with soft highly migrated herniations who underwent PELD with foraminoplasty under local anesthesia from January 2002 to June 2006 were analyzed retrospectively. Patients were evaluated by postoperative Visual Analog Scale for leg pain and Oswestry Disability Index scores. Outcomes were graded according to modified MacNab criteria. Mean follow-up was 25.4 months. Mean visual analog scale score for radicular pain improved from 8.01 to 1.56, and mean Oswestry disability Index improved from 61.6 to 10.76. Based on modified MacNab criteria, 91.4% of patients experienced satisfactory outcome. Three patients had persistent leg pain after surgery. One patient underwent a repeat-PELD on next day and the other after 1 month. Both were relieved of symptoms. Third patient was subjected to open discectomy after 25 weeks from the first operation and showed improvement. Two patients had recurrent herniation at same level after 6 months; 1 patient underwent repeat PELD, and the other underwent open discectomy. Both patients had good results. Foraminoplastic-PELD is safe and effective procedure for surgical treatment of soft migrated herniations. The results are comparable to results of open discectomy.

Percutaneous Endoscopic Transforaminal Lumbar Discectomy: A Critical Appraisal

Percutaneous endoscopic transforaminal lumbar discectomy (PETD) is one of the surgical techniques for the treatment of the lumbar disc herniations. Fenestration of the annulus and partial resection of the nuclear substance are achieved percutaneously by a posterolateral approach under local anaesthesia. The results of the first 42 patients are evaluated regarding the learning curve and indications for this procedure. The mean follow-up time was 15 months. Excellent and good results were evaluated as successful and the overall success rate is 77 %. All six patients with foraminal disc herniations in whom a free fragment could be removed had excellent results. Military personnel can return to work quickly without deficits with the use of this technique.