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

Wooridul Spine Hospital, 50-3 Dongin-dong, Jung-gu, Daegu, 700-732 South Korea
Acta Neurochirurgica (Impact Factor: 1.79). 03/2009; 151(3):199-206. DOI: 10.1007/s00701-009-0204-x

ABSTRACT BackgroundCompared 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.

MethodForty-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.

FindingsThe mean follow-up was 38.8months (range, 25–52months). 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 45years and a lateral disc herniation were independently associated with an excellent outcome (P < 0.05).

ConclusionsPatient selection and an anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic
discectomy for upper lumbar disc herniation.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In conventional percutaneous disc surgery, introducing instruments into disc space starts by inserting a guide needle into the triangular working zone. However, landing the guide needle tip on the annular window is a challenging step in endoscopic discectomy. Surgeons tend to repeat the needling procedure to reach an optimal position on the annular target. Obturator guiding technique is a modification of standard endoscopic lumbar discectomy, in which, obturator is used to access triangular working zone instead of a guide needle. Obturator guiding technique provides more vivid feedback and easy manipulation. This technique decreases the steps of inserting instruments and takes safer route from the peritoneum.
    Journal of Korean Neurosurgical Society 03/2012; 51(3):182-6. DOI:10.3340/jkns.2012.51.3.182 · 0.60 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Technical report and cases series. To present the technique of interlaminar endoscopic lumbar discectomy (ED) with ligamentum flavum (LF) splitting under direct visualization. The most distinguishing advantage of ED is a decrease in tissue trauma, which has been associated postoperatively with less back pain and less adhesion or scar tissue formation. In transforaminal ED the LF is completely spared, whereas in interlaminar ED the LF must be removed under direct visualization, no matter how small the opening may be (3 to 5 mm). It is also possible to keep the LF intact using serial dilators, but this procedure cannot be performed under direct visualization. We performed operations on 16 male and 14 female patients with herniated lumbar disc disease using interlaminar ED with LF splitting under direct visual control. The average age of the patients in the study was 48±15 years. The chief complaint before surgery was radiculopathy confined to 1 leg. The anatomic operative level was L3-4 in 1, L4-5 in 13, and L5-S1 in 16 patients. The ruptured disc had migrated superiorly in 4 cases and inferiorly in 7 cases, and intraoperative electromyographic monitoring was performed in all surgeries. The LF was split with a working channel under direct visualization, and after withdrawing the working channel the split LF closed on its own. The total operation time was 20 to 40 minutes, and the follow-up period was 149±108 days. There were no abnormal signals on the intraoperative electromyography in any of the cases, and the reported symptoms immediately improved in all patients after the operation. Follow-up magnetic resonance imaging showed a disappearance of the ruptured disc with almost no defect in the LF. There were no operation-associated complications. The LF could be safely split under direct visualization using a working channel with a minimal resulting defect. This technique of LF splitting endoscopic discectomy is a feasible approach, even for migrated disc herniation.
    Journal of spinal disorders & techniques 03/2011; 25(4):210-7. DOI:10.1097/BSD.0b013e3182159690 · 1.89 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: We performed a prospective study to examine the influence of the patient's position on the location of the abdominal organs, to investigate the possibility of a true lateral approach for transforaminal endoscopic lumbar discectomy. Pre-operative abdominal CT scans were taken in 20 patients who underwent endoscopic lumbar discectomy. Axial images in parallel planes of each intervertebral disc from L1 to L5 were achieved in both supine and prone positions. The most horizontal approach angles possible to avoid injury to the abdominal organs were measured. The results demonstrated that the safe approach angles were significantly less (i.e., more horizontal) in the prone than in the supine position. Obstacles to a more lateral approach were mainly the liver, the spleen and the kidneys at L1/2 (39 of 40, 97.5%) and L2/3 (28 of 40, 70.0%), and the intestines at L3/4 (33 of 40, 82.5%) and L4/5 (30 of 30, 100%). A true lateral approach from each side was possible for 30 of the 40 discs at L3/4 (75%) and 23 of the 30 discs at L4/5 (76.7%). We concluded that a more horizontal approach for transforaminal endoscopic lumbar discectomy is possible in the prone position but not in the supine. Prone abdominal CT is more helpful in determining the trajectory of the endoscope. While a true lateral approach is feasible in many patients, our study shows it is not universally applicable.
    The Bone & Joint Journal 10/2011; 93(10):1395-9. DOI:10.1302/0301-620X.93B10.26833 · 2.80 Impact Factor


Available from