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: 1.77). 03/2009; 151(3):199-206. DOI: 10.1007/s00701-009-0204-x


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.

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    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 · 0.64 Impact Factor
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    ABSTRACT: Disc herniations at the L1-L2 and L2-L3 levels are different from those at lower levels of the lumbar spine with regard to clinical characteristics and surgical outcome. Spinal canals are narrower than those of lower levels, which may compromise multiple spinal nerve roots or conus medullaris. The aim of this study was to evaluate the clinical features and surgical outcomes of upper lumbar disc herniations. We retrospectively reviewed the clinical features of 41 patients who had undergone surgery for single disc herniations at the L1-L2 and L2-3 levels from 1998 to 2007. The affected levels were L1-L2 in 14 patients and L2-L3 in 27 patients. Presenting symptoms and signs, patient characteristics, radiologic findings, operative methods, and surgical outcomes were investigated. The mean age of patients with upper lumbar disc was 55.5 years (ranged 31 to 78). The mean follow-up period was 16.6 months. Most patients complained of back and buttock pain (38 patients, 92%), and radiating pain in areas such as the anterior or anterolateral aspect of the thigh (32 patients, 78%). Weakness of lower extremities was observed in 16 patients (39%) and sensory disturbance was presented in 19 patients (46%). Only 6 patients (14%) had undergone previous lumbar disc surgery. Discectomy was performed using three methods : unilateral laminectomy in 27 cases, bilateral laminectomy in 3 cases, and the transdural approach in 11 cases, which were performed through total laminectomy in 10 cases and unilateral laminectomy in 1 case. With regard to surgical outcomes, preoperative symptoms improved significantly in 33 patients (80.5%), partially in 7 patients (17%), and were aggravated in 1 patient (2.5%). Clinical features of disc herniations at the L1-L2 and L2-L3 levels were variable, and localized sensory change or pain was rarely demonstrated. In most cases, the discectomy was performed successfully by conventional posterior laminectomy. On the other hand, in large central broad based disc herniation, when the neural elements are severely compromised, the posterior transdural approach could be an alternative.
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    Journal of spinal disorders & techniques 03/2011; 25(4):210-7. DOI:10.1097/BSD.0b013e3182159690 · 2.20 Impact Factor
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