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.     

椎间孔镜YESS与TESSYS技术治疗腰椎间盘突出症

目的 探讨椎间孔镜YESS(Yeung endoscopic spine system)和TESSYS(transforaminal en-doscopic spine system)技术治疗腰椎间盘突出症的适应证、手术技巧及临床效果.方法 2005年9月至2008年5月,201例腰椎间盘突出症患者分别采用YESS(150例)和TESSYS(51例)椎间孔镜手术治疗.男122例,女79例;年龄17～79岁,平均33.5岁.疗效评定依据疼痛视觉模拟评分(visual analogue score,VAS)和Nakai分级法.结果 162例(80.6%)获得随访,YESS手术组119例(79.3%)、TESSYS手术组43例(84.3%).随访3～36个月,平均12.5个月.YESS手术组术前腿痛VAS评分(8.4±2.1)分,术后1年(2.4±0.8)分,差异有统计学意义;TESSYS手术组术前腿痛VAS评分(8.6±2.3)分,术后1年(2.6±1.3)分,差异有统计学意义.YESS手术组优良率87.5%,TESSYS手术组88.4%.两组均无永久性神经根损伤、大血管损伤和硬脊膜囊撕裂等并发症.YESS手术组6例术后无效,4例术后复发者行翻修术;TESSYS手术组1例术后无效,2例术后复发者行翻修术.结论 椎间孔镜手术治疗腰椎间盘突出症安全、有效.根据不同类型和不同部佗,正确选择YESS技术或TESSYS技术是手术成功的关键.     

Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy

Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18–65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.     

腰椎间盘突出症手术疗效与突出类型及纤维环完整性的关系

目的探讨腰椎间盘突出症手术疗效与突出类型及纤维环完整性的关系。方法回顾性分析经后路椎板开窗髓核摘除术治疗的260例腰椎间盘突出症患者的疗效。病例选择条件:均为下腰椎单节段突出,侧突型(单侧坐骨神经症状),不伴有椎管狭窄。随访6～14年,平均8.5年。根据术中所见椎间盘突出的髓核形态及纤维环破损大小,将椎间盘突出症分为四种类型,并对不同类型的术后疗效进行统计学分析比较。结果椎间盘髓核突出较大、纤维环破损较小者,术后疗效佳,复发率低;反之,髓核突出较小或纤维环破损大者,术后疗效差,复发率高。结论腰椎间盘突出症的手术效果与椎间盘突出类型及纤维环的完整性有密切的联系。对临床症状较轻、间盘突出较小且突出物基底较宽的患者应尽量避免开放式手术。椎间盘突出摘除术中除应注意保持脊柱骨性结构的稳定性,还应尽量避免过多地破坏椎间盘纤维环的完整性。     

Irrigation endoscopic discectomy: a novel percutaneous approach for lumbar disc prolapse

Purpose

The purpose of this study is to present a new endoscopic procedure, aiming to achieve the success rate equivalent to microsurgical discectomy, while addressing the drawbacks and limitations of other percutaneous techniques.

Methods

A series of 43 patients with uncontained lumbar disc herniation underwent surgery with irrigation endoscopic discectomy (IED). The endoscope and instruments are placed directly over the surface of the lamina through two posterior skin portals 5 mm each without any muscle retraction or dilatation. Pump irrigation is used for the opening of a potential working space. The rest of the procedure is performed endoscopically like the standard microsurgical discectomy.

Results

Outcome according to modified Macnab criteria was excellent in 78 %, good in 17 %, and poor in 5 % of patients. VAS for leg pain dropped from 78 preoperatively to 7, and the Oswestry Low-Back Pain Disability Questionnaire dropped from 76 to 19. The mean time for postoperative ambulation was 4 h, hospital stay was 8 h, and for return to work was 7 days.

Conclusions

Preliminary clinical experience with IED shows it to be as effective as microsurgical discectomy, and in comparison to other percutaneous procedures addressing noncontained herniations, a reduction in the cost, technical difficulty and surgical invasiveness has been demonstrated.     

The microsurgical approach to extraforaminal lumbar disc herniations. An analysis of 15 cases

AIM: Extraforaminal lumbar disc herniations are uncommon, but thanks to recent progress in imaging procedures, they may be easily diagnosed. Several surgical approaches have been described and employed to remove these herniations. The aim of this study is to evaluate the clinical, radiological and surgical features which differentiate the treatment of this type of hernia from the more common surgical approaches to other types of lumbar disc hernias. METHODS: The authors report the results of the surgical treatment of 15 cases of extraforaminal lumbar disc herniation through an extracanalicular, intertransverse microsurgical approach and describe the technique employed. RESULTS: All cases experienced a prompt recovery from the preoperative symptoms with no complications, which notably reduced the time necessary for postoperative care. No instability was documented and none of the cases observed presented the neuropathic pain sometimes reported with this method of approach to these herniations. CONCLUSION: This particular site of disc herniation can be approached effectively through the extracanalicular route. The procedure, however, requires an extremely accurate preoperative anatomical evaluation and a good microsurgical experience.     

Full endoscopic contralateral transforaminal discectomy for distally migrated lumbar disc herniation

Background  

Discectomy of distally, inferiorly migrated disc herniations below midpedicle level of the vertebral body in the lower lumbar spine is known to be very difficult by endoscopy. The purpose of this study was to introduce the technical possibility of percutaneous endoscopic lumbar discectomy using a contralateral transforaminal approach for distally migrated disc herniation.     

Transtubular versus microsurgical approach for single lumbar disc herniation: a prospective study

Earlier studies have compared transtubular discectomy with microsurgical discectomy in the treatment of lumbar disc herniations, but a few prospective studies with homogeneous groups of patients have been conducted. The aim of this study was to compare intraoperative and immediate postoperative results in a group of patients submitted to discectomy with the use of a tubular retractor (TTD) to the one operated with standard microdiscectomy as described by Caspar (MSD). A total of 83 patients were prospectively observed and reviewed. Two homogeneous groups of patients were compared. All patients were preoperatively examined by the operating surgeon and the anaesthesiologist. All surgical data and constatations were collected on the operative summary. Several parameters like operative time, morphinic consumption in recovery room, length of hospital stay and peri- and post-operative complications were compared. Results show that both procedures lead to excellent recovery and that TTD is a viable alternative to MSD. There was no statistically significant difference in most of the examined parameters between the two techniques.     

Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach

Anterior cervical fusion was initially described in the 1950s for cervical spondylotic radiculopathy. The indications for this procedure in the management of soft disc herniation have not been clearly defined. In addition, controversy exists as to whether a cervical soft herniation should be managed by an anterior approach or a posterior cervical laminotomy-foraminotomy. The authors report the results of a prospective study comparing anterior discectomy and fusion to posterior laminotomy-foraminotomy for the management of soft cervical disc herniation. Twenty-eight patients underwent anterior discectomy and fusion (Robinson horseshoe graft) while 16 patients underwent posterior laminotomy-foraminotomy. The disc herniations were classified into two types. Type I were single level anterolateral herniations (33 patients) while type II were central soft disc herniations (11 patients). Clinically, patients with type I herniations manifested signs and symptoms of radiculopathy while patients with type II herniations manifested signs of myelopathy or neck pain and bilateral upper extremity paresthesias in 4 patients. Confirmatory studies were myelography in 12 patients, myelography combined with computed tomography (CT) in 26 patients, and magnetic resonance imaging (MRI) in 6 patients. For type I herniations, 17 patients underwent anterior fusion while 16 patients had a posterior laminotomy-foraminotomy. The 11 patients classified as type II herniation all underwent anterior discectomy and fusion. There were 27 men and 17 women. The age range was 21 to 52 years (mean, 41 years). The follow-up was 1.6 to 8.2 years (mean, 4.2 years).(ABSTRACT TRUNCATED AT 250 WORDS)     

Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral lumbar disc herniations in children

Purpose

The use of transforaminal percutaneous endoscopic discectomy for the treatment of far-lateral lumbar disc herniations has been applied mostly in adults. However, transforaminal percutaneous endoscopic discectomy in children has probably been rarely documented. The aim of this study was to assess the efficacy of transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral lumbar disc herniations in children.

Methods

Overall, 12 cases of far-lateral lumbar disc herniations were treated with the procedure of transforaminal percutaneous endoscopic discectomy between January 2010 and December 2014. There were seven male and five female children included, with an average age of 12.6 years (11–16 years). Pre-operative and post-operative (6 weeks, 6 months and 12 months) clinical outcome data (back and leg visual analog scale [VAS] and Macnab criteria) were collected along with clinical assessments of motor strength (graded 0–5).

Results

All patients were discharged to home on the same day of surgery. The average leg VAS score improved from 8.6?±?1.6 to 2.1?±?0.4 (p?<?0.005). Six patients had excellent outcomes, five had good outcomes, one had fair outcomes, and none had poor outcomes, according to the Macnab criteria. Eleven of 12 patients had excellent or good outcomes, for an overall success rate of 91.6 %. No patients required re-operation. There were no incidental durotomies, infections, vascular or visceral injuries. There was one complication, a case of leg numbness caused by ganglion injury. The numbness improved after two weeks. After three months, it was obvious that the total area of numbness in the legs had become smaller. At last follow-up, the patient had no pain, and only a few areas with numbness remained and did not affect the patient’s activities of daily living.

Conclusions

Transforaminal percutaneous endoscopic discectomy achieved satisfactory results for children with far-lateral lumbar disc herniations.

     

Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations

The objective of this study is to evaluate the efficacy of the endoscopic technique, as applied to patients with foraminal and extraforaminal disc herniations, and to report the outcome and complications. A retrospective analysis was performed of 35 consecutive cases of foraminal and extraforaminal lumbar disc herniation managed by posterolateral endoscopic discectomy. Pain was measured by means of the Visual Analog Score. Patient satisfaction was evaluated by the Macnab outcome criteria. The median follow-up period was 18 months (range 10 to 35 months). The mean Visual Analog Score improved from 8.6 before the surgery to 3.2 after the surgery. Overall, excellent or good outcomes were obtained in 30 (85.7%) of the 35 patients at the last follow-up examination, with both these outcomes showing statistically significant improvement (P<0.01). There were no complications related to the surgery, nor was any spinal instability detected. Three patients (8.6%) experienced persistent radiculopathy and subsequently underwent open microdiscectomy at the same level. We concluded that transforaminal percutaneous endoscopic discectomy is safe and efficacious in the treatment of foraminal or extraforaminal disc herniations. However, proper patient selection is paramount to ensure a satisfactory outcome after decompression of foraminal and extraforaminal disc herniations.     

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

Background

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.

Method

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.

Findings

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).

Conclusions

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

Microendoscopic lumbar discectomy versus open surgery: an intraoperative EMG study

This study investigated electromyographic (EMG) activity as a marker of nerve root irritation during two different surgical procedures for lumbar disc herniation. Mechanically elicited EMG activity was recorded during the dynamic stages of surgery in muscle groups innervated by lumbar nerve roots. Confirmation of surgical activity was correlated with the activity of the electromyogram. Fifteen patients with lumbar disc herniations were treated via an endoscopic medial approach, and 15 patients via the open microscopic surgical technique. Results indicated that the endoscopic technique was superior to the open surgical technique and produced less irritation of the nerve root. Significantly less mechanically elicited activity was recorded during both the approach and the root mobilization. The study showed that microendoscopic discectomy allows a smaller incision and less tissue trauma with comparable visualization of the nerve structures than does open surgery.     

Anterior lumbar microdiscectomy and interbody fusion for the treatment of recurrent disc herniation

OBJECTIVE: To demonstrate the feasibility of anterior lumbar microdiscectomy in patients with recurrent, sequestered lumbar disc herniations. METHODS: Between 1997 and 1999, six patients underwent a muscle-sparing "minilaparotomy" approach and subsequent microscopic anterior lumbar microdiscectomy and fragmentectomy for recurrent lumbar disc extrusions at L5-S1 (n = 4) or L4-L5 (n = 2). A contralateral distraction plug permitted ipsilateral discectomy under microscopic magnification. Effective resection of the extruded disc fragments was accomplished by opening the posterior longitudinal ligament. Interbody fusion was performed by placing cylindrical threaded titanium cages (n = 4) or threaded allograft bone dowels (n = 2). RESULTS: There were no complications, and blood loss was minimal. Follow-up magnetic resonance imaging revealed complete resection of all herniated disc material. Plain x-rays revealed excellent interbody cage position. Radicular pain and neurological deficits resolved in all six patients (mean follow-up, 14 mo). CONCLUSION: Anterior lumbar microdiscectomy with interbody fusion provides a viable alternative for the treatment of recurrent lumbar disc herniations. Recurrent herniated disc fragments can be removed completely under direct microscopic visualization, and interbody fusion can be performed in the same setting.     

Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature

The study design includes a systematic literature review. The objective of the study was to evaluate the effectiveness of transforaminal endoscopic surgery and to compare this with open microdiscectomy in patients with symptomatic lumbar disc herniations. Transforaminal endoscopic techniques for patients with symptomatic lumbar disc herniations have become increasingly popular. The literature has not yet been systematically reviewed. A comprehensive systematic literature search of the MEDLINE and EMBASE databases was performed up to May 2008. Two reviewers independently checked all retrieved titles and abstracts and relevant full text articles for inclusion criteria. Included articles were assessed for quality and outcomes were extracted by the two reviewers independently. One randomized controlled trial, 7 non-randomized controlled trials and 31 observational studies were identified. Studies were heterogeneous regarding patient selection, indications, operation techniques, follow-up period and outcome measures and the methodological quality of these studies was poor. The eight trials did not find any statistically significant differences in leg pain reduction between the transforaminal endoscopic surgery group (89%) and the open microdiscectomy group (87%); overall improvement (84 vs. 78%), re-operation rate (6.8 vs. 4.7%) and complication rate (1.5 vs. 1%), respectively. In conclusion, current evidence on the effectiveness of transforaminal endoscopic surgery is poor and does not provide valid information to either support or refute using this type of surgery in patients with symptomatic lumbar disc herniations. High-quality randomized controlled trials with sufficiently large sample sizes are direly needed to evaluate if transforaminal endoscopic surgery is more effective than open microdiscectomy.     

脊柱内窥镜技术治疗腰椎间盘突出症的进展

近年来,微创脊柱外科发展迅速,脊柱内窥镜技术在腰椎间盘突出症的手术治疗中具有损伤小、恢复期短、疗效确切、保持脊柱的稳定性等优势,其应用越来越广泛。目前应用于腰椎间盘突出症LDH的脊柱内窥镜技术包括：后路椎间盘镜下腰椎间盘摘除术（MED）、经皮穿刺椎间孔镜下椎间盘摘除术（PELD）及完全内窥镜下腰椎间盘摘除术（FLD）等。正确认识脊柱内窥镜技术,严格适应证和熟练的操作技巧是取得良好疗效的关键。本文将总结各种脊柱内窥镜手术方法在腰椎间盘突出症治疗中应用的现状与进展。     

经皮内窥镜激光椎间盘摘除术治疗腰椎间盘突出症的近期疗效

[目的]探讨经皮内窥镜激光椎间盘摘除术对腰椎间盘突出症的近期治疗效果.[方法]2008年7月～2009年1月,36名腰椎间盘突出症患者在本院接受利用结合侧方发射激光和Ellman高频射频装备的经皮内窥镜椎间盘摘除术,疗效判断采用了术前及术后腰痛及腿痛视觉模拟评分(VAS)的变化情况,术后1年时MacNab功能评分.[结果]全部手术均顺利完成,手术时间为30～70 min,平均42 min,无术中并发症发生,手术成功率为97%,手术复发率为3%.所有患者最终随访时间均为1年,腰痛VAS评分术前6.19分,术后1年2.25分;腿痛VAS评分术前8.25分,术后1年1.75分;术后腰痛和腿痛的VAS评分较术前均明显降低(P<0.01).按照MacNab评分标准,术后1年随访时,优28例,良6例,优良率94%.[结论]经皮内窥镜激光椎间盘摘除术治疗腰椎间盘突出症创伤小、安全,而且近期疗效好.     

Posterior endoscopic discectomy (and other procedures)

Percutaneous approaches to lumbar discectomy were somewhat controversial, because of their limited indications. They have not proven to be as effective as standard open lumbar disc surgery, because of longer operating times and some technical problems in addressing all the different aspects of lumbar disc herniations. New percutaneous posterior procedures for lumbar disc disease have been described in the last few years, but the MicroEndoscopic Discectomy (MED) introduced by Foley and Smith in 1997 seems to be the most promising one. MED, and METR’x which evolved from it, . allow the surgeon to address not only contained lumbar disc herniations, but also free-fragment disc pathology and symptomatic lateral recess stenosis secondary to bony hypertrophy. The surgical technique is summarized and some preliminary clinical results of a prospective multicenter study with 13 months’ mean follow-up are presented.     

后路椎间盘镜技术治疗游离型腰椎间盘突出症

目的研究腰椎后路椎间盘镜手术治疗游离型腰椎间盘突出症的手术方法、对策及效果。方法2000年9月至2004年6月利用后路腰椎间盘镜技术治疗游离型腰椎间盘突出症8例。结果8例患者均获得随访,时间9~54个月,平均27.2个月。本组优5例,良3例,优良率100%。本组病例无神经损伤、感染等并发症。结论采用腰椎后路椎间盘镜手术治疗,减压充分,损伤小,临床疗效满意。