Strategies for Noncontained Lumbar Disc Herniation by an Endoscopic Approach : Transforaminal Suprapedicular Approach, Semi-Rigid Flexible Curved Probe, and 3-Dimensional Reconstruction CT with Discogram

Abstract

Objective : The purpose of this study was to evaluate the efficacy of a transforaminal suprapedicular approach, semi-rigid flexible curved probe, and 3-dimensional reconstruction computed tomography (3D-CT) with discogram in the endoscopic treatment of non-contained lumbar disc herniations. Methods : The subjects were 153 patients with difficult, non-contained lumbar disc herniations undergoing endoscopic treatment. The types of herniation were as follows : extraforaminal, 17 patients; foraminal, 21 patients; high grade migration, 59 patients; and high canal compromise, 56 patients. To overcome the difficulties in endoscopic treatment, the anatomic structures were analyzed by 3D reconstruction CT and the high grade disc was extracted using a semi-rigid flexible curved probe and a transforaminal suprapedicular approach. Results : The mean follow-up was 18.3 months. The mean visual analogue scale (VAS) of the patients prior to surgery was 9.48, and the mean postoperative VAS was 1.63. According to Macnab's criteria, 145 patients had excellent and good results, and thus satisfactory results were obtained in 94.77% cases. Conclusion : In a posterolateral endoscopic lumbar discectomy, the difficult, non-contained disc is considered to be the most important factor impeding the success of surgery. By applying a semi-rigid flexible curved probe and using a transforaminal suprapedicular approach, good surgical results can be obtained, even in high grade, non-contained disc herniations.

Learning Curve of Percutaneous Endoscopic Lumbar Discectomy Based on the Period (Early vs. Late) and Technique (in-and-out vs. in-and-out-and-in): A Retrospective Comparative Study

“…A microdiscectomy has been considered to be the gold standard procedure for symptomatic lumbar disc diseases 1 4 8 10 14 15 18 20 23 25 26 27) . However, open surgery requires laminectomies, muscle damages, removal of yellow ligament and nerve retraction.…”

Clinical Application of Transforaminal Percutaneous Endoscopic Lumbar Discectomy Via Superior Notch of Inferior Vertebral Pedicle Approach for Very High-grade Inferiorly Migrated Disc Herniation

“…However, open discectomy will inevitably destroy paravertebral muscles, vertebral lamina, and articular processes, affecting spinal instability [6]. To overcome these limitations, some methods have been developed, such as the extreme lateral approach, epiduroscopic approach, superior vertebral notch approach, and suprapedicular approach [6,[13][14][15][16]. No matter what surgical approach, the most fundamental breakthrough is that the working cannula should be as close to the target as possible [6].…”

Percutaneous Endoscopic Lumbar Discectomy for All Types of Lumbar Disc Herniations (LDH) Including Severely Difficult and Extremely Difficult LDH Cases

“…In 2007, Lee et al (9) introduced the half-an-half technique and the epiduroscopic approach. In 2009, suprapedicular approach was introduced by Kim et al (10) for high grade inferior migrated discs and Chae et al (11) introduced a semi-rigid flexible curved probe. Foraminoplasty techniques (12)(13)(14)(15) are also described in the literature.…”

“…Due to these anatomical barriers, the L4-5 inferior migrated disc is difficult to reach with a rigid percutaneous endoscope. For cases of a highly inferior migrated disc, epidural exposure around the suprapedicular area (10,11) will be helpful to expose the epidural space. This suprapedicular area is usually covered with abundant fatty tissue.…”