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J Neurol Surg A Cent Eur Neurosurg 2018; 79(01): 060-065
DOI: 10.1055/s-0037-1601875
Technical Note
Georg Thieme Verlag KG Stuttgart · New York

Combination of Transforaminal and Interlaminar Percutaneous Endoscopic Lumbar Diskectomy for Extensive Down-migrated Disk Herniation

Kyung-Chul Choi
1   Department of Neurosurgery, the Leon Wiltse Memorial Hospital, Anyang, Korea
,
Jung Hyun Lee
1   Department of Neurosurgery, the Leon Wiltse Memorial Hospital, Anyang, Korea
,
Jin-Sung Kim
2   Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
,
Dong Chan Lee
1   Department of Neurosurgery, the Leon Wiltse Memorial Hospital, Anyang, Korea
,
Choon Keun Park
3   Department of Neurosurgery, the Leon Wiltse Memorial Hospital, Suwon, Korea
› Author Affiliations
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Publication History

01 December 2016

16 February 2017

Publication Date:
28 April 2017 (online)

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Abstract

Background and Study Aims The technique and instrumentation of percutaneous endoscopic lumbar diskectomy (PELD) have significantly improved. Thus its indications have been gradually expanding. Down-migrated disk, in particular, is regarded inaccessible by rigid instrumentation due to poor visualization and limited accessibility. We introduce a combination of transforaminal and interlaminar PELD for extensive down-migrated disk herniation at the L4–L5 level.

Patients and Methods In the first case, a 48-year-old man had left L5 radicular pain. Magnetic resonance imaging (MRI) showed that L4–L5 disk herniation extended to the L5 lower end-plate level. In the second case, a 39-year-old man presented with right L5 and S1 radiculopathy. MRI showed right huge extensive down-migrated disk herniation from the L4–L5 disk space to the S1 pedicle level. Back pain and leg pain were measured using the visual analog scale (VAS). In the first case, transforaminal PELD with foraminoplasty removed the disk fragment from the L4–L5 disk space to the mid-L5 pedicle level. Interlaminar PELD removed the remaining disk below the mid-L5 pedicle. In the second case, first, contralateral (left) transforaminal PELD at L4–L5 removed disk fragments located at the subannular and subligamentous area as well as the upper part of the down-migrated disk herniation. Second, interlaminar PELD via an ipsilateral (right) L5–S1 interlaminar space removed the remains of the extensively down-migrated disk herniation.

Results In the first case, the VAS scores for back and leg pain were improved from 6 and 8 to 2 and 1, respectively. Postoperative MRI showed complete removal of the disk fragment. In the second case, the VAS scores for back and leg pain improved from 7 and 9 to 3 and 1, respectively, after PELD. Postoperative MRI showed complete removal of a huge disk herniation. Both patients were discharged the day after PELD. Follow-up examinations showed no recurrence.

Conclusions It is difficult to remove entire disk fragments using only a transforaminal or interlaminar approach for extensive down-migrated disk herniation. Therefore a combination of transforaminal and interlaminar PELD may be effective for extensive down-migrated disk herniation at L4–L5.

Keywords

percutaneous endoscopic lumbar diskectomy - transforaminal - interlaminar - down-migrated disk herniation - foraminoplasty
 

  • References

  • 1 Akçakaya MO, Yörükoğlu AG, Aydoseli A. , et al. Serum creatine phosphokinase levels as an indicator of muscle injury following lumbar disc surgery: comparison of fully endoscopic discectomy and microdiscectomy. Clin Neurol Neurosurg 2016; 145: 74-78
    CrossrefPubMedGoogle Scholar
  • 2 Choi KC, Kim JS, Park CK. Percutaneous endoscopic lumbar discectomy as an alternative to open lumbar microdiscectomy for large lumbar disc herniation. Pain Physician 2016; 19 (02) E291-E300
    PubMedGoogle Scholar
  • 3 Kambin P, Sampson S. Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res 1986; (207) 37-43
    PubMedGoogle Scholar
  • 4 Choi KC, Lee JH, Kim JS. , et al. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10,228 cases. Neurosurgery 2015; 76 (04) 372-380 ; discussion 380–381, quiz 381
    CrossrefPubMedGoogle Scholar
  • 5 Lee SH, Kang BU, Ahn Y. , et al. Operative failure of percutaneous endoscopic lumbar discectomy: a radiologic analysis of 55 cases. Spine 2006; 31 (10) E285-E290
    CrossrefPubMedGoogle Scholar
  • 6 Hijikata S. Percutaneous nucleotomy. A new concept technique and 12 years' experience. Clin Orthop Relat Res 1989; (238) 9-23
    PubMedGoogle Scholar
  • 7 Choi G, Lee SH, Lokhande P. , et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine 2008; 33 (15) E508-E515
    CrossrefPubMedGoogle Scholar
  • 8 Choi G, Prada N, Modi HN, Vasavada NB, Kim JS, Lee SH. Percutaneous endoscopic lumbar herniectomy for high-grade down-migrated L4-L5 disc through an L5-S1 interlaminar approach: a technical note. Minim Invasive Neurosurg 2010; 53 (03) 147-152
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Lee SH, Choi KC, Baek OK, Kim HJ, Yoo SH. Percutaneous endoscopic intra-annular subligamentous herniotomy for large central disc herniation: a technical case report. Spine 2014; 39 (07) E473-E479
    CrossrefPubMedGoogle Scholar
  • 10 Choi G, Kim JS, Lokhande P, Lee SH. Percutaneous endoscopic lumbar discectomy by transiliac approach: a case report. Spine 2009; 34 (12) E443-E446
    CrossrefPubMedGoogle Scholar
  • 11 Kim JS, Choi G, Lee SH. Percutaneous endoscopic lumbar discectomy via contralateral approach: a technical case report. Spine 2011; 36 (17) E1173-E1178
    CrossrefPubMedGoogle Scholar
  • 12 Lee S, Kim SK, Lee SH. , et al. Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches. Eur Spine J 2007; 16 (03) 431-437
    CrossrefPubMedGoogle Scholar
  • 13 Lee SH, Kang HS, Choi G. , et al. Foraminoplastic ventral epidural approach for removal of extruded herniated fragment at the L5-S1 level. Neurol Med Chir (Tokyo) 2010; 50 (12) 1074-1078
    CrossrefPubMedGoogle Scholar
  • 14 Osman SG, Sherlekar S, Malik A. , et al. Endoscopic trans-iliac approach to L5-S1 disc and foramen—a report on clinical experience. Int J Spine Surg 2014; 8: 20
    CrossrefPubMedGoogle Scholar
  • 15 Lee CW, Yoon KJ, Ha SS, Kang JK. Foraminoplastic superior vertebral notch approach with reamers in percutaneous endoscopic lumbar discectomy: technical note and clinical outcome in limited indications of percutaneous endoscopic lumbar discectomy. J Korean Neurosurg Soc 2016; 59 (02) 172-181
    CrossrefPubMedGoogle Scholar
  • 16 Li ZZ, Hou SX, Shang WL, Cao Z, Zhao HL. Percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar decompression for lateral recess stenosis through transforaminal approach: technique notes and 2 years follow-up. Clin Neurol Neurosurg 2016; 143: 90-94
    CrossrefPubMedGoogle Scholar
  • 17 Schubert M, Hoogland T. Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation. Oper Orthop Traumatol 2005; 17 (06) 641-661
    CrossrefPubMedGoogle Scholar
  • 18 Ruetten S, Komp M, Godolias G. A new full-endoscopic technique for the interlaminar operation of lumbar disc herniations using 6-mm endoscopes: prospective 2-year results of 331 patients. Minim Invasive Neurosurg 2006; 49 (02) 80-87
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Choi KC, Kim JS, Ryu KS, Kang BU, Ahn Y, Lee SH. Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: transforaminal versus interlaminar approach. Pain Physician 2013; 16 (06) 547-556
    PubMedGoogle Scholar
  • 20 Ahn Y, Jang IT, Kim WK. Transforaminal percutaneous endoscopic lumbar discectomy for very high-grade migrated disc herniation. Clin Neurol Neurosurg 2016; 147: 11-17
    CrossrefPubMedGoogle Scholar
  • 21 Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S. A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect. Spine 2006; 31 (06) 653-657
    CrossrefPubMedGoogle Scholar
  • 22 Mochida J, Nishimura K, Nomura T, Toh E, Chiba M. The importance of preserving disc structure in surgical approaches to lumbar disc herniation. Spine 1996; 21 (13) 1556-1563 ; discussion 1563–1564
    CrossrefPubMedGoogle Scholar
  • 23 Ruan W, Feng F, Liu Z, Xie J, Cai L, Ping A. Comparison of percutaneous endoscopic lumbar discectomy versus open lumbar microdiscectomy for lumbar disc herniation: a meta-analysis. Int J Surg 2016; 31: 86-92
    CrossrefPubMedGoogle Scholar
  • 24 Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev 2014; 4 (09) CD010328
    PubMedGoogle Scholar