Transforaminal Percutaneous Endoscopic Discectomy for L3/4 and L4/5 Foraminal and Extraforaminal Lumbar Disc Herniation: Clinical Outcomes and Technical Note

Abstract

Study Design

Retrospective cohort study.

Background

Foraminal and extraforaminal disc herniations account for 7 to 12% of lumbar herniated discs. Various surgical methods, including midline approaches with facetectomy and paramedian techniques, involve significant bone removal, risking spinal instability. The percutaneous transforaminal approach for endoscopic access to lateral disc herniations presents several advantages over traditional techniques and may be more suitable for these cases.

Objectives

This article evaluates the clinical outcomes and potential complications associated with the treatment of foraminal and extraforaminal lumbar disc herniations at the L3/4 and L4/5 levels in patients who have undergone transforaminal percutaneous endoscopic lumbar discectomy.

Materials and Methods

Between 2016 and 2020, a total of 32 patients diagnosed with single-level lumbar disc herniation at the L3/4 or L4/5 foraminal or extraforaminal levels, who had not responded to conservative management, underwent transforaminal endoscopic discectomy. Follow-up evaluations were performed on postoperative day 1 and at 2 weeks, 6 weeks, 3 months, and 12 months. Both pre- and postoperative assessments employed the visual analog scale (VAS) and the Oswestry Disability Index (ODI) to quantify pain levels and functional outcomes. Clinical outcomes were assessed according to the MacNab criteria to determine the efficacy of the surgical intervention.

Results

The average age of patients was 52.6 years, with L4/5 (81.3%) and L3/4 (18.7%) being the most affected levels. The median follow-up was 18.2 months (range, 1–44 months). There was a significant reduction in VAS and ODI scores at follow-ups compared to preoperative levels (p < 0.01). All patients with preoperative neurological deficits improved, though six patients (18.7%) experienced transient dysesthesia that resolved in 6 weeks. Per the MacNab criteria, clinical efficacy was excellent in 56.3% of patients, good in 37.5%, and fair in 6.2%.

Conclusion

Transforaminal endoscopic lumbar discectomy is a safe and effective minimally invasive procedure for foraminal and extraforaminal lumbar disc herniations at the L3/4 and L4/5 levels. It preserves spinal stability, minimizes blood loss, reduces postoperative pain, and allows for quicker recovery, presenting a strong alternative for patients needing surgery for these conditions.

Keywords

foraminal lumbar disc herniation - far lateral lumbar disc herniation - transforaminal endoscopic discectomy

Ethical Approval

The study was approved by the ethics committee of Lerdsin Hospital.

Publication History

Article published online:
10 March 2025

• References

• 1 Abdullah AF, Ditto III EW, Byrd EB, Williams R. Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J Neurosurg 1974; 41 (02) 229-234
• 2 O'Hara LJ, Marshall RW. Far lateral lumbar disc herniation. The key to the intertransverse approach. J Bone Joint Surg Br 1997; 79 (06) 943-947
• 3 Darden II BV, Wade JF, Alexander R, Wood KE, Rhyne III AL, Hicks JR. Far lateral disc herniations treated by microscopic fragment excision. Techniques and results. Spine 1995; 20 (13) 1500-1505
• 4 Epstein NE. Different surgical approaches to far lateral lumbar disc herniations. J Spinal Disords 1995; 8: 383-394
• 5 Garrido E, Connaughton PN. Unilateral facetectomy approach for lateral lumbar disc herniation. J Neurosurg 1991; 74 (05) 754-756
• 6 Jackson RP, Glah JJ. Foraminal and extraforaminal lumbar disc herniation: diagnosis and treatment. Spine 1987; 12 (06) 577-585
• 7 Maroon JC, Kopitnik TA, Schulhof LA, Abla A, Wilberger JE. Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 1990; 72 (03) 378-382
• 8 Halldin K, Zoëga B, Kärrholm J, Lind BI, Nyberg P. Is increased segmental motion early after lumbar discectomy related to poor clinical outcome 5 years later?. Int Orthop 2005; 29 (04) 260-264
• 9 Kotilainen E. Long-term outcome of patients suffering from clinical instability after microsurgical treatment of lumbar disc herniation. Acta Neurochir (Wien) 1998; 140 (02) 120-125
• 10 Kramer J, Ludwig J. Surgical treatment of lumbar intervertebral disc displacement. Indications and methods. Orthopade 1999; 28: 579-584
• 11 Kuroki H, Goel VK, Holekamp SA, Ebraheim NA, Kubo S, Tajima N. Contributions of flexion-extension cyclic loads to the lumbar spinal segment stability following different discectomy procedures. Spine 2004; 29 (03) E39-E46
• 12 Schaller B. Failed back surgery syndrome: the role of symptomatic segmental single-level instability after lumbar microdiscectomy. Eur Spine J 2004; 13 (03) 193-198
• 13 Yeung AT. The evolution of percutaneous spinal endoscopy and discectomy: state of the art. Mt Sinai J Med 2000; 67 (04) 327-332
• 14 Viswanathan R, Swamy NK, Tobler WD, Greiner AL, Keller JT, Dunsker SB. Extraforaminal lumbar disc herniations: microsurgical anatomy and surgical approach. J Neurosurg 2002; 96 (2, suppl): 206-211
• 15 Sasani M, Ozer AF, Oktenoglu T, Canbulat N, Sarioglu AC. Percutaneous endoscopic discectomy for far lateral lumbar disc herniations: prospective study and outcome of 66 patients. Minim Invasive Neurosurg 2007; 50 (02) 91-97
• 16 Lew SM, Mehalic TF, Fagone KL. Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations. J Neurosurg 2001; 94 (2, suppl): 216-220
• 17 Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am 1971; 53 (05) 891-903
• 18 Zhang L, Yang J, Hai Y. et al. Relationship of the exiting nerve root and superior articular process in Kambin's triangle: assessment of lumbar anatomy using cadavers and computed tomography imaging. World Neurosurg 2020; 137: e336-e342
• 19 Lindblom K. Protrusions of disks and nerve compression in the lumbar region. Acta Radiol 1944; 25: 195-212
• 20 Porchet F, Chollet-Bornand A, de Tribolet N. Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations. J Neurosurg 1999; 90 (1, suppl): 59-66
• 21 An HS, Vaccaro A, Simeone FA, Balderston RA, O'Neill D. Herniated lumbar disc in patients over the age of fifty. J Spinal Disord 1990; 3 (02) 143-146
• 22 Eichholz KM, Hitchon PW. Far lateral lumbar disc herniation. Contemp Neurosurg 2003; 25 (16) 1-5
• 23 Ahn Y, Lee SH, Lee JH, Kim JU, Liu WC. Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration. Acta Neurochir (Wien) 2009; 151 (03) 199-206
• 24 Salame K, Lidar Z. Minimally invasive approach to far lateral lumbar disc herniation: technique and clinical results. Acta Neurochir (Wien) 2010; 152 (04) 663-668
• 25 Lübbers T, Abuamona R, Elsharkawy AE. Percutaneous endoscopic treatment of foraminal and extraforaminal disc herniation at the L5-S1 level. Acta Neurochir (Wien) 2012; 154 (10) 1789-1795
• 26 Jang JS, An SH, Lee SH. Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. J Spinal Disord Tech 2006; 19 (05) 338-343
• 27 Cho JY, Lee SH, Lee HY. Prevention of development of postoperative dysesthesia in transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation: floating retraction technique. Minim Invasive Neurosurg 2011; 54 (5-6): 214-218
• 28 Ahn Y. Transforaminal percutaneous endoscopic lumbar discectomy: technical tips to prevent complications. Expert Rev Med Devices 2012; 9 (04) 361-366