A Comparative Outcome of Full Endoscopic Lumbar Discectomy for L4/5 Central–Paracentral Disc Herniation: Interlaminar versus Transforaminal Approach: A 2-Year Prospective Randomized Controlled Follow-Up Study

Abstract

Background The interlaminar and transforaminal approaches are commonly employed in full endoscopic lumbar spine surgery. Both approaches are well-suited for addressing specific types of lumbar disc herniation, particularly at the L4/5 level.

Objective This article compares the clinical outcomes of full endoscopic discectomy for L4/5 central–paracentral disc herniation between the interlaminar and transforaminal approaches.

Materials and Methods Sixty patients were randomly assigned to either a full endoscopic interlaminar discectomy group or a full endoscopic transforaminal discectomy group, with 30 patients each. The procedures were performed by a single spine surgeon at our institution between 2017 and 2019. Over a 2-year follow-up period, various parameters, including operative time, postoperative hospitalization duration, Visual Analog Scale (VAS) scores for leg and back pain, Oswestry Disability Index (ODI), and modified MacNab criteria, were assessed and compared between the two groups. Additionally, the complication rates were documented.

Results The two full endoscopic approaches resulted in significant improvements in back–leg pain measured by the VAS and in the ODI scores postsurgery. A comparison between the two approaches revealed a significant difference in the ODI score at the 6-week postoperative mark (p = 0.02). However, other clinical outcome parameters did not show significant differences at the other follow-up time points. Postoperative dysesthesia was more prevalent in patients who underwent endoscopic transforaminal discectomy (p < 0.05). The operative time was notably longer for the interlaminar approach compared with the transforaminal approach (62.6 ± 18.0 vs. 37.0 ± 13.6). Postoperative hospitalization time did not exhibit significant differences between the two groups.

Conclusion Both the interlaminar and transforaminal approaches demonstrate similar clinical outcomes in treating central–paracentral L4/5 disc herniation. Each technique presents distinct advantages and disadvantages regarding operative time and postoperative dysesthesia. The full endoscopic interlaminar and transforaminal approaches have proven to be safe and effective methods for addressing L4/5 central–paracentral disc herniation.

Keywords

lumbar disc herniation - full endoscope - discectomy - interlaminar approach - transforaminal approach

Introduction

In cases of lumbar disc herniation characterized by predominant leg pain, discectomy is a viable treatment option. The full endoscopic technique, which has been in practice for over two decades, serves as a minimally invasive surgical approach for lumbar disc herniation.[1] An escalating body of clinical research has substantiated that endoscopic lumbar discectomy yields comparable efficacy to traditional surgery while affording several advantages, including smaller incisions, reduced damage to soft tissues, minimal wound discomfort, decreased blood loss, expedited recovery, and diminished postoperative complications.[2] [3] [4] [5]

Lumbar disc herniation can be effectively addressed through the full endoscopic technique, which involves the use of high-speed burrs and other specialized instruments to achieve precise bone and soft tissue resection while maintaining continuous visual oversight. This approach typically results in adequate discectomy. There are two primary methods for endoscopic discectomy: the interlaminar approach and the transforaminal approach. Both techniques are considered minimally invasive, yet each has its distinct advantages and disadvantages.

The interlaminar approach offers heightened mobility, enabling the removal of a significant portion of the disc herniation within the spinal canal. Furthermore, the anatomical exposure associated with this method is well-recognized by most spine surgeons. Conversely, the transforaminal approach requires less soft tissue dissection, representing a notable benefit of this technique.[5] [6]

Several studies have conducted comparative analyses of the two endoscopic approaches for lumbar disc herniation, particularly at the L5/S1 level.[7] [8] [9] [10] Both approaches demonstrated similar outcomes at the L5/S1 level; however, the interlaminar approach reduced radiation exposure (fluoroscopic times) and shortened operative time. At the L4/5 level, the anatomical considerations differ from those at the L5/S1 level. The L4/5 level features a narrower interlaminar window, necessitating more extensive bone resection (including part of the facet and lamina) for the interlaminar approach. Conversely, the transforaminal approach at L4/5 is less obstructed by the iliac crest and allows direct access to the intervertebral disc. Both interlaminar and transforaminal approaches may be suitable for treating patients with central–paracentral disc herniation at the L4/5 level. Presently, limited literature exists studying the variation in clinical outcomes between these two approaches for L4/5 disc herniation. Therefore, the primary objective of this study was to compare the clinical outcomes of interlaminar and transforaminal endoscopic discectomy in patients presenting with L4/5 central–paracentral disc herniation.

Materials and Methods

General Information

The study received approval from the institutional review board of Lerdsin Hospital, Bangkok, Thailand. The research enrolled 60 patients who underwent full endoscopic discectomy for L4/5 central–paracentral disc herniation performed by a senior spine surgeon at Lerdsin Hospital between January 2017 and October 2019. The patients were divided into two groups: one undergoing full endoscopic interlaminar discectomy and the other undergoing full endoscopic transforaminal discectomy. Allocation was achieved through nonblind randomization using a box of four methods, with 30 patients in each group. Diagnostic investigations included plain radiographs of the lumbosacral spine, anterior–posterior view, lateral view, and dynamic views (flexion and extension), and a magnetic resonance imaging (MRI) was obtained to confirm the diagnosis. [Table 1] presents data on mean age, gender, smoking history, neurological deficit (weakness), straight-leg raising test results, and type of disc herniation based on the recommendations of the combined task force of the North American Spine Society.[11] Inclusion criteria involved central or paracentral disc herniation at the L4/5 level following failed conservative treatment for 6 weeks.[12] The exclusion criteria encompassed foraminal or extraforaminal disc herniation, disc migration requiring a transforaminal approach, concomitant spinal canal stenosis from degenerative changes, and spondylolisthesis.

Table 1 General information of patients in the two groups

	Interlaminar group (n = 30)	Transforaminal group (n = 30)	p-Value
Mean age	39.30 ± 2.11	37.71 ± 1.68	> 0.05
Gender
Male	16 (53.3%)	21 (70%)	> 0.05
Female	14 (46.7%)	9 (30%)
Smoking	5 (16.7%)	5 (16.7%)	> 0.05
Neurological deficit	24 (80%)	25 (83.3%)	> 0.05
Straight leg raising test positive	28 (93.3%)	29 (96.7%)	> 0.05
Types of disc herniation
Protrusion	9 (30%)	10 (33.3%)	> 0.05
Extrusion	21 (70%)	20 (66.7%)
Preoperative VAS leg pain	6.87 ± 1.89	6.87 ± 1.46	1.00
Preoperative VAS back pain	4.23 ± 2.98	5.13 ± 2.44	0.21
Preoperative ODI score	45.87 ± 19.08	45.17 ± 14.45	0.88

Abbreviations: ODI, Oswestry Disability Index; VAS, Visual Analog Scale.

Surgical Technique

We utilized a Richard-Wolf Endoscopy system with a 6.9-mm scope for both transforaminal and interlaminar discectomy procedures. The patients were positioned prone, kneeling on the Jackson operative table, and all interventions were performed under general anesthesia ([Fig. 1]).

Fig. 1 The magnetic resonance imaging (MRI) images depict a 31-year-old male with a 2-month history of left leg pain (A, B) and a 34-year-old male with a 6-month history of left leg pain (E, F). The endoscopic views display an interlaminar approach revealing a free fragment disc (C) and a transforaminal approach showing a free fragment disc (G), followed by images postdiscectomy (D, H).

Interlaminar Approach

The L4/5 interlaminar window was precisely located using fluoroscopy.[6] A 1-cm skin incision was made close to the midline of the L4/5 interlaminar window. A dilator was then carefully inserted into the interlaminar space, situated laterally to the ligamentum flavum and in close proximity to the medial side of the facet joint. In cases where the interlaminar windows are narrow and require significant facet and laminar resection, a power burr would be utilized. The resection of the ligamentum flavum was performed, followed by the identification and retraction of the lateral border of the nerve root by rotating the working sleeve. Discectomy was performed until no free fragments were detected, and the pulsatile nature of the neural structure was verified. Finally, the skin was sutured using a single stitch of 3–0 nonabsorbable suture ([Fig. 2]).

Fig. 2 The endoscopic interlaminar approach is illustrated in the model for the treatment of L4/5 disc herniation, showcasing the location of the working sleeve.

Transforaminal Approach

A 1-cm skin incision was made between the intersection line of the L4/5 disc level under the posteroanterior (PA) fluoroscopic image and the tip of the spinous process and dorsal part of the facet under the lateral fluoroscopic image.[13] The puncture needle was inserted at the mid-level of the disc space, not passing the medial pedicle line under the PA fluoroscopic image. The needle's tip is aligned with the posterior vertebral line and the middle level of the disc space under the lateral fluoroscopic image.

Subsequently, a guidewire, dilator, and working sleeve were sequentially introduced into the disc space, also not passing the medial pedicle line under the PA fluoroscopic image. Verification of the working sleeve position was performed again under the lateral fluoroscopic image, revealing the opening of the working sleeve to be in a half-half location, with the upper half being in the spinal canal and the lower half in the L4/5 disc.

Following confirmation of the proper position, the endoscope was applied. Free disc fragments were removed according to MRI images until the pulsation of the neural structure was observed. The skin was then sutured with one stitch of 3–0 nonabsorbable suture ([Fig. 3]).

Fig. 3 The endoscopic transforaminal approach is being utilized for the treatment of L4/5 disc herniation. The model illustrates the precise location of the working sleeve.

Data Collection and Outcome

Patients were monitored over a 2-year period, with the primary objective being the comparison of clinical outcomes between full endoscopic interlaminar discectomy and full endoscopic transforaminal discectomy for L4/5 central–paracentral disc herniation (intergroup analysis). Clinical outcomes were evaluated based on the Visual Analog Scale (VAS) of leg pain and back pain, as well as the Oswestry Disability Index (ODI) score[14] at preoperative, postoperative day 1 (24 hours after surgery), 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years, in addition to the modified MacNab criteria at the last follow-up. Patient-reported questionnaires were utilized for recording clinical outcome data. Secondary objectives included comparing the clinical outcomes of each approach before and after surgery (intragroup analysis). Additionally, operative time and postoperative hospitalization time between the two approaches were compared. The collection of complications encompassed surgical wound infection, spondylodiscitis, recurrent disc herniation, reoperation, incidental durotomy, postoperative motor weakness, and postoperative numbness/dysesthesia.

Statistical Analysis

The data were analyzed using SPSS software version 20 (SPSS Inc, Chicago, Illinois, United States). Categorical data will be reported using percentages. Continuous data were presented as mean ± standard deviation. A paired t-test was utilized to compare the mean VAS back-leg pain and mean ODI score between the interlaminar approach and the transforaminal approach, as well as the comparison between preoperative and postoperative data in each group, in the case of normal distribution. If there was nonnormal distribution, the Mann–Whitney test was employed. A significance level of p < 0.05 was set.

Results

In this study, a total of 60 patients were enrolled, with 30 patients allocated to each group. Upon analysis, no statistically significant variances were observed between the two groups in terms of age, gender, presenting symptoms, physical findings, disc herniation classification, preoperative VAS scores, or ODI scores, as delineated in [Table 1].

Surgical Result

In the interlaminar group, the average surgical duration was 62.6 ± 18.0 minutes, with a mean postoperative hospital stay of 1.13 ± 0.35 days. Conversely, in the transforaminal group, the average surgical duration was 37.0 ± 13.6 minutes, and the mean postoperative hospital stay was 1.20 ± 0.41 days. The disparity in average surgical duration between the two groups was statistically significant (p < 0.05); however, the variance in mean postoperative hospital stay did not reach statistical significance (p > 0.05).

Therapeutic Effects

The postoperative average VAS scores for leg pain and back pain showed significant improvement in both groups compared with preoperative levels (p < 0.05). Additionally, the mean ODI scores in both groups demonstrated a significant improvement compared with preoperative ODI scores (p < 0.05). At each postoperative time point, there was no significant difference in VAS and ODI scores between the two groups (p > 0.05), except for the mean ODI score at the 6-week postoperative assessment, as detailed in [Tables 2] [3] [4] and [Graphs 1] [2] [3]. Notably, at 6 weeks postoperation, the mean ODI score in the interlaminar group was 9.83 ± 10.78, which was significantly lower than the transforaminal group's score of 19.04 ± 17.10 (p = 0.02).

Table 2 Comparison of VAS leg pain between the two groups

VAS leg	Interlaminar	Transforaminal	p-Value
Preop	6.87 ± 1.89	6.87 ± 1.46	1.00
Day 1	1.53 ± 1.36	1.97 ± 1.54	0.25
2 wk	1.57 ± 2.13	1.96 ± 2.19	0.49
6 wk	1.13 ± 1.43	2.00 ± 2.22	0.08
3 mo	0.87 ± 1.11	1.19 ± 1.50	0.36
6 mo	0.77 ± 0.97	1.22 ± 1.35	0.15
1 y	0.77 ± 1.07	1.12 ± 1.43	0.28
2 y	0.83 ± 1.73	1.62 ± 2.47	0.17

Abbreviation: VAS, Visual Analog Scale.

Table 3 Comparison of VAS back pain between the two groups

Vas back	Interlaminar	Transforaminal	p-Value
Preop	4.23 ± 2.98	5.13 ± 2.44	0.21
Day 1	1.97 ± 1.77	2.53 ± 1.93	0.24
2 wk	1.43 ± 1.63	1.21 ± 1.45	0.59
6 wk	1.40 ± 1.25	1.93 ± 1.92	0.22
3 mo	1.37 ± 1.27	1.46 ± 1.41	0.79
6 mo	1.60 ± 1.65	1.61 ± 1.63	0.98
1 y	1.60 ± 1.48	1.59 ± 1.76	0.99
2 y	1.62 ± 2.04	2.04 ± 2.25	0.47

Abbreviation: VAS, Visual Analog Scale.

Table 4 Comparison of ODI score between the two groups

ODI score	Interlaminar	Transforaminal	p-Value
Preop	45.87 ± 19.08	45.17 ± 14.45	0.88
Day 1	21.48 ± 16.39	27.97 ± 18.30	0.16
2 wk	16.17 ± 16.45	17.42 ± 14.07	0.81
6 wk	9.83 ± 10.78	19.04 ± 17.10	0.02
3 mo	8.53 ± 9.80	13.78 ± 10.90	0.06
6 mo	8.53 ± 10.95	12.22 ± 11.58	0.22
1 y	9.53 ± 10.11	10.74 ± 9.80	0.65
2 y	9.76 ± 12.07	10.73 ± 4.59	0.79

Abbreviation: ODI, Oswestry Disability Index.

Graph 1 Comparison of Visual Analog Scale (VAS) leg pain between the two groups.

Graph 2 Comparison of Visual Analog Scale (VAS) back pain between the two groups.

Graph 3 Comparison of Oswestry Disability Index (ODI) score between the two groups.

According to the modified MacNab criteria, the interlaminar group yielded 19 cases of excellence, 8 cases of good, 1 case of fair, and 2 cases of poor, resulting in an excellence/good rate of 90%. In comparison, the transforaminal group had 16 cases of excellence, 9 cases of good, 1 case of fair, and 4 cases of poor (resulting in the need for reoperation), with an excellence/good rate of 83.33%. There was no significant difference in the modified MacNab criteria between the two approaches (p = 0.38).

Complications

In the interlaminar group, two patients experienced recurrent disc herniation, occurring at 6 months and 2 years postsurgery, resulting in a reoperation rate of 3.3% (one case). In the transforaminal group, four patients experienced recurrent disc herniation, occurring at 2 days, 2 weeks, 6 weeks, and 6 months postsurgery, resulting in a reoperation rate of 13.3% (four cases). All reoperation cases were due to recurrent disc herniation and were treated with full endoscopic discectomy.

Numbness/dysesthesia was reported in one patient in the interlaminar group and nine patients in the transforaminal group. Spontaneous recovery to normal sensation occurred in most patients within 3 to 6 months, except for one patient in the transforaminal group who exhibited spontaneous recovery at the 1-year follow-up. Additionally, motor weakness was observed in two patients in the transforaminal group—one patient experienced mild weakness and recovered without further treatment at the 6-week follow-up, while the other patient displayed significant weakness of ankle dorsiflexion (from grade 4 to grade 2) and nearly fully recovered at the 1-year follow-up. Furthermore, a small dural tear was identified in one patient of the interlaminar group. There were no occurrences of wound infection or spondylodiscitis in the study ([Table 5]).

Table 5 Complications between the two groups

	Interlaminar discectomy (n = 30)	Transforaminal discectomy (n = 30)
Recurrence	2 (6.7%)	4 (13.3%)
Reoperation	1 (3.3%)	4 (13.3%)
Numbness/dysesthesia	1 (3.3%)	9 (30%)
Motor weakness	0 (0%)	2 (6.7%)
Dural tear	1 (3.3%)	0
Spondylodiscitis	0	0
Wound infection	0	0

Discussion

Full endoscopic lumbar spine surgery has emerged as a reliable surgical option for patients suffering from lumbar disc herniation and single-level central or lateral recess spinal canal stenosis with radicular symptoms.[15] The L4/5 disc herniation is frequently encountered, often in the paracentral location, and occasionally involving both the central and paracentral areas. In the lumbar region, the interlaminar and transforaminal endoscopic approaches are utilized. The interlaminar approach provides familiarity with the exposed anatomy and wide trajectory, enabling enhanced accessibility to most disc herniations within the spinal canal. On the other hand, the transforaminal approach necessitates less soft tissue dissection and offers a simpler trajectory due to the absence of obstruction by the iliac crest. For cases involving paracentral and central L4/5 disc herniation without disc fragment migration of more than 3 mm in sagittal view MRI, either the interlaminar or transforaminal approach is appropriate for surgical intervention.

The clinical outcomes of our study indicated favorable results in both endoscopic approaches. There was a significant improvement in the VAS of leg pain, VAS of back pain, and ODI score between the preoperation and early postoperation stages, and these improvements were maintained throughout the 2-year postoperation period in both approaches. At the 6-week postoperative stage, there was a noteworthy difference in the ODI score between the interlaminar and transforaminal approaches (p-value = 0.02). However, there were no significant differences in the VAS of leg pain, VAS of back pain, and ODI score between the two groups at any time point during the 2-year follow-up period. We hypothesize that patients' concerns about dysesthesia/numbness may have contributed to the higher ODI score in the transforaminal group at the 6-week postoperation stage. Subsequently, patients reported an improvement in the ODI score after a spontaneous recovery during the 3 to 6 months postoperation period, demonstrating comparable results between the two endoscopic approaches. Interestingly, there was no significant difference in the VAS of back pain between the two approaches at any time point despite substantial bone resection using a power burr in the interlaminar approach.

The analysis of previous studies predominantly indicated that disc herniation at the L5/S1 level resulted in a longer operative time for the transforaminal approach in comparison with the interlaminar approach.[7] [8] [9] [10] However, our study yielded contrary findings, demonstrating a significantly longer operative time for the interlaminar approach when compared with the transforaminal approach. This disparity could be attributed to several factors. First, the interlaminar approach often necessitates the resection of the lamina and facet joint, with our cases showing a notable 83.3% (25/30 cases) requiring significant bone resection using a power burr. Second, the interlaminar approach occasionally entails time-consuming intradiscal free fragment removal, further contributing to the prolonged operative time. Conversely, while the transforaminal approach facilitates shorter duration required to remove superficial free disc fragments, it does present limitations in the removal of deep intradiscal fragments.

Our study is consistent with the previous study[2] regarding the postoperative complication rate, demonstrating a higher reoperation rate in the transforaminal discectomy group. The reoperations primarily resulted from recurrent herniation. In the interlaminar group, recurrent herniation occurred at 6 months and 2 years postoperation, while in the transforaminal group, occurrences were noted at 2 days, 2 weeks, 6 weeks, and 6 months. Our hypothesis suggests the possible presence of retained free disc fragments in the intradiscal area that the transforaminal approach cannot effectively remove. Patients who underwent transforaminal surgery experienced a higher frequency of postoperative dysesthesia/numbness, albeit most cases were mild. This elevated frequency could be attributed to the inclusion of all cases with altered sensation, even minor ones, and the use of general anesthesia, limiting the ability to detect neural injury during the transforaminal approach. Nonetheless, many patients with dysesthesia/numbness showed improvement without further intervention within 3 to 6 months, consistent with previous research.[16] Notably, we encountered one case with significant new motor weakness (foot drop) posttransforaminal approach, with recovery from grade 2 to grade 4 at 1 year, which was sustained at the 2-year mark postoperation. Additionally, a small dural tear was observed in one case following the interlaminar approach, although no clinical impact was detected.

Both the interlaminar and transforaminal approaches have shown efficacy in alleviating leg and back pain associated with L4/5 disc herniation. However, the interlaminar approach appears to be more advantageous due to a lower incidence of postoperative dysesthesia and reduced rates of recurrence and reoperation compared with the transforaminal approach.

This study has certain limitations that need to be acknowledged. First, it should be noted that it employed a nonblind randomization method. Owing to the differing skin incisions used in each approach, it was not feasible to blind the patients. Second, the follow-up period for the patients was limited to 2 years, which may be considered relatively short for observing recurrence and reoperation rates. Therefore, a longer follow-up period would be required for future studies. It was observed that both interlaminar and transforaminal approaches can yield similar clinical outcomes for central–paracentral L4/5 disc herniation when patients were monitored for 2 years. Furthermore, there are both advantages and disadvantages associated with each technique in terms of operative time and postoperative dysesthesia. Specifically, the study found that the interlaminar approach resulted in less postoperative dysesthesia and lower rates of recurrence/reoperation compared with the transforaminal approach. It is important to highlight that while there was a higher occurrence of postoperative dysesthesia in the transforaminal approach the majority of instances were of a mild nature and resolved spontaneously within a span of 6 months.

In conclusion, for patients with L4/5 central–paracentral disc herniation, both interlaminar and transforaminal endoscopic approaches can be effectively utilized to achieve satisfactory clinical outcomes, notwithstanding their respective disadvantages.

Conflict of Interest

None declared.

Ethical Approval

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

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30. Dezember 2024