Percutaneous Endoscopic Discectomy for Far Lateral Lumbar Disc Herniations: Prospective Study and Outcome of 66 Patients

Abstract

Background: Extraforaminal disc herniations represent up to 11% of all lumbar herniated discs. Numerous surgical approaches have been described. Percutaneous endoscopic discectomy (PED) is one of the minimally invasive techniques; after mastering this procedure it is a practical method that is used for treatment of foraminal or extraforaminal disc herniation. The outcome of PED for treatment of foraminal or extraforaminal disc herniation has been studied.

Method: A total of 66 patients with foraminal or extraforaminal lumbar disc herniation was treated by applying the PED technique between January 1998 and June 2005. The positions of the herniated disc levels were L2-3 (n=5, 8%), L3-4 (n=19, 28%) and L4-5 (n=42; 64%). The selected patients had no previous surgery, appropriate conservative therapies were done before the operations, and MRI was the main diagnostic method with the clinical findings. Evaluation of the patients with clinical examinations, visual analogue pain scale (VAS) and Oswestry scale was performed preoperatively, on postoperative day 7 and in the postoperative 6-12 months period.

Results: In two patients (n=1, L4-5 and n=1, L3-4) disc material could not be removed with PED, so discectomy was performed with microscopic visualization during the same session. Three patients (n=3, L4-5) were reoperated on three to six months after primary surgery due to recurring disc problems with microscope visualization. In two patients (n=2, L4-5) root nerves were partially damaged, and in two patients (n=2, L4-5) root nerves were impinged by the working channel. These 4 patients had dysesthesias from just after surgery to a mean of 45 days after surgery. One of recurrent cases was among these patients. Neurological examinations showed minimal muscle weakness of the quadriceps femoris and diminished sensation of the L4 dermatomal area in patients with partial nerve root damage. This patient improved and the neurologic examination became normal with disappearance of the dysesthesia. There was no sign of reflex sympathetic dystrophy (RDS). With these two patients VAS and Oswestry scales scores decreased significantly early in the postoperative follow-up. The postoperative 6-month average scores are favourable in comparison with the average score at postoperative day 7. The postoperative 12-month scores showed no significant differences to those of postoperative month 1.

Conclusion: Percutaneous endoscopic discectomy is a minimally invasive method and offers many benefits to the patient, but extensive surgical practice is needed to become a capable surgeon. Consequently this technique can only be a treatment option on appropriate patients. This study reconfirmed that the removal of fragmented disc material is achieved and offers a pain-free status.

Key words

Endoscopic discectomy - intervertebral disc herniation - lumbar spine - foraminal or extraforaminal disc herniation

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;  41 229-234
• 2 Abdullah AF, Wolber PG, Warfield JR, Gunadi IK. Surgical management of extreme lateral lumbar disc herniations: review of 138 cases.  Neurosurgery. 1988;  22 648-653
• 3 O’Hara U, Marshall QW. Farlateral disc herniation. The key to the intertransverse approach.  J. Bone Joint Surg [Br]. 1997;  79 943-947
• 4 Quigley MR, Bost J, Maaron JC, Elrifai A, Panahandeh M. Outcome after microdiscectomy: results of a prospective single institutional study.  Surg Neurol. 1998;  49 263-267
• 5 Kambin P, Gennarelli T, Hermantin F. Minimally invasive techniques in spinal surgery: current practice.  Neurosurg Focus. 1988;  4 1-10
• 6 Hult L. Retroperitoneal disc fenestration in low back pain and sciatica.  Acta Orthop Scand. 1956;  20 342-348
• 7 Hijikata S. Percutaneous discectomy: A new treatment method for lumbar disc herniation.  J Toden Hosp. 1975;  5 5-13
• 8 Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine. A preliminary report.  Clin Orthop. 1983;  174 127-132
• 9 Darden B, 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 1500-1505
• 10 Epstein NE. Different surgical approaches to farlateral lumbar disc herniation.  J Spinal Disords. 1995;  383-394
• 11 Garrido E, Connaughon PN. Unilateral facetectomy approach for lateral lumbar disc herniation.  J Neurosurg. 1991;  74 754-756
• 12 Jackson RP, Glah JJ. Foraminal and extraforaminal lumbar disc hemiation: Diagnosis and treatment.  Spine. 1987;  12 577-585
• 13 Maroon JC, Kopitnik TA, Schulof LA, Abla A, Wilberger JE. Diagnosis and microsurgical approach to farlateral disc herniation in the lumbar spine.  J Neurosurg. 1990;  72 378-382
• 14 Halldin K, Zoega B, Karrholm J, Lind BI, Nyberg P. Is increased segmental motion early after lumbar discectomy related to poor clinical outcome 5 years later?.  Int Orthop. 2005;  29 240-244
• 15 Kotilainen E. Long term outcome of patients suffering from clinical instability after microsurgical treatment of lumbar disc herniation.  Acta Neurochir (Wien). 1998;  140 120-125
• 16 Kramer J, Ludwig J. Surgical treatment of lumbar intervertebral disc displacement. Indications and methods.  Orthopäde. 1999;  28 579-584
• 17 Kuroki H, Goel VK, Hdekamp SA, Ebraheim NA, Kubo S, Jajima N. Contributions of flexion-extension cyclic loads to the lumbar spinal segment stability following different discectomy procedures.  Spine. 2004;  29 E39-46
• 18 Schaller B. Failed back surgery syndrome: The role of symptomatic segmental single level instability after lumbar microdiscectomy.  Eur Spine J. 2004;  13 193-198
• 19 Shaikh, Chung F, Imarengiaye C, Yung D, Bernstain M. Pain, nausea vomiting and ocular complications delay discharge following ambulatory microdiscectomy.  Can J Anaesth. 2003;  50 514-518
• 20 Gamberdella G, Gervasio O, Zaccone C, Puglisi E. Prevention of recurrent radicular pain after lumbar disc surgery: A prospective study.  Acta Neurochir. 2005;  92 151-154
• 21 Swartz KR, Trost GR. Recurrent lumbar disc herniation.  Neurosurg Focus. 2003;  15 E10
• 22 Ganzer D, Giese K, Volker L, Pietzner U, Follak N, Merk H. Two year results after lumbar microdiscectomy with and without prophylaxis of a peridural fibrosis using Adcon-L.  Arch Orthop Trauma Surg. 2003;  123 17-21
• 23 Gerszten PG, Moossy JJ, Flickinger JC, Gerszten K, Kalend A, Martinez AJ. Inhibitition of peridural fibrosis after laminectomy using low-dose external beam radiation in a dog model.  Neurosurgery. 2000;  46 1478-1485
• 24 Vogelsang JP, Finkenstaedt M, Vogelsang M, Markais E. Recurrent pain after lumbar discectomy: The diagnostic value of peridural scar on MRI.  Eur Spine J. 1999;  8 475-479
• 25 Kambin P, Casey K, O’Brien E. Transforaminal arthroscopic decompression of lateral recess stenosis.  J Neurosurg. 1996;  64 462-467
• 26 Lew SM, Mehalic TF, Fagone KL. Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations.  J Neurosurg (Spine 2). 2001;  94 216-220
• 27 Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy.  J Neurosurg. 1993;  78 216-225
• 28 Scott J, Huskisson EC. Graphic representation of pain.  Pain. 1976;  2 175-184
• 29 Ditsworth DA. Endoscopic transforaminal lumbar discectomy and reconfiguration: a posterolateral approach in to the spinal canal.  Surg Neurol. 1998;  49 588-597
• 30 Haag M. Transforaminal endoscopic lumbar discectomy. Indications and short term to intermediate term results.  Orthopäde. 1999;  28 615-621
• 31 Lew SM, Mehalic TF, Fagone KL. Transforaminal percutaneous endoscopic discectomy in the treatment of farlateral and foraminal lumbar disc herniations.  J Neurosurg. 2001;  94 216-220
• 32 Mathews HH. Transforaminal endoscopic microdiscectomy.  Neurosurg Clin N Am. 1996;  7 59-63
• 33 Onik G, Helms C, Ginsburg L. Percutaneous lumbar discectomy using a new aspiration probe.  AJR Am J Roentgenol. 1985;  144 1137-1140
• 34 Revel M, Payan D, Vallee C. Automated percutaneous lumbar discectomy versus chemonucleolysis in the treatment of sciatica.  A randomized multicenter trial. Spine. 1999;  18 1-7
• 35 Ray CD. Transfacet decompression with dowel fixation: A new technique for lumbar lateral spinal stenosis.  Acta Neurochir. 1988;  43 ((Suppl)) 48-54
• 36 Reulen HJ, Muller A, Ebeling U. Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations.  Neurosurgery. 1996;  39 345-350
• 37 Casey KF, Chang MK, O’Brien ED, Yuan HA, MacCullen GM, Schaffer J, Kambin P. Arthroscopic microdiscectomy: comparison of preoperative and postoperative imaging studies.  Arthroscopy. 1997;  13 438-445
• 38 Kunogi J, Hasve M. Diagnosis and operative treatment of intraforaminal nerve root compression.  Spine. 1991;  16 1312-1320
• 39 Mixter WJ, Barr JS. Rupture of intervertebral disc with involvement of the spinal canal.  N Eng J Med. 1934;  211 210-215
• 40 Miyawaki T, Kohjitani A, Maeda S, Egusa M, Mon T, Higuschi H, Kita F, Shimada M. Intravenous sedation for dental patients with intellectual disability.  J Intellect Disabil Res. 2004;  48 764-768
• 41 Smith AF, Pittaway AJ. Premedication for anxiety in adult day surgery.  Cochrane Databa Syst Rev. 2003;  1 CDOO2192
• 42 Wu CL, Hso W, Richman JM, Raja SN. Postoperative cognitive function as an outcome of regional anesthesia and analgesia.  Reg Anesth Pain Med. 2004;  29 257-268
• 43 Voon LW, Au Eong KG, Saw SM, Verma D, Laude A. Effect of preoperative counselling on patient fear from the visual experience during phacoemulsification under topical anesthesia: Multicenter randomized clinical trial.  J Cataract Refract Surg. 2005;  31 1966-1969

Correspondence