Full-Endoscopic Transforaminal Approach for Lumbar Discectomy
Summary
The present protocol describes the full-endoscopic transforaminal approach for lumbar discectomy, which is a safe technique that does not require muscle retraction or bone removal.
Abstract
With technical advancements, the full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity. This technique utilizes various tools and instruments, including a dilator, a beveled working sleeve, and an endoscope with a 20-degree angle and 177 mm length, equipped with a 9.3-diameter oval shaft and a 5.6 mm diameter working channel. Additionally, the procedure involves using a Kerrison punch (5.5 mm), rongeur (3-4 mm), punch (5.4 mm), tip control radioablator applying a radiofrequency current of 4 MHz, fluid control irrigation and suction pump device, 5.5 mm oval burr with lateral protection, burr round, and the diamond round. During the surgery, it is essential to identify significant landmarks, including the caudal pedicle, ascending facet, annulus fibrosis, posterior longitudinal ligament, and the exiting nerve root. The steps of the technique are relatively easy to follow, especially when utilizing the appropriate instruments and having a good understanding of the anatomy. Research studies have demonstrated comparable outcomes to open microdiscectomy techniques. ETALD presents itself as a safe option for lumbar discectomy, as it minimizes tissue disruption, results in low postoperative surgical site pain, and allows for early mobilization.
Introduction
The full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity as a minimally invasive technique in various medical centers. It offers the advantage of requiring less muscular retraction and bone removal compared to conventional techniques1,2. Over time, the technique has undergone advancements since its initial description. Conventional surgeries have shown good results; however, epidural fibrosis occurs in around 10% of cases, leading to symptoms3,4.
The transforaminal approach provides lateral access, eliminating the risk of disrupting spinal canal structures, making it a more physiological route and reducing the risk of operation-induced destabilization. It also facilitates easier revision surgery if needed5,6,7,8. ETALD is effective in removing both intra- and extraforaminal disc herniations, and it allows for the removal of disc material from the spinal canal by approaching the disc space9,10.
Despite its advantages, ETALD does have limitations, such as limited access due to abdominal and pelvic structures, and obstruction by a high iliac crest8,11,12,13. Initially, disc space evacuation was required for adequate decompression, but with advancements in surgical tools and optics, direct visualization enables the removal of the disc fragment from its location14,15,16.
The primary goal of this new procedure is to minimize tissue damage and reduce negative long-term outcomes. This study aims to describe the current technique for ETALD in detail.
Protocol
Representative Results
Discussion
In cases of spinal disc herniation, achieving complete decompression is essential and can be optimally accomplished under visual control17,18,19. Technical advancements have made it possible to achieve such decompression even through a full-endoscopic approach. The development of improved optics, endoscopes, and instruments introduced through the working channel has expanded the safe usage of this technique20</…
Divulgazioni
The authors have nothing to disclose.
Acknowledgements
There is no funding source for this study.
Materials
| BURR OVAL Ø 5.5 mm | RiwoSpine | 899751505 | PACK=1 PC, WL 290 mm, with lateral protection |
| C-ARM | ZIEHM SOLO | C-arm with integrated monitor | |
| DILATOR ID 1.1 mm OD 9.4 mm | RiwoSpine | 892209510 | For single-stage dilatation, TL 235 mm, reusable |
| ENDOSCOPE | RiwoSpine | 892103253 | 20 degrees viewing angle and 177 mm length with a 9.3 mm diameter oval shaft with a 5.6 mm diameter working channel |
| KERRISON PUNCH 5.5 x 4.5 mm WL 380 mm | RiwoSpine | 892409445 | 60°, TL 460 mm, hinged pushrod, reusable |
| PUNCH Ø 3 mm WL 290 mm | RiwoSpine | 89240.3023 | TL 388 mm, with irrigation connection, reusable |
| PUNCH Ø 5.4 mm WL 340 mm | RiwoSpine | 892409020 | TL 490 mm, with irrigation connection, reusable |
| RADIOABLATOR RF BNDL | RiwoSpine | 23300011 | |
| RF INSTRUMENT BIPO Ø 2.5 mm WL 280 mm | RiwoSpine | 4993691 | for endoscopic spine surgery, flexible insert, integrated connection cable WL 3 m with device plug to Radioblator RF 4 MHz, sterile, for single use |
| RONGEUR Ø 3 mm WL 290 mm | RiwoSpine | 89240.3003 | TL 388 mm, with irrigation connection, reusable |
| WORKING SLEEVE ID 9.5 mm OD 10.5 mm | RiwoSpine | 8922095000 | TL 120, distal end beveled, graduated, reusable |
Riferimenti
- Eustacchio, S., Flaschka, G., Trummer, M., Fuchs, I., Unger, F. Endoscopic percutaneous transforaminal treatment for herniated lumbar discs. Acta Neurochirurgica. 144 (10), 997-1004 (2002).
- Haag, M. Transforaminal endoscopic microdiscectomy. Indications and short-term to intermediate-term results. Orthopade. 28 (7), 615-621 (1999).
- Ebeling, U., Reichenberg, W., Reulen, H. J. Results of microsurgical lumbar discectomy. Review on 485 patients. Acta Neurochirurgica. 81 (1-2), 45-52 (1986).
- Holtas, S., Jonsson, B., Strornqvist, B. No relationship between epidural fibrosis and sciatica in the lumbar postdiscectomy syndrome. A study with contrast-enhanced magnetic resonance imaging in symptomatic and asymptomatic patients. Spine (Phila Pa 1976). 20 (4), 449-453 (1995).
- Kim, S. S., Michelsen, C. B. Revision surgery for failed back surgery syndrome. Spine (Phila Pa 1976). 17 (8), 957-960 (1992).
- Fritsch, E. W., Heisel, J., Rupp, S. The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments. Spine (Phila Pa 1976). 21 (5), 626-633 (1996).
- Ruetten, S., Komp, M., Merk, H., Godolias, G. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976). 33 (9), 931-939 (2008).
- Ruetten, S., Komp, M., Godolias, G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine (Phila Pa 1976). 30 (22), 2570-2578 (2005).
- Kambin, P., Casey, K., O’Brien, E., Zhou, L. Transforaminal arthroscopic decompression of lateral recess stenosis. Journal of Neurosurgery. 84 (3), 462-467 (1996).
- Lew, S. M., Mehalic, T. F., Fagone, K. L. Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations. Journal of Neurosurgery. 94 (2 Suppl), 216-220 (2001).
- Hua, W., et al. Full-endoscopic discectomy via the interlaminar approach for disc herniation at L4-L5 and L5-S1: An observational study. Medicina. 97 (17), e0585 (2018).
- Ruetten, S. The full-endoscopic interlaminar approach for lumbar disc herniations. Minimally Invasive Spine Surgery (Second Edition): A Surgical Manual. , 346-355 (2006).
- Ruetten, S., Komp, M. Endoscopic Lumbar Decompression. Neurosurgery Clinics of North America. 31, 25-32 (2020).
- Haag, M. Transforaminal endoscopic microdiscectomy. Indication and results. Orthopade. 28 (7), 615-621 (1999).
- Hoogland, T., Van Den Brekel-Dijkstra, K., Schubert, M., Miklitz, B. Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine (Phila Pa 1976). 33 (9), 973-978 (2008).
- Jang, J. S., An, S. H., Lee, S. H. Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. Journal of Spinal Disorders and Techniques. 19 (5), 338-343 (2006).
- Yeung, A. T., Tsou, P. M. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976). 27 (7), 722-731 (2002).
- Tsou, P. M., Yeung, A. T. Transforaminal endoscopic decompression for radiculopathy secondary to intracanal noncontained lumbar disc herniations: Outcome and technique. Spine Journal. 2 (1), 41-48 (2002).
- Kambin, P., Casey, K., O’Brien, E., Zhou, L. Transforaminal arthroscopic decompression of lateral recess stenosis. J Neurosurg. 84, 462-467 (1996).
- 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. 49, 80-87 (2006).
- Ruetten, S., Komp, M., Godolias, G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine (Phila Pa 1976). 30, 2570-2578 (2005).
- Ruetten, S., Komp, M., Merk, H., Godolias, G. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976). 33, 931-939 (2008).
- Mayer, H. M., Brock, M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. Journal of Neurosurgery. 78 (2), 216-225 (1993).
- Hermantin, F. U., Peters, T., Quartararo, L., Kambin, P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. Journal of Bone and Joint Surgery. 81 (7), 958-965 (1999).
- Ahn, Y., Lee, U., Kim, W. K., Keum, H. J. Five-year outcomes and predictive factors of transforaminal full-endoscopic lumbar discectomy. Medicina. 97 (48), e13454 (2018).
- Park, H. W., et al. The Comparisons of surgical outcomes and clinical characteristics between the far lateral lumbar disc herniations and the paramedian lumbar disc herniations. Korean Journal of Spine. 10 (3), 155 (2013).
- O’Hara, L. J., Marshall, R. W. Far lateral lumbar disc herniation. The key to the intertransverse approach. Journal of Bone and Joint Surgery. 79 (6), 943-947 (1997).
- Nellensteijn, J., et al. Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature. European Spine Journal. 19 (2), 181-204 (2010).
- Kambin, P. Arthroscopic microdiscectomy. Arthroscopy. 8 (3), 287-295 (1992).
- Kim, M. J., et al. Targeted percutaneous transforaminal endoscopic diskectomy in 295 patients: comparison with results of microscopic diskectomy. Surgical Neurology International. 68 (6), 623-631 (2007).
- Kafadar, A., Kahraman, S., Akbörü, M. Percutaneous endoscopic transforaminal lumbar discectomy: a critical appraisal. Minimally Invasive Neurosurgery. 49 (2), 74-79 (2006).
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