Full-Endoscopic Foraminoplasty and Lumbar Discectomy for Single-Level Lumbar Disc Herniation
Summary
Compared to conventional transforaminal endoscopic surgery, full-endoscopic foraminoplasty and lumbar discectomy (FEFLD) is a unique technique that allows full visualization of foraminoplasty and reduces the need for intraoperative fluoroscopies. This article describes the surgical steps involved in the FEFLD technique, shedding light on surgical tips and potential pitfalls to ensure outstanding performance.
Abstract
The Transforaminal Endoscopic Surgical System (TESSYS) technique has gained popularity for the treatment of lumbar disc herniations. Foraminoplasty is the key procedure in TESSYS. However, it requires advanced skills and long-term learning, which hinder its widespread adoption among surgeons. Recently, the introduction of full-endoscopic solutions has made the process more manageable. The main difference from traditional single-portal endoscopic surgery is that full-endoscopic surgery is equipped with a larger working channel, allowing full visualization of foraminoplasty and decreasing reliance on intraoperative fluoroscopy. Recently, published studies have shown that full-endoscopic foraminoplasty and lumbar discectomy (FEFLD) could achieve comparable results to conventional microdiscectomy in terms of pain relief and functional outcomes, while enhancing postoperative recovery. This study describes the technique of FEFLD in detail, including every crucial step, such as patient positioning, puncture trajectory, endoscopic dissection of the superior articular process (SAP), endoscopic foraminoplasty, and more. We hope this will be helpful to beginners who wish to apply this approach.
Introduction
Percutaneous endoscopic transforaminal discectomy (PETD) is a well-accepted technique for the surgical treatment of lumbar disc herniation (LDH)1,2. The significant advantages of PETD include fast recovery to daily activities, a lower risk of spinal destabilization, and reduced wound complications2,3,4. Although various approaches have been developed over the decades, the anatomical basis of each PETD originates from the concept of a safe transforaminal triangle proposed by Parviz Kambin5. The Yeung endoscopic spine system (YESS) and transforaminal endoscopic spine system (TESSYS) are the two most representative techniques that have greatly promoted the development of PETD6,7.
Technique modifications based on TESSYS have significantly expanded the surgical indications for PETD, such as central disc herniations, highly migrated disc herniations, lateral recess stenosis, recurrent LDHs, and others8,9,10,11,12. The biggest innovation in TESSYS is the performance of outside-in transforaminal foraminoplasty prior to the insertion of the working channel7. After the gradual resection of the ventral part of the superior articular process (SAP), the working channel can be placed into the spinal canal through the lower part of the intervertebral foramen, allowing direct exposure and decompression of the nerve root.
However, conventional multi-step foraminoplasty is challenging for most beginners2,13,14. Performing successful foraminoplasty heavily relies on fluoroscopic guidance and years of experience. This process has been associated with exiting root injury, which hinders the fast recovery of patients15,16. The reported incidence of exiting root injury varies from 1% to 8.9% in transforaminal endoscopic surgery15,17,18,19,20. Although the introduction of innovative instruments, such as the eccentric trephine and the duck-mouth protective cannula, has greatly reduced technical difficulties, it still involves complicated surgical procedures with repeated fluoroscopies9,21.
The full-visualized foraminoplasty has been proposed to address this issue. In 2020, Chen et al. first reported full-endoscopic foraminoplasty with the aid of a periendoscopic trephine in the treatment of LDHs22. Benefiting from the larger protective cannula, the endoscope, and the trephine can work simultaneously for full visualization of foraminoplasty. Meanwhile, the inner diameter of the working channel is further enlarged, which can be adapted to efficient surgical instruments. Besides, the expanded endoscopic field of view (FOV) allows the surgeon to identify more anatomical structures, which is friendly to beginners with open operative experience. Our recent clinical study showed that full-endoscopic foraminoplasty and lumbar discectomy (FEFLD) could yield comparable functional outcomes to conventional microdiscectomy (MD) in treating single-level LDHs without neural complications occurring23. Other clinical series also showed the advantages of FEFLD in treating disc herniation and lumbar stenosis of the lateral recess24,25.
Herein, we performed a detailed step-by-step description of the FEFLD surgical technique, shedding light on surgical tips and pitfalls for outstanding performance. The procedure is structured in consecutive stages from the preoperative phase to the end of the operation: patient positioning, the trajectory of puncture, endoscopic dissection of the superior articular process (SAP), endoscopic foraminoplasty, endoscopic discectomy, and others. We also described the clinical outcomes of 30 consecutive patients who underwent FEFLD between December 2022 and May 2023.
Protocol
Representative Results
Discussion
Despite significant advances in minimally invasive treatment of lumbar disc herniations (LDHs), percutaneous endoscopic transforaminal discectomy (PETD) surgery still remains technically demanding regarding various surgical steps, and it has not become a widely adopted surgical treatment yet26. The concept of targeted discectomy requires accurate puncture and placement of the working cannula, which can be challenging for beginners27. Yong et al. reported a mean cutoff of 24…
Declarações
The authors have nothing to disclose.
Acknowledgements
None.
Materials
| Dilator 1 | UninTech | UNT-II-241540 | 1.5 mm × OD 4.0 mm × L 240 mm |
| Dilator 2 | UninTech | UNT-II-214266 | 4.2 mm × OD 6.6 mm × L 215 mm |
| Dilator 3 | UninTech | UNT-II-196888 | 6.8 mm × OD 8.8 mm × L195 mm |
| Endoscope | UninTech | UNTV-076.30.171 | WL 171 mm/OD 7.6 mm/30°/ WChD 4.7 mm/2 x IC 1.5 mm |
| Radiofrequency coagulator | Kai Zhuo | RFS-4000KD | None |
| T-head cannula | UninTech | UNT-II-167989T | 7.9 mm × OD 8.9 mm × L168 mm |
| Trephine | UninTech | UNT-III-177888 | 7.8 mm × OD 8.8mm × L 171 mm |
| U-head cannula | UninTech | UNT-II-159010U | 9.0 mm × OD 10.2 mm × L151 mm |
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