Full Endoscopic Interlaminar Approach for Paracentral L5-S1 Disc Herniation
Summary
Here, we present a protocol to describe the full endoscopic interlaminar approach (FEILA) technique, including every cutoff step required to reach technical proficiency. FEILA is a surgery with a relatively steep learning adaptation. Despite this, any surgeon capable of microdiscectomy can perform FEILA with enough practice and suitable patient selection.
Abstract
The full endoscopic interlaminar approach (FEILA) is a minimally invasive technique for lumbar discectomy. It has multiple advantages over other conventional discectomy methods, including less traumatization of the soft tissues, fewer complication rates (dural injury, bleeding), rapid rehabilitation, quick return to daily life activities, and preferable cosmetic results. FEILA is a surgery with a relatively steep learning adaptation. Endoscopic surgery is a closed tubular approach, and all surgical maneuvers are performed within a uniportal single working channel. Also, the technique has not yet been standardized and well-documented. Therefore, the early learning stages of this technique may not be easy for most surgeons. Despite these, FEILA is easy, and the operation length is comparable to and even shorter than other techniques of lumbar discectomy. FEILA for lumbar discectomy could be considered a safe and effective alternative procedure for paracentral L5-S1 disc herniation. Here, we describe the technique of FEILA, including every cutoff step required to reach technical proficiency for surgeons who want to start applying this approach.
Introduction
Lumbar degenerative disc disease is an anatomical and morphological change causing clinical complaints1. Surgery is the appropriate treatment in cases that do not respond to conservative treatments2. Conventional surgeries have been used, but they have disadvantages such as prolonged hospital stay, high amount of tissue damage, delayed mobilization, and risk of epidural fibrosis and instability. Because of these disadvantages, researchers have tried to develop less invasive methods. The full endoscopic (interlaminar-transforaminal) technique with posterolateral access evolved out of this2.
Due to the lateral iliac blocks of the L5-S1 segment, the transforaminal approach is limited. However, the L5-S1 level usually has the widest interlaminar window and a sufficient interval for the endoscope to fit. FEILA provides a direct route for decompression at the L5-S1 level. Therefore, this article aims to enable surgeons who are trying this technique for the first time to learn the technique in more detail and faster.
FEILA is a minimally invasive method to decompress lumbar disc herniation under excellent visualization and continuous saline irrigation3,4. FEILA is performed via a dilator placed through a small skin incision in the lumbar region. The dilator allows surgeons to place the working sleeve and endoscope over the dilator. Then, the surgeons use tools through the endoscope to perform a discectomy and decompression of the nerve. It has multiple advantages compared to conventional surgeries, including less traumatization of the soft tissues, fewer complication rates (less dural injury and bleeding), rapid rehabilitation, quick return to daily life activities, better cosmetic results, and a lower cost4.
FEILA is a surgery with a relatively steep learning adaptation. Because full endoscopic surgery is a closed tubular approach, all surgical maneuvers are performed within a uniportal single working channel5. In addition, the technique has not yet been standardized and well-documented. Therefore, the early learning stages of this technique may not be easy for most surgeons6. Despite these facts, the surgery is easy, and the operation length is comparable to and even shorter than other techniques of lumbar discectomy, especially at the L5-S1 level.
Surgical indications and contraindications for FEILA are evaluated after physical examination of the patients and neuroradiological imaging (X-ray and magnetic resonance imaging [MRI]) are performed. FEILA is indicated for sequestered or non-sequestered disc herniations (especially paracentral disc herniation), recurrent disc herniations after traditional or other minimally invasive methods, zygapophyseal joint cysts, and lateral bony and ligament spinal canal stenosis. FEILA is contraindicated for compressive intra- or extraforaminal pathologies, extensive central spinal canal stenoses, a pronounced bony shift in the interlaminar window and calcified discs, severe adhesion due to fibrotic tissue, fusions or instabilities in the spinal canal, cauda equina syndrome, weakness without pain, spondylodiscitis, and other severe spine infections7,8,9.
Protocol
Representative Results
Discussion
The results of recent studies depict the possibility of sufficient decompression via FEILA; these results are equal to those of traditional methods. Also, the advantages of the significant relief of back pain, faster recovery after surgery (short period of hospital stay), fewer complications, lower recurrence rate, minimizing soft-tissue disruption (small incision, less muscle cutting, less blood loss), and reducing segment instability have been shown10,1…
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° 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 mm 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 |
References
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