Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 413-421
World Neurosurgery

Original Article
Transforaminal Endoscopic Lumbar Discectomy for Lumbar Disc Herniation Causing Bilateral Symptoms

https://doi.org/10.1016/j.wneu.2017.06.191Get rights and content

Background

Transforaminal endoscopic lumbar discectomy (TELD), a minimally invasive spinal technique, has advantages over open discectomy. Unilateral TELD for disc herniation causing bilateral symptoms is challenging. In this study, we describe a percutaneous endoscopic herniotomy technique by using a unilateral approach for lumbar disc herniation with bilateral obvious symptoms.

Methods

From June 2014 to October 2015, 26 patients who had back as well as bilateral leg pain and/or weakness due to lumbar disc herniation were treated by TELD with a unilateral approach. Clinical outcomes were evaluated via a visual analogue scale (VAS; 0–10), and functional status was assessed with the Oswestry Disability Index (0–100%) postoperatively and 3 and 12 months postoperatively. Surgical satisfaction rate was assessed during the final follow-up.

Results

The mean VAS for leg pain on the operative side improved from preoperative 8.39 ± 1.84 to 2.18 ± 1.26 postoperatively, 1.96 ± 0.83 at 3 months postoperatively, and 2.05 ± 1.42 at 1 year postoperatively (P < 0.01). The mean VAS for leg pain on the contralateral was 7.12 ± 1.74 and improved to 1.57 ± 1.66 postoperatively, 1.22 ± 1.58 at 3 months postoperatively, and 1.15 ± 1.35 at 1 year postoperatively (P < 0.01). The mean preoperative Oswestry Disability was 83.63 ± 8.49, with 23.58 ± 7.24 at 1 week postoperatively, 19.81 ± 11.26 at 3 months postoperatively, and 17.54 ± 13.40 at 12 months postoperatively (P < 0.01). Good or excellent global results were obtained in 96.2% of patients.

Conclusions

TELD can be effective for lumbar disc herniation causing bilateral symptoms, through one working channel.

Introduction

A large number of lumbar disc herniations (LDHs) can result in unilateral leg neurologic symptoms in addition to low back pain; bilateral symptoms also can occur, but this is less common. The herniated disc causing bilateral symptoms often is a huge mass oppressing nerve roots on both sides and sometimes resulting in cauda equina syndrome. Open lumbar discectomy with bilateral partial laminectomy is controversial because of increased approach-related morbidity, including injuries to posterior supporting structures such as bones, ligaments, muscles, and the annulus fibrosus.

Percutaneous endoscopic lumbar discectomy is a minimally invasive procedure of spinal surgery and has been shown to have advantages such as reduced risk of surgery-induced tissue injury, faster rehabilitation, preservation of mobility of operation segments, facilitation of revision operations, and increased patient demands compared with open discectomy techniques.1, 2, 3, 4 Percutaneous endoscopic interlaminar lumbar discectomy without the blockade of crista iliaca is common for paracentral-, and (freely) isolated-type disc herniation, but concerns exist because cauda equina injury or excessive neural retraction for LDH treatment causing bilateral symptoms can occur.2, 5

Transforaminal endoscopic lumbar discectomy (TELD) is conducted for ventral decompression of spinal canal via a posterolateral route, which provides a chance to decompress nerve roots on both sides at the same time. There is an increasing interest in the percutaneous transforaminal endoscopic spine system (TESSYS) for the treatment of LDH.6, 7, 8, 9 Although some scholars argue that the TESSYS technique can be practiced in any type of LDH, the use of TELD with unilateral tunnel by TESSYS for a disc herniation with bilateral symptoms is challenging.10, 11 In the present study, we tested TELD for LDH with bilateral symptoms through one working tunnel.

Section snippets

Study Design

From June 2014 to October 2015, 26 patients with LDH with bilateral obvious radiculopathy due to bilateral nerve root compression were admitted to our hospital unit. The sex distribution of our cohort was 12 male and 14 female patients, and the average age was 41.2 years (range, 22–63 years) (Table 1). The average duration was 15.5 months (range, 4 months to 9 years), with an average 3 months of bilateral symptoms per patient (range, 0.5–4 months) (Table 1). In addition, the average follow-up

Results

Imaging showed that all patients' bilateral nerve root compressions were resolved after TELD (Figures 5 and 6). Operation levels were L3–L4, L4–L5, and L5–S1 in 2 (7.7%), 10 (38.5%), and 14 (53.8%) of patients, respectively. One case of cauda equina syndrome was observed at L4–L5 in 1 patient and at L5–S1 in 2 patients (Table 1).

The mean VAS score for back pain improved from preoperative 6.86 ± 1.33 to 2.65 ± 1.50 postoperatively, 2.14 ± 0.73 at 3 months postoperatively, and 2.28 ± 1.13 at 1

Discussion

The lumbar herniated disc compressing bilateral nerve roots often is located in the central, larger, or a wide base, which usually cause bilateral with one side dominant leg pain. Such patients with bilateral symptoms suffer from a back and/or leg pain that is stronger than in those with general lumbar disc herniation.

TELD can achieve the ventral decompression of nerves without damaging the posterior structures. The posterolateral transforaminal “inside-out” Yeung technique with indirect

Study Limitations

A relatively short follow-up period and the size of patient cohort were noted as study limitations; nonetheless, it is worth pointing out that a 19.3-month follow-up can reflect the neural decompression effect of a minimally invasive discectomy technique.

Conclusions

TELD through one working tunnel offers an affordable and effective technique to treat lumbar disc herniation causing bilateral symptoms via a minimally invasive surgical approach.

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    The concept of retraction injury related to endoscopic decompression is based upon the fact that endoscopic spine surgery (unlike other endoscopic surgery) relies on the creation of a potential space in close proximity to non-deformable structures. For example, during a transforaminal endoscopic lumbar approach, a smaller outer diameter is preferred to safely access the foramen while minimizing injury to the nerve root. [26] Furthermore, the longer side of the beveled tip of the working channel can be used to protect the anatomy against which it rests (i.e. putting the longer side in the axilla of the nerve root to access to the disc space) (Fig. 1).

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    LDH usually causes unilateral neurologic symptoms with low back pain, whereas bilateral symptoms arise less commonly. Located centrally, large or wide base disc herniations often compress bilateral nerve roots and cause bilateral complaints with one-side dominance.6 Peak incidences of LDH occur during the third and fifth decades, and 3%–6% of LDH cases cause symptoms.7

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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