J Korean Neurosurg Soc.  2016 Mar;59(2):172-181. 10.3340/jkns.2016.59.2.172.

Foraminoplastic Superior Vertebral Notch Approach with Reamers in Percutaneous Endoscopic Lumbar Discectomy : Technical Note and Clinical Outcome in Limited Indications of Percutaneous Endoscopic Lumbar Discectomy

Affiliations
  • 1Department of Neurosurgery, St. Peter's Hospital, Seoul, Korea. mannitol240@gmail.com

Abstract

To describe the details of the foraminoplastic superior vertebral notch approach (FSVNA) with reamers in percutaneous endoscopic lumbar discectomy (PELD) and to demonstrate the clinical outcomes in limited indications of PELD. Retrospective data were collected from 64 patients who underwent PELD with FSVNA from August 2012 to April 2014. Inclusion criteria were high grade migrated disc, high canal compromised disc, and disc protrusion combined with foraminal stenosis. The clinical outcomes were assessed using by the visual analogue scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria. Complications related to the surgery were reviewed. The procedure used a unique approach, using the superior vertebral notch as the target and performing foraminoplasty with only reamers under C-arm control. The mean age of the 55 female and 32 male patients was 52.73 years. The mean F/U period was 12.2+/-4.2 months. Preoperative VAS (8.24+/-1.25) and ODI (67.8+/-15.4) score improved significantly at the last follow-up (VAS, 1.93+/-1.78; ODI, 17.14+/-15.7). Based on the modified MacNab criteria, excellent or good results were obtained in 95.3% of the patients. Postoperative transient dysthesia (n=2) and reoperation (n=1) due to recurred disc were reported. PELD with FSVNA could be a good method for treating lumbar disc herniation. This procedure may offer safe and efficacious results, especially in the relatively limited indications for PELD.

Keyword

Percutaneous endoscopic; Foraminoplasty; Superior vertebral notch

MeSH Terms

Constriction, Pathologic
Diskectomy*
Female
Follow-Up Studies
Humans
Male
Reoperation
Retrospective Studies

Figure

  • Fig. 1 A : Size of herniated disc. B : Size of the spinal canal.

  • Fig. 2 Comparison between standard percutaneous endoscopic lumbar discectomy (PELD) and foraminoplastic superior vertebral approach (FSVNA) (A). Standard PELD (B). FSVNA Rod : approach trajectory, Asterisk : approach target, Blue circle : initial placement of working cannula, Dotted area : resected area by foraminoplasty.

  • Fig. 3 Endoscopic instrument system (THESSYS®) for FSVNA 18-gauge needle (1), guide wire (2), straight guide rod (3), curved guide rod (4), guide tubes of increasing diameter (5), three reamers from 5.5 mm to 8.5 mm (6), working cannula (7), handle grip for the reamers (8), various grasping forceps (9), endoscope (10).

  • Fig. 4 Determination of skin entry point (A). Skin marking of entry point (B). Radiologic illustration of skin entry point in lumbar X-ray anteroposterior view. The point of intersection between the marked horizontal line (a) and the oblique directional line (b) gives the point of insertion of the needle. Asterisk : entry point.

  • Fig. 5 A-F : Needle insertion to target.

  • Fig. 6 A-C : Guide rod insertion.

  • Fig. 7 A-C : Guide tube insertion and sequential reaming.

  • Fig. 8 Initial endoscopic view around the foramen after foraminoplasty with reamer. TNR : traversing nerve root, DS : disc space, Arrow : upper margin of lower vertebra, Asterisk : tail of ruptured disc.

  • Fig. 9 A : Visual analog pain score (VAS) for radicular pain preoperatively and at 6 weeks, and at the final review post-surgery. B : VAS for back pain preoperatively, at 6 weeks, and at the final review post-surgery.

  • Fig. 10 Oswestry disability index (ODI) scores preoperatively, at 6 weeks, and at the final review post-surgery.

  • Fig. 11 The global outcome according to the modified MacNab criteria. Sixty-one of the 64 patients (95.3%) experienced excellent or good results.

  • Fig. 12 Illustrated case of a 68-year-old female patient. A and B : Preoperative MR images showing severe foraminal stenosis at the Lt. L4–5 level. C and D : Postoperative MR images showing resected area (arrow) by reamer to provide safe approach route.


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