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Table 4 Literature review of full endoscopic spine surgery to manage high-grade migrated lumbar disc herniation

From: Functional outcomes of full-endoscopic spine surgery for high-grade migrated lumbar disc herniation: a prospective registry-based cohort study with more than 5 years of follow-up

Name

Surgical Technique

Details

Patients

Modified MacNab

VAS Preop

VAS Postop

ODI Preop

ODI Postop

Recurrent Herniation

Gun Choi 2008 [4]

PELD with foraminoplasty under local anesthesia

Anesthetizing methods/positioning: Local anesthesia with the patient in prone position

Site of annular puncture

• L4–L5 and below: Medial pedicular line

• L3–L4 and above: Midpedicular line

Inclination of the Needle Trajectory

• Approximately 30° with the lower or upper endplate

Down-migrated herniation

• Remove undersurface of the articular process

• Use endoscopic drill with a round diamond burr tip to removal bony part

• Allows for placement for endoscope in anterior epidural space

• Ligamentum flavum, fibrotic bands, part of anulus removed using Holmium: Yttrium–Aluminum–Garnet (YAG) laser

• Intermittently blocking the irrigation fluid outflow allows traversing nerve root to move freely: Confirms complete decompression

Up-migrated herniation

• Use of round-ended cannula

• Placement of cannula at the lower part of the disc

• Upward shifting with twisting motion till the exiting root is partially visible

• Release of the foraminal ligament and the Ligamentum flavum using laser

• Removal of the exposed ruptured fragment with forceps

59

91.4% of patients experienced satisfactory outcome

Good: 37 patients (63.8%)

Fair: 16 (27.6%)

Poor: 4 patients (6.9%)

Poor: 1 (1.7%)

8.01

1.56

61.6

10.76

2

Hyeun Sung Kim 2009 [14]

Endoscopic transforaminal suprapedicular

Anesthetizing methods: Favor local anesthetic

Skin entry approximately 8–12 cm from the midline

Removal of the superior margin of the pedicle

Spondylosis in the upper margin of the lower vertebrae

• Traversing nerve root is exposed

• Remove ruptured disc material

Inferior migrated ruptured material below the traversing nerve root

• Be aware of not to injure the traversing nerve root

• Semirigid flexible curved forceps to pull the disc material

• Bleeding may occur. Use bipolar coagulation and saline irrigation

• Check for blue-stained disc material

• No stain implies successful removal

53

N/a

Leg: 9.32 ± 0.43

Leg: 1.78 ± 0.71

79.82 ± 4.53

15.27 ± 3.82

N/a

G. Choi 2010 [19]

Percutaneous Endoscopic Lumbar Herniectomy for high-grade down-migrated L4–L5 disc through an L5–S1 IELD

Anesthetizing methods/positioning

• Lateral decubitus position with the affected side upwards

• Conscious sedation

Skin entry point

• Used 1% lidocaine

• 0.5-mm to 0.7-mm skin incision

Herniectomy was performed using various grasping forceps and side-firing holmium-YAG laser

Flexible tip of the Ellman radiofrequency probe can be used for hemostasis and tissue dissection.

4

N/a

Back: 3.75

Leg: 8.5

Back: 1.75

Leg: 0.75

65%

3%

N/a

Kyeong-seong Yeom 2011 [13]

Full endoscopic contralateral transforaminal discectomy

Anesthetizing methods/positioning

• Prone position on a radiolucent operating table

• Epidural anesthesia

Skin entry site: L3–L4 and L4–L5 levels: Dorsal portion of the facet joint of index level on the lateral view of the C-arm.

Inject a mixture of indigo–carmine and radio-opaque dye

Endoscope was inserted to the anterolateral side of facet joint

Foraminoplasty was done provided enough working space

Using C-arm guidance to confirm facet articulation

Insert trephine removed anterolateral bony portions of the facet joint

• Unsuccessful: Micro-osteotome under endoscopic visualization was used for foraminoplasty

Explore site between the posterior longitudinal ligament and the dural sac.

- Protect the dural sac by turning the working sheath ventrally facing the posterior longitudinal ligament

12

Excellent: 10

Good: 2

Back: 6.8

Radicular pain: 8.2

Back: 1.5

Radicular pain: 1.4

N/a

N/a

N/a

Jianwei Du

2016 [17]

Translaminar approach

Anesthetizing methods/positioning

• Prone position with mild flexion of the hips and knees

• Local anesthesia

Target site of puncture: 8 to 10 mm from midline

Building of the working cannula

• Guide wire inserted through needle

• Insert endoscope with an eccentric 2.7-mm working

Drilling bony tunnel in the lamina

• Expose bony surface of lamina with endoscopic forceps and a flexible radio frequency probe

• Trepan was used to mark the site for drilling

• Round diamond burr tip was used to remove the bony portion of the site

• Diameter of the tunnel approximately 8 mm

Removal of the migrated herniation

• Use 90-degree angle blunt hook to explore the canal and the ventral aspect of the dural sac

• Use endoscopic forceps to remove the migrated herniation through the lateral aspect of the dura

7

N/a

7.6 ± 0.8

1.3 ± 0.8

61.6

8.4

0

Yong Ahn 2004 [3]

Standardized technique of transforaminal PELD

Anesthetizing methods/positioning

• Local anesthesia with conscious sedation

• Midazolam (0.05 mg/kg) intramuscularly and fentanyl (0.8 g/kg)

• Prone positioned on a radiolucent table.

Direction-oriented transforaminal TELD

• Entry point: 10–15 cm lateral to the midline

• Discography with indigo–carmine

Intradiscal and annular release

• Release of annular anchorage

• Intradiscal subannular debulking

• Use grasping forceps, radiofrequency bipolar ablator, and side-firing laser for intradiscal release

• Use annulus scissors to cut outer layer of the annulus and the annulus posterior longitudinal ligament

Epiduroscopic fragmentectomy using navigable instruments

• Semiflexible forceps, articulating forceps, and flexible curved probe is for complete removal

• Ventral decompression can increase working space

• Removed in one piece or in multiple pieces

13

Excellent: 4 patients (30.8%)

Good: 7 patients (53.8%)

Fair: 1 patient (7.7%)

Poor: 1 patient (7.7%)

7.86 ± 1.28

6 weeks:

2.54 ± 1.51

1 year: 1.85 ± 1.07

84.92 ± 6.36

6 weeks: 27.83 ± 7.34

1 year: 17.54 ± 13.40

N/a

Jinwei Ying 2016 [29]

Transforaminal PELD

Contralateral transforaminal PELD

Interlaminar PELD

Anesthetizing methods/positioning

• Prone position

• Local anesthesia and sedation

Transforaminal PELD

• Entry point 10–13 cm from the midline

• Mixture of methylene blue and Iohexol (2 mL)

• Partial pediculectomy was done if fragment of disc was blocked by the pedicle or more space was needed for manipulation

Interlaminar PELD

• 18-gauge spinal needle was inserted into the disc with the conventional IELD

• 2 mL mixture of methylene blue and iohexol for discography

• Partial medial laminectomy can be performed if view is blocked

Contralateral Transforaminal PELD

• Entry point approximately 14 cm from the midline

• An 18-gauge spinal needle was introduced into the disc under fluoroscopic guidance

• A mixture of methylene blue and Iohexol (2 mL) for discography

• Dyed migrated disc fragment was observed

• MRI was performed 24 h after surgery confirm complete decompression

73

Transforaminal PELD

Excellent: 14

Good: 13

Fair: 4

Poor: 0

Contralateral transforaminal PELD

Excellent: 8

Good: 6

Fair: 0

Poor: 1

Interlaminar PELD

Excellent: 15

Good: 10

Fair: 2

Poor: 0

Transforaminal PELD

Back: 5.8

Leg: 7.2

Contralateral transforaminal PELD

Back: 5.5

Leg: 6.5

Interlaminar PELD

Back: 5.4

Leg: 7.2

Transforaminal PELD

Back: 2

Leg: 2

Contralateral transforaminal PELD

Back: 1.9

Leg: 2.1

Interlaminar PELD

Back: 2.1

Leg: 2.3

Transforaminal PELD

55

Contralateral transforaminal PELD

57

Interlaminar PELD

55

Transforaminal PELD

18

Contralateral transforaminal PELD

14

Interlaminar PELD

13

N/a

Chi Heon Kim

2016 [20]

TELD

Percutaneous endoscopic interlaminar discectomy

Anesthetizing methods/positioning

• Prone position

• General anesthesia

Superior migration

• Interlaminar window at the same level of the disc herniation

Inferior migration

• Interlaminar window at a lower level than the disc

Entry point

• Sagittal CT scan at midway between the medial margin of the lamina and the spinous process

• Extension line was drawn to the skin

• Point of intersection between the extension line and skin was the entry point

Enlargement of laminar window

• Superior migration: not needed

• Inferior migration: needed

Discography

• Posterolateral approach using indigo carmine mixed with radio-opaque dye

Ligamentum flavum was opened or split

• Compromised more than 50% of the anterior–posterior diameter of the spinal canal: Open Ligamentum flavum

• Less than 50%: Ligamentum flavum was split

Identify thecal sac and root

• Remove disc material

18

Excellent: 12

Good: 3

Fair: 2

Poor: 1

Trunk: 6.1 ± 2.5

Limb: 7.5 ± 1.7

Trunk: 2.8 ± 1.8

Limb: 2.1 ± 2.0

25.7 ± 9.0

8.4 ± 6.1

0

Guntram Krzok 2016 [15]

Transpedicular Lumbar Endoscopic Surgery

Anesthetizing methods/positioning

• Lateral decubitus position

• Local anesthesia and intravenous sedation

Entry point

• L3: 10 cm lateral from the pedicle

• L4: 11 cm lateral from the pedicle

• L5: 12 cm lateral from the pedicle

Insert a 25-cm; an 18-gauge needle was at the lateral pedicle between vertebral body and transverse process

• Confirm with fluoroscopy

Replace needle with K wire

• Insert dilators of 4 and 8 mm to the pedicle

• Removed dilator and insert a Yamshidi needle into the pedicle with fluoroscopic guidance

Yamshidi needle insertion

• Middle of the pedicle in the AP and lateral views

• Loss of resistance and occasionally leg pain of the patient means the pedicle has been penetrated

• Replaced Yamshidi needle with 2-mm K wire and disposable bone drill of 4 mm

Small bone hole is then increased in size increasing diameters of drills or reamers to 8 mm

7.2-mm tubular retractor is inserted

Mixture of contrast medium (Solutrast 3 mL) and Toluidine blue dye (0.1 mL)

• Remove the blue-stained disc sequestration with bendable forceps

21

N/a

8.1

1.3

N/a

N/a

N/a

Xinbo Wu 2016 [8]

TELD

Two-channel technique

Anesthetizing methods/positioning

• Prone

• Local anesthesia with lidocaine (1%)

Surgical puncture point

• 10 cm from the midline for L3–L4 segment

• 11–14 cm from midline for L4–L5 segment

Lateral fluoroscopy confirmed the needle positioned above the vertebral foramen

22

Excellent: 14

Good: 6

Fair: 2

Back: 7.82 ± 0.96

Leg: 8.59 ± 1.05

Back: 1.14 ± 0.71

Leg: 0.95 ± 0.72

71.18 ± 7.90

16.91 ± 4.13

1

Kyung-Chul Choi, 2016 [5, 9]

Epiduroscopic Laser Neural Decompression (ELND) for Down-migrated Disc Herniation

Anesthetizing methods/positioning:

• Local anesthesia

• Prone position

Underwent PELD via the transforaminal route for removal of a paracentral extruded disc

Opening of the epidural space between the extruded disc and traversing nerve root

Cannula location

• 25° trajectory angle

• Between the spinous process and medial pedicle line on anteroposterior radiography

Herniated disc was removed using endoscopic forceps

Using bipolar and endoscopic scissor, release the outer annulus and posterior longitudinal ligament

ELND was done via sacral hiatus for removal of the down-migrated disc by

using a Holmium: YAG laser

The flexible epidural fiber optic catheter system was inserted through the sacral hiatus

With fluoroscopic guidance, catheter went up to the pedicle along the ventral surface of the epidural space

Differentiate nerve root under epiduroscopic view and vaporized with laser (5 J at 5–10 Hz)

Performing PELD remove free fragments with forceps

1

N/a

N/a

N/a

N/a

N/a

N/a

Hyeun Sung Kim 2018 [14]

Percutaneous endoscopic transforaminal lumbar discectomy

Percutaneous endoscopic interlaminar lumbar discectomy

Anesthetizing methods/positioning

• Prone position

Spine needle insertion point

• Toward the lowest part and most dorsal part of disc space

• Infltrated with 7–10 mL 1% lidocaine followed by epinephrine mixed 2–3 cc 1.6% lidocaine, 3–5 min after the first injection

Discography using a contrast mixture consisting of 6 mL iohexol dye and 1 mL indigo–carmine

Tapered cannulated obturator inserted over the guide wire and advanced into the foraminal space

Internal disc decompression

Remove tissue around the pedicle

Perform suprapedicular circumferential opening technique

• Drilling ventral part of superior articular process, the upper part of pedicle that builds the suprapedicular notch, upper-posterior margin of the lower vertebra

Use semirigid flexible curved probe and forceps to hook and pull the disc material out

98

Poor: 1 (1.0%)

Fair: 3 (2.9%)

Good: 54 (51.9%)

Excellent: 46 (44.2%)

Leg: 7.13

Leg: 1.95

54.67 ± 7.52

24.50+ 6.45

N/a

Quillo-Olvera 2018 [28]

PELD transpedicular approach

Anesthetizing methods/positioning

• Prone with hips and knees in flexion

• Local anesthesia with conscious sedation

Skin entry

• 10 cm lateral from the midline for the L3 pedicle

• 11 cm lateral from the midline for the L4 pedicle

• 12 cm lateral from the midline for the L5 pedicle

Skin is infiltrated with 1% lidocaine

An 18-gauge spinal needle is advanced and placed on the lateral wall of the pedicle, behind the transverse process

The spinal needle is replaced with K wire

Insert obturator and the tip should be placed on the lateral wall of the pedicle

• Right pedicle at 3 o’clock, and for the left pedicle at 9 o’clock

25° rod-lens endoscope of 6.3-mm outer diameter is advanced to visualize the lateral wall of the pedicle

Create a transpedicular tunnel

Remove a thin layer of cortical bone from its medial wall with endoscopic Kerrison punch

• Endoscope is advanced through the tunnel to visualize the migrated disc herniation directly

Endoscopic nerve hook used to confirm that the herniated disc has been completely removed

N/a

N/a

N/a

N/a

N/a

N/a

N/a

  1. IELD Interlaminar endoscopic lumbar discectomy, ODI Oswestry disability index, PELD Percutaneous endoscopic lumbar discectomy, TELD Transforaminal endoscopic lumbar discectomy, VAS visual analog scale