Modified Percutaneous Endoscopic Interlaminar Discectomy through the Near-spinous Process Approach for L4/5 Disc Herniation: A Retrospective Clinical Study

Abstract

Objective: Compared with traditional open surgery, percutaneous endoscopic lumbar discectomy (PELD) has the advantages of less trauma, faster recovery, and less postoperative pain, so it has been widely used in the field of spinal surgery. However, it still has the defect of intraoperative fluoroscopy occurrences, complications, and even the risk of damage to the spinal cord and nerve. This study aims to compare the clinical efficacy of modified percutaneous endoscopic interlaminar discectomy (MPEID) with percutaneous endoscopic transforaminal discectomy (PETD) in treating L4/5 lumbar disc herniation (LDH) and to evaluate the effectiveness and safety of MPEID.

Methods: Thirty-four L4/5 LDH patients treated at the Second Affiliated Hospital of Nanchang University from June 2020 to June 2021 were studied retrospectively. Seventeen underwent MPEID and seventeen PETD. Variables analyzed included demographics, operative duration, intraoperative fluoroscopy occurrences, and surgical outcomes. Effectiveness was evaluated using the visual analogue scale (VAS), Oswestry disability index (ODI), and modified MacNab criteria. Lumbar Magnetic Resonance Imaging (MRI) was used to assess radiological outcomes. A paired t-test was performed to compare intragroup pre- and postoperative clinical data, VAS, and ODI scores.

Results: The average operative time in PETD group was 91.65 ± 14.04 min, and the average operative time in MPEID group was 65.41 ± 12.61 min (p < 0.001). In PETD group, the fluoroscopy occurrences averaged 9.71 ± 1.05 times, with fluoroscopy occurrences averaging 6.47 ± 1.00 times (p < 0.001) in MPEID group. At 12 months follow-up, the clinical effect showed significant improvement in both two groups. The MPEID group showed a decrease in average VAS-back score from 5.41 ± 2.18 to 1.76 ± 1.09 (p < 0.001) and VAS-leg score from 6.53 ± 1.66 to 0.82 ± 0.64 (p < 0.001). The ODI scores decreased from 51.35 ± 10.65 to 11.71 ± 2.91 (p < 0.001). In the PETD group, the VAS-back score decreased from 4.94 ± 1.98 to 2.06 ± 1.25 (p < 0.001), VAS-leg score from 7.12 ± 1.73 to 1.12 ± 0.60 (p < 0.001), and ODI scores from 48.00 ± 11.62 to 12.24 ± 2.56 (p < 0.001). According to the modified MacNab criteria, MPEID had 15 excellent and two good results; PETD had 12 excellent and 5 good (p = 0.23). No nerve root injuries, dural tears, or significant complications were reported.

Conclusion: MPEID and PETD effectively treat L4/5 LDH, with MPEID showing shorter operative times and fewer fluoroscopies. Furthermore, the MPEID group can provide excellent clinical efficacy as the PETD group in the short term.

Keywords

L4/5 Lumbar disc herniation / Percutaneous endoscopic interlaminar discectomy / Percutaneous endoscopic lumbar discectomy / Percutaneous endoscopic transforaminal discectomy

References

[1] ScaturroD, AsaroC, LauricellaL, Tomasello S, VarrassiG, LetiziaMG. Combination of rehabilitative therapy with Ultramicronized Palmitoylethanolamide for chronic low Back pain: an observational study. Pain Ther. 2020;9(1):319–326.

[2] YuH, ZhuB, LiuX. Comparison of percutaneous endoscopic lumbar discectomy and open lumbar discectomy in the treatment of adolescent lumbar disc herniation: a retrospective analysis. World Neurosurg. 2021;151:e911–e917.

[3] YeungAT, TsouPM. Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine. 2002;27:722–731.

[4] RuettenS, KompM, GodoliasG. A new full-endoscopic technique for the interlaminar operation of lumbar disc herniations using 6-mm endoscopes: prospective 2-year results of 331 patients. Minim Invasive Neurosurg. 2006;49:80–87.

[5] KapetanakisS, Gkantsinikoudis N, CharitoudisG. Implementation of percutaneous Transforaminal endoscopic discectomy in competitive elite athletes with lumbar disc herniation: original study and review of the literature. Am J Sports Med. 2021;49(12):3234–3241.

[6] SchultzA, Andersson G, OrtengrenR, HaderspeckK, Nachemson A. Loads on the lumbar spine. Validation of a biomechanical analysis by measurements of intradiscal pressures and myoelectric signals. J Bone Joint Surg Am. 1982;64:713–720.

[7] HuangK, ChenG, LuS, LinC, WuS, ChenB, et al. Early clinical outcomes of percutaneous endoscopic lumbar discectomy for L4-5 highly Down-migrated disc herniation: Interlaminar approach versus Transforaminal approach. World Neurosurg. 2021;146:e413–e418.

[8] WuH, HuS, LiuJ, HeD, ChenQ, Cheng X. Risk factors involved in the early and medium-term poor outcomes of percutaneous endoscopic Transforaminal discectomy: a single-center experience. J Pain Res. 2022;15:2927–2938.

[9] WangD, XieW, CaoW, HeS, FanG, ZhangH. A cost-utility analysis of percutaneous endoscopic lumbar discectomy for L5-S1 lumbar disc herniation: Transforaminal versus Interlaminar. Spine (Phila Pa 1976). 2019;44(8):563–570.

[10] MoX, ShenJ, JiangW, Zhang X, ZhouN, WangY, et al. Percutaneous endoscopic lumbar diskectomy for axillar herniation at L5–S1 via the transforaminal approach versus the Interlaminar approach: a prospective clinical trial. World Neurosurg. 2019;125:e508–e514.

[11] GaoA, YangH, ZhuL, HuZ, LuB, JinQ, et al. Comparison of Interlaminar and Transforaminal approaches for treatment of L5 /S1 disc herniation by percutaneous endoscopic discectomy. Orthop Surg. 2021;13(1):63–70.

[12] ChengL, CaiH, LiuZ, YuY, LiW, LiQ. Modified full-endoscopic Interlaminar discectomy via an inferior endplate approach for lumbar disc herniation: retrospective 3-year results from 321 patients. World Neurosurg. 2020;141:e537–e544.

[13] LinH, ZhangS, WuG, JinJ, LiuL. Two different access intervertebral foraminoscopic techniques for treating L4/5 disc herniation. China Orthopaedic Injury. 2019;32(10):904–909.

[14] LiY, WangB, LvG, LiL, et al. Application of interlaminar gap-forming technique in treating L4/5 disc herniation by complete endoscopic surgery via interlaminar approach. Chin J Spine Cord. 2017;27(3):193–199.

[15] HuangH, HuH, LinX, WuC, TanL. Percutaneous endoscopic interlaminar discectomy via inner border of inferior pedicle approach for downmigrated disc herniation: a retrospective study. J Orthop Surg Res. 2022;17(1):359.

[16] XieTH, ZengJC, LiZH, WangL, NieHF, Jiang HS, et al. Complications of lumbar disc herniation following full-endoscopic Interlaminar lumbar discectomy: a large, single-center. Retrospect Stud Pain Physician. 2017;20(3):E379–E387.

[17] HeoDH, LeeDK, LeeDC, Kim HS, ParkCK. Fully endoscopic Transforaminal lumbar discectomy for upward migration of upper lumbar disc herniation: clinical and radiological outcomes and technical considerations. Brain Sci. 2020;10(6):363.

[18] TonosuJ, OshimaY, ShiboiR, Hayashi A, TakanoY, InanamiH, et al. Consideration of proper operative route for interlaminar approach for percutaneous endoscopic lumbar discectomy. J Spine Surg. 2016;2(4):281–288.

[19] FengF, XuQ, YanF, XieY, DengZ, Hu C, et al. Comparison of 7 surgical interventions for lumbar disc herniation: a network meta-analysis. Pain Physician. 2017;20(6):E863–E871.

[20] RuettenS, KompM, MerkH, Godolias G. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976). 2008;33(9):931–939.

[21] SencerA, Yorukoglu AG, AkcakayaMO, ArasY, Aydoseli A, BoyaliO, et al. Fully endoscopic interlaminar and transforaminal lumbar discectomy: short-term clinical results of 163 surgically treated patients. World Neurosurg. 2014;82(5):884–890.

[22] WangZ, JianF, WuH, WangX, WangK, Duan W, et al. Treatment of upper lumbar disc herniation with a Transforaminal endoscopic technique. Front Surg.2022;9:893122.

[23] AhnY, LeeSH, ParkWM, Lee HY, ShinSW, KangHY. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine (Phila Pa 1976). 2004;29(16):E326–E332.

[24] Perez-CruetMJ, Fessler RG, PerinNI. Review: complications of minimally invasive spinal surgery. Neurosurgery. 2002;51(5 Suppl):S26–S36.

[25] YangJ, YangQ, TianL, Wang B, LiuY. Differences in L4/L5 lamina gap morphology in hyperflexed kneeling and prone positions and their significance in percutaneous endoscopic discectomy via interlaminar approach for lumbar disc herniation. J Spine Surg. 2018;16(5):289–292.

[26] JiaJ, DingR, LiuX, LiW, XiongX, Wu T, et al. Coronal magnetic resonance imaging of three-dimensional fast-field echo with water-selective excitation improves the sensitivity and reliability of identification of extraforaminal lumbar disc herniation. J Int Med Res. 2019;47(12):6053–6060.

[27] DowlingTJ, Munakomi S, DowlingTJ. Microdiscectomy. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.

[28] WangY, WuJ, WangT, Liu Y, JiangM, WangZ, et al. Modified lumbar foraminoplasty using a power-aided reciprocating burr for percutaneous transforaminal endoscopic lumbar discectomy: a technical note and clinical report. Front Surg. 2023;5:1091187.

RIGHTS & PERMISSIONS

2024 2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.