Introduction: Complex lumbar disc herniation (CLDH), including huge, migrated, and calcified variants, poses surgical challenges due to factors such as deep-seated lesions, irregular morphology, and adhesion to neural structures. This study aimed to compare the clinical outcomes of two minimally invasive endoscopic approaches—percutaneous endoscopic interlaminar discectomy (PEID) and percutaneous endoscopic transforaminal discectomy (PETD)—in the management of CLDH.
Methods: In this retrospective cohort study, 270 patients with CLDH treated between January 2020 and January 2024 were analyzed. Patients were categorized into three CLDH subtypes and were further divided into PEID and PETD groups based on preoperative imaging findings. Surgical parameters, perioperative data, and complications were recorded. Functional outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria. Imaging measurements included the cross-sectional area of facet joints (CSA-FJ) and dural sac (DSCA). Statistical analyses were performed using the chi-square test, Wilcoxon rank-sum test, Shapiro–Wilk test, independent-samples t-test, and two-way repeated-measures ANOVA.
Results: All procedures were successfully completed. PEID showed shorter operative time and significantly fewer fluoroscopy exposures compared to PETD (p < 0.05). PETD was associated with a higher facet joint resection rate (p < 0.05), though DSCA improvements were similar between groups. Both groups demonstrated significant reductions in VAS and ODI scores at all follow-up points (p < 0.05), with no statistically significant differences between approaches. Over 80% of patients achieved excellent or good outcomes according to modified MacNab grading. Complications were uncommon and included dural tears (n = 3), epidural hematoma (n = 1), nerve root injury (n = 1), and recurrent herniation (n = 2).
Conclusion: Both PEID and PETD are effective and safe surgical options for treating CLDH. PEID offers reduced operative time and radiation exposure, while PETD requires more extensive facet resection. This study further outlines tailored surgical strategies for different CLDH subtypes, supporting individualized endoscopic treatment selection.
| [1] |
Y.-K. Kim, D. Kang, I. Lee, and S.-Y. Kim, “Differences in the Incidence of Symptomatic Cervical and Lumbar Disc Herniation According to Age, Sex and National Health Insurance Eligibility: A Pilot Study on the Disease's Association With Work,” International Journal of Environmental Research and Public Health 15, no. 10 (2018): 2094.
|
| [2] |
J. S. Virdee, A. Nadig, G. Anagnostopoulos, and K. J. George, “Comparison of Peri-Operative and 12-Month Lifestyle Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Conventional Lumbar Fusion,” British Journal of Neurosurgery 31, no. 2 (2017): 167–171.
|
| [3] |
R. A. Deyo, S. K. Mirza, B. I. Martin, W. Kreuter, D. C. Goodman, and J. G. Jarvik, “Trends, Major Medical Complications, and Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults,” Journal of the American Medical Association 303, no. 13 (2010): 1259–1265.
|
| [4] |
A. T. Yeung, “Minimally Invasive Disc Surgery With the Yeung Endoscopic Spine System (YESS),” Surgical Technology International 8 (1999): 267–277.
|
| [5] |
S. Han, X. Zeng, K. Zhu, et al., “Clinical Application of Large Channel Endoscopic Systems With Full Endoscopic Visualization Technique in Lumbar Central Spinal Stenosis: A Retrospective Cohort Study,” Pain and Therapy 11, no. 4 (2022): 1309–1326.
|
| [6] |
S. Sivakanthan, S. Hasan, and C. Hofstetter, “Full-Endoscopic Lumbar Discectomy,” Neurosurgery Clinics of North America 31, no. 1 (2020): 1.
|
| [7] |
M. Kong, D. Xu, C. Gao, et al., “Risk Factors for Recurrent L4-5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Analysis of 654 Cases,” Risk Management and Healthcare Policy 13 (2020): 3051–3065.
|
| [8] |
T. Li, G. Yang, W. Zhong, J. Liu, Z. Ding, and Y. Ding, “Percutaneous Endoscopic Transforaminal vs. Interlaminar Discectomy for L5–S1 Lumbar Disc Herniation: A Retrospective Propensity Score Matching Study,” Journal of Orthopaedic Surgery and Research 19, no. 1 (2024): 64.
|
| [9] |
M. Pan, Q. Li, S. Li, et al., “Percutaneous Endoscopic Lumbar Discectomy: Indications and Complications,” Pain Physician 23, no. 1 (2020): 49–56.
|
| [10] |
Y.-P. Cheng, X.-K. Cheng, and H. Wu, “A Comparative Study of Percutaneous Endoscopic Interlaminar Discectomy and Transforaminal Discectomy for L5-S1 Calcified Lumbar Disc Herniation,” BMC Musculoskeletal Disorders 23, no. 1 (2022): 244.
|
| [11] |
C. Ma, H. Li, T. Zhang, et al., “Comparison of Percutaneous Endoscopic Interlaminar Discectomy and Open Fenestration Discectomy for Single-Segment Huge Lumbar Disc Herniation: A Two-Year Follow-Up Retrospective Study,” Journal of Pain Research 15 (2022): 1061–1070.
|
| [12] |
C.-W. Lee, K.-J. Yoon, S.-S. Ha, and J.-K. Kang, “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,” Journal of Korean Neurosurgical Society 59, no. 2 (2016): 172–181.
|
| [13] |
K. Akbary, J.-S. Kim, C. W. Park, S. G. Jun, and I. C. Hwang, “The Feasibility and Perioperative Results of Bi-Portal Endoscopic Resection of a Facet Cyst Along With Minimizing Facet Joint Resection in the Degenerative Lumbar Spine,” Operative Neurosurgery 18, no. 6 (2020): 621–628.
|
| [14] |
L. Henderson, G. Kulik, D. Richarme, N. Theumann, and C. Schizas, “Is Spinal Stenosis Assessment Dependent on Slice Orientation? A Magnetic Resonance Imaging Study,” European Spine Journal 21, no. Suppl 6 (2012): 760–764.
|
| [15] |
J. I. Liounakos and M. Y. Wang, “The Endoscopic Approach to Lumbar Discectomy, Fusion, and Enhanced Recovery: A Review,” Global Spine Journal 10, no. 2_suppl (2020): 65S–69S.
|
| [16] |
J. B. Gross, “Estimating Allowable Blood Loss: Corrected for Dilution,” Anesthesiology 58, no. 3 (1983): 277–280.
|
| [17] |
S. B. Nadler, J. H. Hidalgo, and T. Bloch, “Prediction of Blood Volume in Normal Human Adults,” Surgery 51, no. 2 (1962): 224–232.
|
| [18] |
H. Nie, J. Zeng, Y. Song, et al., “Percutaneous Endoscopic Lumbar Discectomy for L5–S1 Disc Herniation via an Interlaminar Approach Versus a Transforaminal Approach: A Prospective Randomized Controlled Study With 2-Year Follow Up,” Spine 41 (2016): B30-B7.
|
| [19] |
W. Cui, X. Zhang, Y. Lu, N. An, and J. Cheng, “Effectiveness of Transforaminal Approach Spinal Endoscopy in the Treatment of Patients With Lumbar Disc Herniation and the Factors Affecting Its Efficacy,” American Journal of Translational Research 16, no. 5 (2024): 1779–1789.
|
| [20] |
S.-Q. Yang, S.-M. Zhang, G.-N. Wu, J. Jin, and H. Lin, “Treatment of Upper Lumbar Disc Herniation With Percutaneous Endoscopic Lumbar Discectomy Through Two Different Approaches,” Zhongguo Gu Shang= China Journal of Orthopaedics and Traumatology 33, no. 7 (2020): 621–627.
|
| [21] |
A. Barriga and C. Villas, “Cauda Equina Syndrome Due to Giant Disc Herniation,” Revista de Medicina de la Universidad de Navarra 46, no. 3 (2002): 33–35.
|
| [22] |
F. Sommer, L. McGrath, S. Kirnaz, et al., “Lumbar Giant Disk Herniations Treated With a Unilateral Approach for Bilateral Decompression,” Operative Neurosurgery 23, no. 1 (2022): 60–66.
|
| [23] |
G. Krzok, A. E. Telfeian, R. Wagner, and M. Iprenburg, “Transpedicular Lumbar Endoscopic Surgery for Highly Migrated Disk Extrusions: Preliminary Series and Surgical Technique,” World Neurosurgery 95 (2016): 299–303.
|
| [24] |
X. Wu, G. Fan, X. Guan, et al., “Percutaneous Endoscopic Lumbar Discectomy for Far-Migrated Disc Herniation Through Two Working Channels,” Pain Physician 19, no. 4 (2016): E675–E680.
|
| [25] |
K. C. Choi, K. Jin-Sung, and C.-K. Park, “Percutaneous Endoscopic Lumbar Discectomy as an Alternative to Open Lumbar Microdiscectomy for Large Lumbar Disc Herniation,” Pain Physician 19, no. 2 (2016): E291.
|
| [26] |
G. Choi, S.-H. Lee, P. Lokhande, et al., “Percutaneous Endoscopic Approach for Highly Migrated Intracanal Disc Herniations by Foraminoplastic Technique Using Rigid Working Channel Endoscope,” Spine 33, no. 15 (2008): E508–E515.
|
| [27] |
W. Jing, “Percutaneous Endoscopic Lumbar Discectomy and Research Progress of Endoscopic Treatment of Complex Migrated Lumbar Disc Herniation,” Fudan University Journal of Medical Sciences 50, no. 6 (2023): 911–918.
|
| [28] |
Y. Yu, M. Li, K. Zhang, and Q. Shi, “Comparison of a Progressive Bone Drilling System and a Visualized Reaming System in Percutaneous Transforaminal Endoscopic Discectomy: A Comparative Study,” European Spine Journal 34 (2025): 4395–4403.
|
| [29] |
K. Ishibashi, Y. Oshima, H. Inoue, et al., “A Less Invasive Surgery Using a Full-Endoscopic System for L5 Nerve Root Compression Caused by Lumbar Foraminal Stenosis,” Journal of Spine Surgery 4, no. 3 (2018): 594–601.
|
| [30] |
L. Yu, J.-K. Wen, S. Wang, W.-H. Wang, J.-M. Yu, and X.-J. Ye, “Removal of Calcified Lumbar Disc Herniation With Endoscopic-Matched Ultrasonic Osteotome–Our Preliminary Experience,” British Journal of Neurosurgery 34, no. 1 (2020): 80–85.
|
| [31] |
Y. Zhao, Y. Fan, L. Yang, et al., “Percutaneous Endoscopic Lumbar Discectomy (PELD) via a Transforaminal and Interlaminar Combined Approach for Very Highly Migrated Lumbar Disc Herniation (LDH) Between L4/5 and L5/S1 Level,” Medical Science Monitor: International Medical Journal of Experimental and Clinical Research 26 (2020): e922777-1.
|
| [32] |
H. Wang, T. Zhou, Y. Gu, and Z. Yan, “Evaluation of Efficacy and Safety of Percutaneous Transforaminal Endoscopic Surgery (PTES) for Surgical Treatment of Calcified Lumbar Disc Herniation: A Retrospective Cohort Study of 101 Patients,” BMC Musculoskeletal Disorders 22, no. 1 (2021): 65.
|
| [33] |
Y. Ahn, “Transforaminal Percutaneous Endoscopic Lumbar Discectomy: Technical Tips to Prevent Complications,” Expert Review of Medical Devices 9, no. 4 (2012): 361–366.
|
| [34] |
G. P. Kalanchiam, A. K. Kaliya-Perumal, L. Sampath, E. T. H. Boey, and J. Y. Oh “Complications in Uniportal vs Unilateral Biportal Endoscopic Decompression for Lumbar Spinal Stenosis: A Scoping Review,” Global Spine Journal 16, no. 1 (2026): 724–733.
|
| [35] |
T. A. Nazwar, F. Bal'afif, D. W. Wardhana, and C. Panjaitan, “A Comparative Study of Transforaminal and Interlaminar Approaches in Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation: Systematic Review,” Journal of Clinical Neuroscience 133 (2025): 111022.
|
| [36] |
X. Mo, J. Shen, W. Jiang, 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 Neurosurgery 125 (2019): e508–e514.
|
| [37] |
X.-r. Li, J. Yu, W. Zhang, et al., “Biomechanical Model Study of the Effect of Partial Facetectomy on Lumbar Stability Under Percutaneous Endoscopy,” World Neurosurgery 139 (2020): e255–e264.
|
| [38] |
S. Ahuja, A. Moideen, A. Dudhniwala, E. Karatsis, L. Papadakis, and E. Varitis, “Lumbar Stability Following Graded Unilateral and Bilateral Facetectomy: A Finite Element Model Study,” Clinical Biomechanics 75 (2020): 105011.
|
RIGHTS & PERMISSIONS
2026 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.
PDF
(2293KB)
