Transpedicular endoscopic removal of highly migrated disc herniations of lumbar spine

Background. Highly migrated disc herniations are usually localized in the area of pars interarticularis medially to the vertebral pedicle. Removal of disk herniations of this localization is a difficult technical task.

The study objective is to demonstrate the effectiveness of the transpedicular endoscopic discectomy in the treatment of patients with highly migrated disc herniations.

Materials and methods. The results of treatment of 12 patients with Macnab zone herniations who were in hospital from 2016 to 2018 were analyzed. All patients underwent transpedicular endoscopic sequestrectomy.

Results. Leg pain after surgery regressed in all patients from the initial 7.41 points (visual-analog scale) to 0.67 points by the end of the 1st day, and it was 0.35 points a year later. The average level of back pain by VAS before surgery was 5.25, on the 1st day after surgery – 1.25 points, 1 year after – 0.67 points. Neurological disorders completely regressed in 10 (91.6 %) patients, there were a slight residual L4 dermatome hypesthesia in 2 patients, without disrupting their quality of life. The average Oswestry Disability Index before surgery was 69.17, and 1 year after surgery was 14.12. There were no complications and reoperations.

Conclusion. Transpedicular endoscopic discectomy allowed us to achieve good treatment results in patients with migration of a lumbar hernia by the pedicle. It can be a safe and effective alternative to the transforaminal or interlaminar endoscopic technique.

1. Byvaltsev V.A., Sorokovikov V.A., Belykh E.G. et al. Comparative analysis of long-term results of microsurgical, endoscopic and endoscopically assisted discectomies for lumbar intervertebral disc hernia. Endoskopicheskaya khirurgiya = Endoscopic surgery 2012;18(3):38–46. (In Russ.).

2. Gushcha A.O., Shevelev I.N., Arestov S.O. Experience with endoscopic interventions in diseases of the vertebral column. Zhurnal “Voprosy nejrokhirurgii” im. N.N. Burdenko = N.N. Burdenko Journal of Neurosurgery 2007;(2):26–32. (In Russ.).

3. Essentials of Spinal Microsurgery. Ed. by J.A. McCulloch, P.H. Young. Philadelphia: Lippincott-Raven, 1998. Pp. 329–382. DOI: 10.1007/bf02767774.

4. Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am 1971;53(5):891–903. DOI: 10.2106/00004623-197153050-00004.

5. Reinshagen C., Redjal N., Molcanyi M., Rieger B. Surgical approaches to the lumbar hidden zone: current strategies and future directions. EBioMedicine 2015;2(9):1005–7. DOI: 10.1016/j.ebiom.2015.09.010.

6. Hassler W., Brandner S., Slansky I. Microsurgical management of lateral lumbar disc herniations: combined lateral and interlaminar approach. Acta Neurochir (Wien) 1996;138(8):907–11. DOI: 10.1007/bf01411277.

7. Postacchini F., Cinotti G., Gumina S. Microsurgical excision of lateral lumbar disc herniation through an interlaminar approach. J Bone Joint Surg Br 1998;80(2):201–7. DOI: 10.1302/0301-620x.80b2.0800201.

8. Schulz C., Kunz U., Mauer U.M., Mathieu R. Early postoperative results after removal of cranially migrated lumbar disc prolapse retrospective comparison of three different surgical strategies. Adv Orthop 2014;2014:702163. DOI: 10.1155/2014/702163.

9. Alimi M., Njoku I. Jr, Cong G.T. et al. Minimally invasive foraminotomy through tubular retractors via a contralateral approach in patients with unilateral radiculopathy. Neurosurgery 2014;10 Suppl 3:436–47. DOI: 10.1227/neu.0000000000000358.

10. Morgenstern R., Morgenstern C. Percutaneous transforaminal lumbar interbody fusion (pTLIF) with a posterolateral approach for the treatment of degenerative disk disease: feasibility and preliminary results. Int J Spinal Surg 2015;9:41. DOI: 10.14444/2041.

11. Afaunov A.A., Basankin I.V., Kuzmenko A.V., Shapovalov V.K. Complications of surgical treatment of degenerative lumbar stenosis. Khirurgiya pozvonochnika = Spine Surgery 2016;13(4):66–72. (In Russ.). DOI: 10.14531/ss2016.4.66-72.

12. Ruetten S., Komp M., Merk H., Godolias G. et al. Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique: a prospective, randomized, controlled study. J Neurosurg Spine 2009;10(5):476–85. DOI: 10.3171/2008.7.17634.

13. Choi G., Prada N., Modi H.N. et al. Percutaneous endoscopic lumbar herniectomy for high-grade downmigrated L4 –L5 disc through an L5 –S1 interlaminar approach: a technical note. Minim Invasive Neurosurg 2010;53(3): 147–52. DOI: 10.1055/s-0030-1254145.

14. Yeom K.S., Choi Y.S. Full endoscopic contralateral transforaminal discectomy for distally migrated lumbar disc herniation. J Orthop Sci 2011;16(3):263–9. DOI: 10.1007/s00776-011-0048-0.

15. Choi G., Lee S.-H., Lokhande P. et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976) 2008;33(15):E508–15. DOI: 10.1097/brs.0b013e31817bfa1a.

16. Krzok G., Telfeian A.E., Wagner R., Iprenburg M. Transpedicular lumbar endoscopic surgery for highly migrated disk extrusions: preliminary series and surgical technique. World Neurosurg 2016;95:299–303. DOI: 10.1016/j.wneu.2016.08.018.

17. Uniyal P., Choi G., Khedkkar B. Percutaneous transpedicular lumbar endoscopy: a case report. Int J Spine Surg 2016;10:31. DOI: 10.14444/3031.

18. Quillo-Olvera J., Akbary K., Kim J.S. Percutaneous endoscopic transpedicular approach for high-grade down-migrated lumbar disc herniations. Acta Neurochir (Wien) 2018;160(8):1603–7. DOI: 10.1007/s00701-018-3586-9.

19. Krzok G. Transpedicular endoscopic surgery for highly downmigrated L5 –S1 disc herniation. Case Rep Med 2019;2019:5724342. DOI: 10.1155/2019/5724342.