Percutaneous Transforaminal Endoscopic Lumbar Discectomy

Percutaneous Transforaminal Endoscopic Lumbar Discectomy

Transforaminal lumbar endoscopic discectomy (TLED) is a minimally invasive surgery for removing lumbar disc herniations. This technique was initially reserved for herniations in the foraminal or extraforaminal region.

It seems to be a promising technique to effectively treat LDH. The reported complication rate of PTED is low, as is the percentage of patients requiring additional surgery due to recurrent LDH. Due to its steep learning curve, however, PTED should be further investigated before widespread implementation. Open microdiscectomy remains the current standard therapy for the surgical decompression of LDH. High-quality randomized controlled trials are needed to generate Class I evidence on the efficacy and cost-effectiveness of PTED 1).

A technique for percutaneous nonvisualized indirect spinal canal decompression—percutaneous nucleotomy— through a posterolateral approach was described by Parviz Kambin in 1973 2) and Hijikata et al. in 19753).

Kambin described using a Craig cannula and Hijikata a 2.6-mm cannula. The technical challenge of achieving sufficient removal of nucleus pulposus material through a needle was addressed by Kambin and coworkers in 1986 and 1987 with the introduction of working cannulas possessing diameters up to 5 mm and flexible forceps 4) 5).

The next step in the advancement of the percutaneous discectomy technique was the addition of the endoscope. The first endoscopic views of a herniated nucleus pulposus were published by Kambin et al. in 1988 6) and the first reported introduction of a modified arthroscope into the intervertebral disc space was reported by Forst and Hausman in 1983 7)

Schreiber et al. 8) and Suezawa et al. 9) published their bilateral approach for a percutaneous nucleotomy under endoscopic control and described injecting indigo carmine into the disc space to stain the abnormal nucleus pulposus and anular fissures.

Percutaneous endoscopic discectomy certainly must receive a great portion of the credit for advancing endoscopic spine surgery, but it also must likely take responsibility for endoscopic spine surgery’s slow rate of acceptance as a feasible technique by most orthopedic and neurosurgical spine specialists. The surgical goal of percutaneous endoscopic discectomy is to indirectly decompress the neural elements by selectively removing the nucleus pulposus from the posterior one-third of the disc space. From its origin, the technique showed promising results: Kambin and Gellman reported a 72% success rate in 136 patients with their percutaneous technique in 1983, but it has been difficult to quantify the impact of such results because they were not matched with nonoperative controls 10)


It has several advantages over open lumbar discectomy, including less paravertebral muscle injury, preservation of bony structure, and rapid recovery, and has gained popularity for removal of herniated disc (HD) material over the past few years since Kambin 11) introduced the percutaneous posterolateral approach in 1983.

Even sequestered disc material – regardless of its size and level – that slipped into the spinal channel can be removed with the minimal invasive method.

Large, uncontained, lumbar disc herniations can be sufficiently removed with remarkable long-term outcome. Although the neurological outcome is the same, the morbidity is significantly less than open discectomy. Maximum benefit can be gained if we adhere to strict selection criteria. The optimum indication is single- or multi-level radiculopathy secondary to a single-level, large, uncontained, lumbar disc herniation 12).

Proper surgical indications and good working channel position are important for successful PELD. PELD techniques should be specifically designed to remove the disc fragments in various types of disc herniation 13).

Immediate pain relief in 95% of the cases – study info needed

Direct access to herniated disc/sequester

The disc-annulus and the ligament remain intact

No general anesthesia, only a sparing local anesthetic necessary

Outpatient treatment

Shorter rehabilitation -study info needed

Faster return to profession and everyday life – study info needed

Small incision (only one stitch) = hardly any scarring.

For adjacent segment degeneration (ASD) and recurrent lumbar disc herniation, PELD had more advantages over open lumbar surgery in terms of reduced blood loss, shorter hospital stay, operating time, fewer complications, and less postoperative discomfort 14).

It can be performed under local anesthesia and requires only an 8-mm skin incision.

PTED performed under local anesthesia and conscious sedation is safe and effective to treat sciatica and yields high satisfaction rates from surgeons, anesthesiologists, and patients 15)

Reoperation rates of PELD have been reported from 2.3% to 15% 16) 17) 18) 19) 20).

According to a nationwide cohort study, there is no significant difference in the reoperation rates between open discectomy (13.7%) and endoscopic discectomy (12.4%) 21).

PELD may not be an applicable option for all ages.

Kim et al. selected 15,817 patients who underwent open discectomy (n = 12,816) or PELD (n = 3,001) in 2003 from Korean Health Insurance Review & Assessment Service (HIRA) database. All patients in the cohort were followed until December 31, 2008, and the minimum follow-up period was 5 years. A time to event survival analysis was performed. Primary end-point was any type of second lumbar spine surgery during the follow-up period. Minimum P-value approach and two-fold cross validation approach were utilized to determine an age cut-off point.

The optimal age cut-off point was determined as 57 years. PELD for elder patients (≥ 57 years) had a higher reoperation risk during postoperative 3.4 years (Hazard ratio [HR] at 1 yr, 1.75; 2 yr, 1.57; 3 yr, 1.41). However, re-operation risk was not higher after PELD for patients of < 57 years from 1.9 years than open diskectomy (HR at 2 yr, 0.86; 3 yr, 0.78; 4 yr, 0.70; 5 yr, 0.63).

In the present study, they showed that an age cut-off point of PELD for optimal reoperation rate may be 57 years with national-wide population based data. Reoperation rate seems to be not higher for patients younger than 57 years after PELD than open diskectomy, but applying PELD for elder patients need careful consideration 22).

Percutaneous Transforaminal Endoscopic Lumbar Discectomy Case series.

Full-endoscopic Transforaminal lumbar endoscopic discectomy is based on a puncture technique using a guide needle to reach the target area of the foramen via a percutaneous posterolateral/lateral approach. It may correlate with specific approach-related complications, as exiting nerve root injury.

Panagiotopoulos et al., report the first case of pseudoaneurysm of the lumbar segmental artery secondary to a transforaminal full-endoscopic surgery in the treatment of a lumbar disc herniation. A 39-year-old man underwent left L4-L5 full-endoscopic transforaminal lumbar discectomy for a herniated disc. Three hours after surgery, he experienced acute progressive abdominal pain. An abdomen CT scan showed contrast extravasation in the left paraspinal compartment at L4 vertebral body level. The selective left lumbar angiogram revealed a pseudoaneurysm of a side branch of the left lumbar segmental artery, which was treated by endovascular coiling. The patient made a rapid postoperative recovery without further complications and was discharged 4 days later. This report identifies a rare complication of transforaminal full-endoscopic surgery in the treatment of a herniated lumbar disc. This is the first case of pseudoaneurysm formation of the lumbar artery following a full-endoscopic transforaminal lumbar discectomy 23).


1)

Gadjradj PS, van Tulder MW, Dirven CM, Peul WC, Sanjay Harhangi B. Clinical outcomes after percutaneous transforaminal endoscopic discectomy for lumbar disc herniation: a prospective case series. Neurosurg Focus. 2016 Feb;40(2):E3. doi: 10.3171/2015.10.FOCUS15484. PubMed PMID: 26828884.
2)

Kambin P: Arthroscopic Microdiscectomy: Minimal Intervention Spinal Surgery Baltimore, MD, Urban & Schwarzenberg, 1990
3)

Hijikata S, Yamagishi M, Nakayma T: Percutaneous discectomy: a new treatment method for lumbar disc herniation. J Todenhosp 5:5–13, 1975
4)

Kambin P, Brager MD: Percutaneous posterolateral discectomy. Anatomy and mechanism. Clin Orthop Relat Res 223145–154, 1987
5)

Kambin P, Sampson S: Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res 20737–43, 1986
6)

Kambin P, Nixon JE, Chait A, Schaffer JL: Annular protrusion: pathophysiology and roentgenographic appearance. Spine (Phila Pa 1976) 13:671–675, 1988
7)

Forst R, Hausmann B: Nucleoscopy—a new examination technique. Arch Orthop Trauma Surg 101:219–221, 1983
8)

Schreiber A, Suezawa Y, Leu H: Does percutaneous nucleotomy with discoscopy replace conventional discectomy? Eight years of experience and results in treatment of herniated lumbar disc. Clin Orthop Relat Res 23835–42, 1989
9)

Suezawa Y, Jacob HA: Percutaneous nucleotomy. An alternative to spinal surgery. Arch Orthop Trauma Surg 105:287–295, 1986
10)

Kambin P, Gellman H: Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop Relat Res 174127–132, 1983
11)

Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop. 1983;174:127–132.
12)

Hussein M, Abdeldayem A, Mattar MM. Surgical technique and effectiveness of microendoscopic discectomy for large uncontained lumbar disc herniations: a prospective, randomized, controlled study with 8 years of follow-up. Eur Spine J. 2014 Sep;23(9):1992-9. doi: 10.1007/s00586-014-3296-9. Epub 2014 Apr 16. PubMed PMID: 24736930.
13)

Choi KC, Lee JH, Kim JS, Sabal LA, Lee S, Kim H, Lee SH. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10 228 cases. Neurosurgery. 2015 Apr;76(4):372-81. doi: 10.1227/NEU.0000000000000628. PubMed PMID: 25599214.
14)

Chen HC, Lee CH, Wei L, Lui TN, Lin TJ. Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Surgery for Adjacent Segment Degeneration and Recurrent Disc Herniation. Neurol Res Int. 2015;2015:791943. Epub 2015 Mar 10. PubMed PMID: 25861474.
15)

Gadjradj PS, Arjun Sharma JRJ, Harhangi BS. Quality of conscious sedation using dexmedetomidine during full-endoscopic transforaminal discectomy for sciatica: a prospective case series. Acta Neurochir (Wien). 2022 Jan 31. doi: 10.1007/s00701-021-05100-x. Epub ahead of print. PMID: 35098351.
16)

Ahn Y, Lee SH, Park WM, Lee HY, Shin SW, Kang HY. 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.
17)

Hoogland T, van den Brekel-Dijkstra K, Schubert M, Miklitz B. Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine (Phila Pa 1976). 2008;33(9):973–978.
18)

Kambin P. Arthroscopic microdiscectomy. Arthroscopy. 1992;8(3):287–295.
19)

Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine (Phila Pa 1976). 2005;30(22):2570–2578.
20)

Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg. 1993;78(2):216–225.
21)

Kim CH, Chung CK, Park CS, Choi B, Kim MJ, Park BJ. Reoperation rate after surgery for lumbar herniated intervertebral disc disease: nationwide cohort study. Spine (Phila Pa 1976). 2013;38(7):581–590.
22)

Kim CH, Chung CK, Choi Y, Shin S, Kim MJ, Lee J, Park BJ. The selection of open or percutaneous endoscopic lumbar diskectomy according to an age cut-off point: national-wide cohort study. Spine (Phila Pa 1976). 2015 Jul 17. [Epub ahead of print] PubMed PMID: 26192722.
23)

Panagiotopoulos K, Gazzeri R, Bruni A, Agrillo U. Pseudoaneurysm of a segmental lumbar artery following a full-endoscopic transforaminal lumbar discectomy: a rare approach-related complication. Acta Neurochir (Wien). 2019 Mar 16. doi: 10.1007/s00701-019-03876-7. [Epub ahead of print] PubMed PMID: 30879131.

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