Percutaneous Endoscopic Lumbar Discectomy for All Types of Lumbar Disc Herniations (LDH) Including Severely Difficult and Extremely Difficult LDH Cases

Abstract

Background: Lumbar disc herniation (LDH) is being treated with limited indication by percutaneous full endoscopic lumbar discectomy. However, microscopic lumbar discectomy (MLD) is still considered as a gold standard. Objective: With the advances in spinal endoscopic instruments and surgical techniques, all LDHs have now become operable with percutaneous full endoscopic lumbar discectomy procedure. We report the results of percutaneous full endoscopic lumbar discectomy (PELD) for all patients diagnosed with LDH, including severely difficult and extremely difficult LDH cases who visited our clinic with leg pain and lower back pain. Study Design: Retrospective study of consecutive prospective patients. Setting: Spine center, Nanoori Suwon Hospital, Suwon, Korea. Methods: Electronic medical records of 98 consecutive patients (104 levels) who underwent surgery from October 2015 to May 2016, by PELD for different LDHs either by percutaneous endoscopic transforaminal lumbar discectomy (PETLD) or percutaneous endoscopic interlaminar lumbar discectomy (PEILD) approach were reviewed retrospectively. The L5-S1 level was accessed with PEILD approach and the other levels were accessed with PETLD approach. Outcomes were analyzed utilizing the visual analog scale (VAS), Oswestry disability index (ODI), Mac Nab Criteria and endoscopic surgical success grade/score. Results: There were 75 (72.1%) men and 29 (27.9%) women patients with a mean age of 48.12 ± 15.88 years. Follow-up range from a minimum of 10 to 15 months (mean 12.77 ± 1.84 months). Most of the LDHs were located at L4-5 level. There were 76% severely difficult and extremely difficult cases. PETLD was the choice of approach in most of the cases (78 cases, 75%). VAS decreased significantly. ODI improved from preoperative 54.67 ± 7.52 to 24.50 ± 6.45 at last follow-up. 96.1% good to excellent result was obtained as per Mac Nab criteria. 98.1% of patients were managed with a successful to completely successful grade according to the endoscopic surgical success grading/ scoring. Two cases (1.9%) developed transient motor weakness. Limitation: Retrospective analysis of consecutive prospective patients. Conclusion: With more than 96% success (98.1% as per endoscopic success grading/scoring) all kinds of LDHs, including severely difficult and extremely difficult LDHs, are accessible by the PELD (PETLD and PEILD) technique. PELD can now be considered an alternative to microscopic lumbar discectomy (MLD) in the treatment of all kinds of disc herniations with the added benefits of keyhole surgery even for severely difficult and extremely difficult LDH cases. Key words: Lumbar disc herniation (LDH), percutaneous endoscopic lumbar discectomy (PELD), percutaneous endoscopic transforaminal lumbar discectomy (PETLD), percutaneous endoscopic interlaminar discectomy (PEILD), evolution of PELD, difficult LDH, highly migrated LDH, high canal compromised LDH, revision LDH, LDH with discal cyst, calcified LDH