Transforaminal Endoscopic Lumbar Discectomy for L5–S1 Disc Herniation With High Iliac Crest: Technical Note and Preliminary Series

Abstract

With the trend of minimally invasive spine surgery, full-endoscopic lumbar discectomy (FELD) has evolved with the advancement of the optics and instruments. Regarding the techniques, the transforaminal and interlaminar approach remain the major accesses in FELD. Transforaminal endoscopic lumbar discectomy (TELD) is an effective and safe treatment for herniation of the lumbar disc. More and more evidence supports the TELD in enhancing recovery and decreasing surgical complications. However, the learning curve of TELD remains steep, especially at the L5-S1 level. The iliac crest height is an essential factor in the operability of TELD at the L5-S1 level. In the situation of the high iliac crest, TELD is technically challenging even for an experienced surgeon. Therefore, the authors report their techniques of TELD with foraminoplasty step-by-step and the preliminary results in this report.

Full Endoscopic Transforaminal Lumbar Discectomy: A Literature Review

“…Yeung and Hoogland 14,31) In 2005, Dr. Ruetten introduced the endoscopic interlaminar approach that facilitates discectomy at the L5/S1 level owing to the high iliac crest and caudal sequestrating disk beyond the pedicle 25,26) . With the development of advanced spinal endoscopic instruments, especially the multiple-diameter Kerrison punches, special reamers, trephines, bone-biting forceps, high-speed/angular burrs, and larger work-ing sheaths (working channel of 5.5 mm as compared with 2.7-4.2 mm), the scope of endoscopic spinal surgery has largely expanded 7) . Though infrequently, endoscopic discectomy has been adopted for the cervical and thoracic regions 2,9,23,25) .…”

“…Transforaminal discectomy at the L5/S1 level was a challenge because the working channel was interfered by the iliac crest and had a narrow foraminal space 7) . Some methods can be used to overcome this obstacle 7,8) .…”

“…Transforaminal discectomy at the L5/S1 level was a challenge because the working channel was interfered by the iliac crest and had a narrow foraminal space 7) . Some methods can be used to overcome this obstacle 7,8) . Choi et al classified the iliac crest height into six types and concluded that the transforaminal approach could be performed without difficulty when the iliac crest height is below the mid-L5 pedicle.…”

“…Migrating disk has been considered a relative contraindication of transforaminal discectomy, and an interlaminar approach is preferred 9,22) . However, with the advancement of surgical instruments and techniques, it was no longer a limitation 7) . Chen et al developed a surgical technique to deal with the downward migration of herniated disk in the transforaminal approach .…”

“…Recurrent disk herniation is the main concern in not only endoscopic discectomy but also traditional laminotomy and microdiscectomy. Some of the identified risk factors included age, upper lumbar level, herniated disk type, disk degenerative grading (based on Pfirrmann's grading system), age, early ambulation, and body mass index (BMI) 7,20,28,32) . Kim et al published an article on predicting early recurrence.…”