Treatment of high-iliac-crest L5-S1 lumbar disc herniation via a transverse process endoscopic transforaminal approach

https://doi.org/10.1016/j.clineuro.2020.106087Get rights and content

Highlights

  • Percutaneous endoscopic transforaminal discectomy (PETD) is difficult for L5-S1 lumbar disc herniation with a high iliac crest and a hypertrophic transverse process.

  • In this study, an innovative transverse process endoscopic transforaminal approach was used to treat high-iliac-crest L5-S1 lumbar disc herniation.

  • The TOMshidi locator was positioned at the base of the L5 transverse process and advanced through the transverse process and articular process until reaching the posterior upper edge of the vertebral body of S1.

  • For these patients, the transverse process transforaminal approach is a safe and effective surgical method.

Abstract

Objective

To investigate the clinical efficacy of transverse process endoscopic transforaminal discectomy for the treatment of high-iliac-crest L5-S1 lumbar disc herniation.

Methods

Seventeen patients with high-iliac-crest L5-S1 lumbar disc herniation who were treated with transforaminal endoscopy from April 2016 to January 2019 in the Department of Neurosurgery of Xuanwu Hospital were selected. The visual analog scale (VAS) and Oswestry disability index (ODI) were used to evaluate the efficacy of the procedure.

Results

All of the patients successfully underwent the surgical treatment. Sixteen patients (94.1 %) completed effective follow-up for more than 12 months. The VAS was 7.8 ± 1.9, 2.9 ± 1.6, 2.3 ± 1.5 and 2.2 ± 1.6 before surgery and at one day, 3 months, and the last follow-up after surgery, respectively. The ODI scores were 52.8 ± 15.2 and 16.9 ± 9.7 before surgery and 3 months after surgery, respectively, both of which were lower than before surgery (both P < 0.01).

Efficacy evaluation

An excellent outcome was achieved in 13 (81.3 %) patients, a good outcome in 1 patient (6.3 %), an acceptable outcome in 1 patient (6.3 %), and a poor outcome in 1 patient (6.3 %).

Conclusions

The transverse process endoscopic transforaminal discectomy is a safe and effective surgical method for the treatment of high-iliac-crest L5-S1 lumbar disc herniation.

Introduction

Percutaneous endoscopic transforaminal discectomy (PETD) for the treatment of lumbar disc herniation has the advantages of less trauma, less impact on spinal stability and well-accepted efficacy and has been widely chosen in the clinic [[1], [2], [3]]. However, for L5-S1 lumbar disc herniation, especially with a high iliac crest and a hypertrophic transverse process, surgery via the transforaminal approach is difficult, with a long operative time and increased numbers of fluoroscopies, and it can even fail [4]. Percutaneous endoscopic interlaminar discectomy (PEID) is a surgical approach without obstruction by the iliac crest, but it has been associated with higher incidence of early nerve injury and difficulty managing lateral and extreme lateral disc herniation [5,6]. Some researchers have used the transiliac approach to manage L5-S1 lumbar disc herniation, and it can directly create a working channel near the target site [7,8]. However, the transiliac approach is a difficult approach with a relatively long operative time, and it has not become popular. In this study, the transverse process endoscopic transforaminal approach was used to treat high-iliac-crest L5-S1 lumbar disc herniation. The operational recommendations and clinical efficacy of this approach are discussed through a summary and analysis of the clinical data of the patients.

Section snippets

Patient population

Seventeen patients with high-iliac-crest L5-S1 lumbar disc herniation who were treated with the transverse process endoscopic transforaminal approach from April 2016 to January 2019 in Department of Neurosurgery of Xuanwu Hospital were selected. There were 10 men and 7 women with an average age of 48.6 years old (range: 31–78 years), the body mass index (BMI) were 26.18 ± 3.25. The duration of disease was between 2 and 28 months, with an average of 7.3 months (range: 2–28). Clinical

Surgical outcomes

All 17 patients underwent PETD. (A patient is shown in Fig. 3.) The mean operative time was 89.3 ± 24.3 min (range: 58−145 min). The intraoperative blood loss was negligible and was therefore not evaluated. The mean number of intraoperative radiographies was 30.2 ± 13.7 (range: 16–63). The mean postoperative length of bed rest was 4.8 ± 1.3 h (range: 4−8 h).

Complications

A dural tear appeared intraoperatively in 1 patient (5.9 %), and the patient presented no symptoms. Lower-limb numbness appeared in 1

PETD and PEID for the treatment of L5-S1 disc herniation

With the improvement in spinal endoscopy, the efficacy of PETD in the treatment of lumbar disc herniation has been comparable to that of open surgery. Moreover, PETD has the advantages of less surgical trauma, quick postoperative recovery, and no adverse effects on spine stability [9,10]. In the case of L5 to S1 disc herniation, it is difficult to perform PETD in this segment due to obstruction of the ala of the ilium and the hypertrophic transverse process and the smaller intervertebral

Conclusion

For patients with L5 to S1 lumbar disc herniation with a high iliac crest and enlarged transverse process, the transverse process transforaminal approach can be used to create an ideal working channel and is a safe and effective surgical method.

CRediT authorship contribution statement

Zuowei Wang: Formal analysis, Methodology, Data curation. Zan Chen: Investigation, Resources. Hao Wu: Investigation, Resources. Xingwen Wang: Software, Data curation, Formal analysis. Kai Wang: Formal analysis, Data curation. Wanru Duan: Formal analysis, Data curation. Jian Guan: Writing - review & editing. Zhenlei Liu: Writing - original draft. Fengzeng Jian: Conceptualization, Methodology, Validation.

Acknowledgement

The authors would like to acknowledge Baohua Xie for their help to the study.

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