A New Full-Endoscopic Technique for the Interlaminar Operation of Lumbar Disc Herniations Using 6-mm Endoscopes: Prospective 2-Year Results of 331 Patients

Abstract

Even with good results, conventional disc operations may result in consecutive damage due to traumatisation. Endoscopic techniques have become the standard in many areas because of the advantages they offer in surgical technique and in rehabilitation. The transforaminal operation is the most common full-endoscopic procedure in surgery of the lumbar spine. It is frequently necessary to reach the spinal canal directly in order to achieve sufficient resection of lumbar disc herniations. Even in using a lateral approach, the authors recognise the clear limitations of the transforaminal procedure. The objective of this prospective study was to examine the technical possibility of a full-endoscopic interlaminar access. The focus was on questions of sufficient decompression, as well as advantages and disadvantages of the minimally invasive procedure. 331 patients were followed for 2 years. The results show that 82 % reported no longer having leg pain, and 13 % had only occasional pain. The decompression results are equivalent to those of conventional procedures. Traumatisation of both the access pathway and the spinal canal structures was reduced. Epidural scarring was minimised. The recurrence rate was 2.4 %. No serious surgical complications were observed. The authors view the technique described, which offers the advantage of a truly minimally invasive procedure, as a sufficient and safe alternative to conventional procedures, when the appropriate indication criteria are heeded. There are technical problems because of the small instruments. In conjunction with the transforaminal procedure, this is an expansion of the spectrum for full-endoscopic surgery of lumbar disc herniations.

Key words

Endoscopic nucleotomy - interlaminar nucleotomy - minimally invasive spine surgery - lumbar disc herniation

References

• 1 Andrews D W, Lavyne M H. Retrospective analysis of microsurgical and standard lumbar discectomy.  Spine. 1990;  15 329-335
• 2 Ebeling U, Reichenberg W, Reulen H J. Results of microsurgical lumbar discectomy. Review of 485 patients.  Acta Neurochir. 1986;  81 45-52
• 3 Ferrer E, Garcia-Bach M, Lopez L. et al . Lumbar microdiscectomy: analysis of 100 consecutive cases. Its pitfalls and final results.  Acta Neurochir Suppl. 1988;  43 39-43
• 4 Hermantin F U, Peters T, Quartarato L A. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy.  J Bone Joint Surg [Am]. 1999;  81 958-965
• 5 Kotilainen E, Valtonen S. Clinical instability of the lumbar spine after microdiscectomy.  Acta Neurochir. 1993;  125 120-126
• 6 McCulloch J A. Principles of microsurgery for lumbar disc diseases. New York: Raven Press 1989
• 7 Nystrom B. Experience of microsurgical compared with conventional technique in lumbar disc operations.  Acta Neurol Scand. 1987;  76 129-141
• 8 Williams R W. Microlumbar discectomy. A 12-year statistical review.  Spine. 1986;  11 851-852
• 9 Annerzt M, Jonsson B, Stromqvist B. et al . No relationship between epidural fibrosis and sciatica in the lumbar postdiscectomy syndrome. A study with contrast-enhanced magnetic resonance imaging in symptomatic and asymptomatic patients.  Spine. 1995;  20 449-453
• 10 Fritsch E W, Heisel J, Rupp S. The failed back surgery syndrome: reasons, intraoperative findings and long term results: a report of 182 operative treatments.  Spine. 1996;  21 626-333
• 11 Krämer J. Intervertebral Disk Diseases. Stuttgart: Thieme 1990
• 12 Lewis P J, Weir B KA, Broad R W. et al . Long-term prospective study of lumbosacral discectomy.  J Neurosurg. 1987;  67 49-54
• 13 Ruetten S, Komp M, Godolias G. Spinal cord stimulation using an 8-pole electrode and double-electrode system as minimally invasive therapy of the post-discotomy and post-fusion syndrome.  Z Orthop. 2002;  140 626-631
• 14 Schoeggl A, Maier H, Saringer W. et al . Outcome after chronic sciatica as the only reason for lumbar microdiscectomy.  J Spinal Disord Tech. 2002;  15 415-419
• 15 Ruetten S, Meyer O, Godolias G. Epiduroscopic diagnosis and treatment of epidural adhesions in chronic back pain syndrome of patients with previous surgical treatment: first results of 31 interventions.  Z Orthop. 2002;  140 171-175
• 16 Abumi K, Panjabi M M, Kramer K M. et al . Biomechanical evaluation of lumbar spinal stability after graded facetectomies.  Spine. 1990;  15 1142-1147
• 17 Haher T R, O'Brien M, Dryer J W. et al . The role of the lumbar facet joints in spinal stability. Identification of alternative paths of loading.  Spine. 1994;  19 2667-2670
• 18 Hopp E, Tsou P M. Post-decompression lumbar instability.  Clin Orthop. 1988;  227 143-151
• 19 Kaigle A M, Holm S H, Hansson T H. Experimental instability in the lumbar spine.  Spine. 1995;  20 421-430
• 20 Kato Y, Panjabi M M, Nibu K. Biomechanical Study of lumbar spinal stability after osteoplastic laminectomy.  J Spinal Disord. 1998;  11 146-150
• 21 Kotilainen E. Clinical instability of the lumbar spine after microdiscectomy. In: Gerber BE, Knight M, Siebert WE (eds). Lasers in the musculoskeletal system. Berlin, Heidelberg, New York: Springer 2001: 241-243
• 22 Sharma M, Langrana N A, Rodrigues J. Role of ligaments and facets in lumbar spinal stability.  Spine. 1995;  20 887-900
• 23 Cooper R, Mitchell W, Illimgworth K. et al . The role of epidural fibrosis and defective fibrinolysis in the persistence of postlaminectomy back pain.  Spine. 1991;  16 1044-1048
• 24 Waddell G, Reilly S, Torsney B. et al . Assessment of the outcome of low back surgery.  J Bone Joint Surg [Br]. 1988;  70 723-727
• 25 Hedtmann A. The so-called post-discotomy syndrome - failure of intervertebral disc surgery?.  Z Orthop. 1992;  130 456-466
• 26 Kim S S, Michelsen C B. Revision surgery for failed back surgery syndrome.  Spine. 1992;  17 957-960
• 27 Parke W W. The significance of venous return in ischemic radiculopathy and myelopathy.  Orhop Clin North Am. 1991;  22 213-220
• 28 Schick U, Doehnert J, Richter A. et al . Microendoscopic lumbar discectomy versus open surgery: an intraoperative EMG study.  Eur Spine. 2002;  11 20-26
• 29 Weber B R, Grob D, Dvorak J. et al . Posterior surgical approach to the lumbar spine and its effect on the multifidus muscle.  Spine. 1997;  22 1765-1772
• 30 Devulder J, De Laat M, Van Batselaere M. et al . Spinal cord stimulation: a valuable treatment for chronic failed back surgery patients.  J Pain Symptom Manage. 1997;  13 296-301
• 31 Rainov N G, Heidecke V, Burkert W. Short test-period spinal cord stimulation for failed back surgery syndrome.  Minim Invas Neurosurg. 1996;  39 41-44
• 32 Maroon J C. Current concepts in minimally invasive discectomy.  Neurosurgery. 2002;  51 137-145
• 33 Adson A W, Ott W O. Results of the removal of tumors of the spinal cord.  Arch Neurol Psychiatry. 1922;  8 520-538
• 34 Bucy P C. Chondroma of intervertebral disc.  JAMA. 1930;  94 1552
• 35 Mixter W J, Barr J S. Rupture of the intervertebral disc with involvement of the spinal canal.  N Engl J Med. 1934;  211 205-210
• 36 Putti V. Pathogenesis of sciatic pain.  Lancet. 1927;  2 53
• 37 Steinke C R. Spinal tumors: Statistics on a series of 330 collected cases.  J Nerv Ment Dis. 1918;  47 418-426
• 38 Stookey B. Compression of spinal cord due to ventral extradural chondromas: diagnosis and surgical treatment.  Arch Neurol Psychiatry. 1928;  20 275-291
• 39 Hult L. Retroperitoneal disc fenestration in low back pain and sciatica.  Acta Orthop Scand. 1956;  20 342-348
• 40 Smith L, Gorvin P J, Gesler R M. et al . Enzyme dissolution of the annulus pulposus.  Nature. 1963;  198 1311-1312
• 41 Gottlob C, Kopchok G, Peng S H. et al . Holmium:YAG laser ablation of human intervertebral disc: Preliminary evaluation.  Lasers Surg Med. 1992;  12 86-91
• 42 Hijikata S. Percutaneous discectomy: a new treatment method for lumbar disc herniation.  J Toden Hosp. 1975;  5 5-13
• 43 Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine: a preliminary report.  Clin Orthop. 1983;  174 127-132
• 44 Maroon J C, Onik G, Sternau L. Percutaneous automated discectomy: a new approach to lumbar surgery.  Clin Orthop. 1989;  238 64-70
• 45 Onik G, Helms C, Ginsburg L. et al . Percutaneous lumbar discectomy using a new aspiration probe.  Am J Roentgenol. 1985;  144 1137-1140
• 46 Valls J, Ottolenghi C E, Schajowicz F. Aspiration biopsy in diagnosis of lesions of vertebral bodies.  JAMA. 1948;  136 376
• 47 Forst R, Hausmann G. Nucleoscopy: A new examination technique.  Arch Orthop Trauma Surg. 1983;  101 219-221
• 48 Epstein J, Adler R. Laser-assisted percutaneous endoscopic neurolysis.  Pain Physician. 2000;  3 43-45
• 49 Ruetten S, Meyer O, Godolias G. Application of holmium:YAG laser in epiduroscopy: extended practicabilities in the treatment of chronic back pain syndrome.  J Clin Laser Med Surg. 2002;  20 203-206
• 50 Kambin P, Casey K, O'Brien E. et al . Transforaminal arthroscopic decompression of the lateral recess stenosis.  J Neurosurg. 1996;  84 462-467
• 51 Kambin P, O'Brien E, Zhou L. et al . Arthroscopic microdiscectomy and selective fragmentectomy.  Clin Orthop. 1998;  347 150-167
• 52 Kambin P, Sampson S. Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs: Report of interim results.  Clin Orthop. 1986;  207 37-43
• 53 Kambin P, Zhou L. History and current status of percutaneous arthroscopic disc surgery.  Spine. 1996;  21 57-61
• 54 Kambin P. Arthroscopic microdiscectomy. Baltimore: Urban & Schwarzenberg 1991
• 55 Lew S M, Mehalic T F, Fagone K L. Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations.  J Neurosurg. 2001;  94 216-220
• 56 Mathews H H. Transforaminal endoscopic microdiscectomy.  Neurosurg Clin North Am. 1996;  7 59-63
• 57 Mayer H M, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy.  J Neurosurg. 1993;  78 261
• 58 Savitz M H. Same-day microsurgical arthroscopic lateral-approach laser-assisted (SMALL) fluoroscopic discectomy.  J Neurosurg. 1994;  80 1039-1045
• 59 Siebert W. Percutaneous nucleotomy procedures in lumbar intervertebral disc displacement.  Orthopade. 1999;  28 598-608
• 60 Stücker R. The transforaminal endoscopic approach. In: Mayer HM (ed). Minimally invasive spine surgery. Berlin, Heidelberg, New York: Springer 2000: 201-206
• 61 Tsou P M, Yeung A T. Transforaminal endoscopic decompression for radiculopathy secondary to intracanal noncontained lumbar disc herniations: outcome and technique.  Spine J. 2002;  2 41-48
• 62 Yeung A T, Tsou P M. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome and complications in 307 consecutive cases.  Spine. 2002;  27 722-731
• 63 Caspar W. A new surgical procedure for lumbar disc herniation causing less tissue damaging through a microsurgical approach. In: Wüllenweber R, Brock M (eds). Advances in Neurosurgery. Berlin: Springer 1977 Vol 7: 74-77
• 64 Goald H J. Microlumbar discectomy - Follow-up of 147 patients.  Spine. 1978;  3 183-185
• 65 Goald H J. Microlumbar discectomy: follow-up of 477 patients.  J Microsurg. 1981;  2 95-100
• 66 Wilson D H, Kenning J. Microsurgical lumbar discectomy: preliminary report of 83 consecutive cases.  Neurosurgery. 1979;  42 137-140
• 67 Brayda-Bruno M, Cinnella P. Posterior endoscopic discectomy (and other procedures).  Eur Spine J. 2000;  9 S24-S29
• 68 Destandau J. A special device for endoscopic surgery of lumbar disc herniation.  Neurol Res. 1999;  21 39-42
• 69 Nakagawa H, Kamimura M, Uchiyama S. et al . Microendoscopic discectomy (MED) for lumbar disc prolapse.  J Clin Neurosci. 2003;  10 231-235
• 70 Perez-Cruet M J, Foley K T, Isaacs R E. et al . Microendoscopic lumbar discectomy: technical note.  Neurosurgery. 2002;  51 129-136
• 71 Andersson G BJ, Brown M D, Dvorak J. et al . Consensus summary on the diagnosis and treatment of lumbar disc herniation.  Spine. 1996;  21 75-78
• 72 McCulloch J A. Focus issue on lumbar disc herniation: macro- and microdiscectomy.  Spine. 1996;  21 45-56
• 73 Daltroy L H, Cats-Baril W L, Katz J N. et al . The North American Spine Society (NASS) Lumbar Spine Outcome Instrument: Reliability and validity tests.  Spine. 1996;  21 741-749
• 74 Pose B, Sangha O, Peters A. et al . Validation of the North American Spine Society Instrument for assessment of health status in patients with chronic backache.  Z Orthop. 1999;  137 437-441
• 75 Fairbank J CT, Couper J, Davies J B. et al . The Oswestry low back pain questionnaire.  Physiotherapy. 1980;  66 271-273
• 76 Ebara S, Harada T, Hosono N. et al . Intraoperative measurement of lumbar spinal instability.  Spine. 1992;  17 44-50
• 77 Faulhauer K, Manicke C. Fragment excision versus conventional disc removal in the microsurgical treatment of herniated lumbar disc.  Acta Neurochir. 1995;  133 107-111
• 78 Goel V K, Nishiyama K, Weinstein J N. et al . Mechanical properties of lumbar spinal motion segments as affected by partial disc removal.  Spine. 1986;  11 1008-1012
• 79 Iida Y, Kataoka O, Sho T. et al . Postoperative lumbar spinal instability occurring or progressing secondary to laminectomy.  Spine. 1990;  15 1186-1189
• 80 Johnsson K E, Redlund-Johnell I, Uden A. et al . Preoperative and postoperative instability in lumbar spinal stenosis.  Spine. 1989;  14 591-593
• 81 Kambin P, Cohen L, Brooks M L. et al . Development of degenerative spondylosis of the lumbar spine after partial discectomy: comparison of laminotomy, discectomy and posterolateral discectomy.  Spine. 1994;  20 599-607
• 82 Mochida J, Nishimura K, Nomura T. et al . The importance of preserving disc structure in surgical approaches to lumbar disc herniation.  Spine. 1996;  21 1556-1564
• 83 Mochida J, Toh E, Nomura T. The risks and benefits of percutaneous nucleotomy for lumbar disc herniation. A 10-year longitudinal study.  J Bone Joint Surg [Br]. 2001;  83 501-505
• 84 Natarajan R N, Andersson G B, Padwardhan A G. et al . Study on effect of graded facetectomy on change in lumbar motion segment torsional flexibility using three-dimensional continuum contact representation for facet joints.  J Biomech Eng. 1999;  121 215-221
• 85 Ross J S, Robertson J T, Frederickson R C. et al . Association between peridural scar and recurrent radicular pain after lumbar discectomy: Magnetic resonance evaluation.  Neurosurgery. 1996;  38 861-863
• 86 Zander T, Rohlmann A, Kloeckner C. et al . Influence of graded facetectomy and laminectomy on spinal biomechanics.  Eur Spine J. 2003;  12 427-434
• 87 Caspar W, Campbell B, Barbier D D. et al . The Caspar microsurgical discectomy and comparison with a conventional standard lumbar disc procedure.  Neurosurgery. 1991;  28 78-87
• 88 Mayer H M. The microsurgical interlaminar, paramedian approach. In: Mayer HM (ed). Minimally Invasive Spine Surgery. Berlin, Heidelberg, New York: Springer 2000: 79-91
• 89 Ramirez L F, Thisted R. Complications and demographic characteristics of patients undergoing lumbar discectomy in community hospitals.  Neurosurgery. 1989;  25 226-231
• 90 Rantanen J, Hurme M, Falck B. et al . The lumbar multifidus muscle five year after surgery for a lumbar intervertebral disc herniation.  Spine. 1993;  18 568-574
• 91 Rompe J D, Eysel P, Zollner J. et al . Intra- and postoperative risk analysis after lumbar intervertebral disk operation.  Z Orthop. 1999;  137 201-205
• 92 Stolke D, Sollmann W P, Seifert V. Intra- and postoperative complications in lumbar disc surgery.  Spine. 1989;  14 56-59
• 93 Wildfoerster U. Intraoperative complications in lumbar intervertebral disc operations. cooperative study of the spinal study group of the German Society of Neurosurgery.  Neurochirurgica. 1991;  34 53-56
• 94 Wilson D H, Harbaugh R. Lumbar discectomy: a comparative study of microsurgical and standard technique. In: Hardy RW (ed). Lumbar disc disease. New York: Raven Press 1992: 147-156
• 95 Donceel P, Du Bois M. Fitness for work after lumbar disc herniation: a retrospective study.  Eur Spine. 1998;  7 29-35
• 96 Balderston R A, Gilyard G G, Jones A M. et al . The treatment of lumbar disc herniation: simple fragment excision versus disc space curettage.  J Spinal Disord. 1991;  4 22-25
• 97 Aydin Y, Ziyal I M, Dumam H. et al . Clinical and radiological results of lumbar microdiscectomy technique with preserving of ligamentum flavum comparing to the standard microdiscectomy technique.  Surg Neurol. 2002;  57 5-13
• 98 Ruetten S, Meyer O, Godolias G. Endoscopic surgery of the lumbar epidural space (epiduroscopy): results of therapeutic intervention in 93 patients.  Minim Invas Neurosurg. 2003;  46 1-4
• 99 Knight M TN, Goswami A, Patko J T. Endoscopic foraminiplasty: a prospective study on 250 consecutive patients with independent evaluation.  J Clin Laser Med Surg. 2001;  19 73-81
• 100 Saberski L R, Kitahata L M. Persistent radiculopathy diagnosed and treated with epidural endoscopy.  J Anesth. 1996;  10 1-4
• 101 Boyer P, Srour R, Buchheit F. et al . Lumbar disc hernia. Excision of hernia with or without complementary discectomy?.  Neurochirurgie. 1994;  40 259-262
• 102 Hirabayashi S, Kumano K, Ogawa Y. et al . Microdiscectomy and second operation for lumbar disc herniation.  Spine. 1993;  18 2206-2211
• 103 Stambough J L. Lumbar disk herniation: an analysis of 175 surgically treated cases.  J Spinal Disord. 1997;  10 488-492
• 104 Wenger M, Mariani L, Kalbarczyk A. et al . Long-term outcome of 104 patients after lumbar sequestrectomy according to Williams.  Neurosurgery. 2001;  49 329-334
• 105 Zollner J, Rosendahl T, Herbsthofer B. et al . The effect of various nucleotomy techniques on biomechanical properties of the intervertebral disc.  Z Orthop. 1999;  137 206-210
• 106 Suk K S, Lee H M, Moon S H. et al . Recurrent lumbar disc herniation: results of operative management.  Spine. 2001;  26 672-676
• 107 De Devitiis E, Cappabianca P. Lumbar discectomy with preservation of the ligamentum flavum.  Surg Neurol. 2002;  58 68-69