Foraminoplastic ventral epidural approach for removal of extruded herniated fragment at the L5-S1 level.

The 'foraminoplastic' ventral epidural approach and its advantages in the treatment of extruded disk herniation at the L5-S1 level are described. Percutaneous endoscopic lumbar discectomy is a minimally invasive procedure applicable to various types of lumbar disk herniation, but the L5-S1 disk space is still challenging to access due to anatomic limitations such as high iliac crest or severely narrowed foramen. The 'foraminoplastic' ventral epidural approach was performed in 25 patients with herniated disk radiculopathy at L5-S1 from March 2003 to May 2004. Their mean age was 39.2 years (range 20-67 years) and the mean follow-up duration was 32.5 months (range 28-42 months). During the procedure, 'foraminoplasty' was performed by undercutting the hypertrophic superior facet with the endoscopic bone cutter under C-arm guidance. The clinical result was assessed according to the visual analogue scale (VAS) and Oswestry disability index (ODI). Preoperative mean VAS score of 7.4 for leg pain fell to 1.6 postoperatively and mean preoperative ODI of 55.5% improved to 16.9% postoperatively, both showing significant improvements (p < 0.001). Mean hospital stay was 14.2 hours. Twenty-two patients had the favorable outcomes. Two patients required conversion to open microdiscectomy due to incomplete decompression and recurrent disk herniation. The 'foraminoplastic' approach is a safe and efficient surgical option for L5-S1 disk herniation even in patients with high iliac crest and narrow foramen.

Comparative study of neck pain in relation to increase of cervical epidural pressure during percutaneous endoscopic lumbar discectomy.

STUDY DESIGN: A prospective study. OBJECTIVE: By monitoring cervical epidural pressure (EP) changes throughout the procedure, we intend to discover the effect of percutaneous endoscopic lumbar discectomy (PELD) on cervical epidural pressure and whether there is a correlation between posterior neck pain and increased cervical EP, which is known to have a linear correlation with intracranial pressure (ICP). SUMMARY OF BACKGROUND DATA: Patients sometimes complain of posterior neck pain during PELD. Due to the massive irrigation fluid used during the procedure, the possibility of increased ICP as the cause is quite strong. METHODS: Twenty-eight patients undergoing PELD with ASA physical status 1 or 2 were enrolled in this study. In all patients, a cervical epidural catheter was placed at the C6-C7 level before the procedure and was connected to a pressure transducer. Cervical EPs were monitored continuously throughout the procedure. Initial stabilized EP (EP), EP at the time of neck pain, maximal EP during the procedure, and EP at the end of the procedure were checked. Neck pain onset time from the beginning of irrigation and total irrigation time were also checked. RESULTS: Of 28 patients, 8 patients complained of neck pain. Neck pain onset time from the beginning of irrigation was 35.6 +/- 11.3 (mean +/- SD) minutes. The EP at the time of neck pain (52.9 +/- 9.2 mm Hg) was significantly higher than the maximal EP in patients without neck pain (34.8 +/- 14.7 mm Hg). In all patients who complained of neck pain, the cervical EP at the time of neck pain showed pressures above 37 mm Hg. The maximal EP in those with neck pain (73.6 +/- 25.8 mm Hg) was also significantly higher than the EP in those without neck pain (34.8 +/- 14.7 mm Hg). In a correlation study, patients with higher maximal EPs had higher probabilities of having neck pain. In 6 of 8 patients, an abrupt increase in EP was observed after the onset of neck pain, while in the other 2 patients, the procedure ended just after neck pain appeared. CONCLUSION: Neck pain occurring during PELD is associated with a highly increased cervical EP generated by continuous infusion.

Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope.

STUDY DESIGN: A retrospective analysis of 59 patients operated for excision of soft highly migrated intracanal lumbar disc herniations by percutaneous endoscopic foraminoplasty. OBJECTIVE: To describe a safe and effective percutaneous endoscopic technique for removal of migrated herniations and report the results on the basis of modified MacNab criteria. SUMMARY OF BACKGROUND DATA: Migrated herniations pose a great challenge even for experienced endoscopic surgeons. These herniations are hidden from the endoscopic view by anatomic barriers like hypertrophied facet, inferior pedicle and foraminal ligaments rendering percutaneous endoscopic transforaminal lumbar discectomy (PELD) by conventional approach, difficult with high failure rate. Foraminoplasty, which means enlargement of foramen by undercutting ventral part of superior-facet, upper border of inferior pedicle along with ablation of foraminal ligament, can help us to address this issue. METHODS: Fifty-nine patients with soft highly migrated herniations who underwent PELD with foraminoplasty under local anesthesia from January 2002 to June 2006 were analyzed retrospectively. Patients were evaluated by postoperative Visual Analog Scale for leg pain and Oswestry Disability Index scores. Outcomes were graded according to modified MacNab criteria. RESULTS: Mean follow-up was 25.4 months. Mean visual analog scale score for radicular pain improved from 8.01 to 1.56, and mean Oswestry disability Index improved from 61.6 to 10.76. Based on modified MacNab criteria, 91.4% of patients experienced satisfactory outcome. Three patients had persistent leg pain after surgery. One patient underwent a repeat-PELD on next day and the other after 1 month. Both were relieved of symptoms. Third patient was subjected to open discectomy after 25 weeks from the first operation and showed improvement. Two patients had recurrent herniation at same level after 6 months; 1 patient underwent repeat PELD, and the other underwent open discectomy. Both patients had good results. CONCLUSION: Foraminoplastic-PELD is safe and effective procedure for surgical treatment of soft migrated herniations. The results are comparable to results of open discectomy.

An oblique paraspinal approach for intracanalicular disc herniations of the upper lumbar spine: technical case report.

OBJECTIVE: To present our experience of treating the central or paramedian disc herniations of the upper lumbar levels through a paraspinal approach. CLINICAL PRESENTATION: We present four patients with intracanalicular disc herniations at the L1-L2 or L2-L3 level. All patients had unilateral or bilateral radicular leg pain and motor weakness. TECHNIQUE: Considering the unique characteristics of the upper lumbar spine, we performed the oblique paraspinal approach to expose the central portion of disc and removed the herniated disc effectively. Postoperatively, their symptoms were improved. There was no instability during the follow-up period. CONCLUSION: The oblique paraspinal approach for the treatment of central disc herniations at the upper lumbar levels is an effective nonfusion technique that preserves most of the facet joint and provides a wide surgical field.