Two-level percutaneous endoscopic lumbar discectomy for highly migrated upper lumbar disc herniation: A case report.

BACKGROUND: The technique of percutaneous endoscopic lumbar discectomy (PELD) as a transforaminal approach has been used to treat highly migrated lower lumbar disc herniations. However, due to the different anatomic characteristics of the upper lumbar spine, conventional transforaminal PELD may fail to remove the highly migrated upper lumbar disc nucleus pulposus. Therefore, the purpose of this study was to describe a novel surgical technique, two-level PELD, for the treatment of highly migrated upper lumbar disc herniations and to report its related clinical outcomes. CASE SUMMARY: A 60-year-old male presented with a complaint of pain at his lower back and right lower limb. The patient received 3 mo of conservative treatments but the symptoms were not alleviated. Physical examination revealed a positive femoral nerve stretch test and a negative straight leg raise test for the right leg, and preoperative visual analog scale (VAS) score for the lower back was 6 points and for the right leg was 8 points. Magnetic resonance imaging (MRI) demonstrated L2-L3 disc herniation on the right side and the herniated nucleus pulposus migrated to the upper margin of L2 vertebral body. According to physical examination and imaging findings, surgery was the primary consideration. Therefore, the patient underwent surgical treatment with two-level PELD. The pain symptom was relieved and the VAS score for back and thigh pain was one point postoperatively. The patient was asymptomatic and follow-up MRI scan 1 year after operation revealed no residual nucleus pulposus. CONCLUSION: Two-level PELD as a transforaminal approach can be a safe and effective procedure for highly migrated upper lumbar disc herniation.

Efficacy of Transforaminal Epidural Steroid Injections According to Nerve Root Enhancement

OBJECTIVE: To determine the efficacy of transforaminal epidural steroid injections according to nerve root enhancement in lumbar disc herniations. METHOD: Twenty seven patients who had extruded or seques tered lumbar disc herniations on enhanced MR imaging were investigated: fifteen patients with corresponding nerve root enhancement (enhanced group), and twelve patients without enhancement (non-enhanced group). All patients received transforaminal epidural steroid injection. Clinical outcomes were measured by visual analogue scale (VAS) for back and radicular pain, Oswestry disability index (ODI) before treatment and one month after injection. RESULTS: The averages of VAS for lower extremity and back pain in both groups one month after injection significantly reduced compared to that of pretreatment, respectively (p<0.001). The amount of decrease in pain in enhanced group was larger than that of non-enhanced group (p<0.05). The averages of ODI in both group one month after injection significantly reduced compared to that of pretreatment (p<0.0001), however, there was no difference between the two groups. CONCLUSION: The nerve root enhancement on contrast-enhanced MR imaging indicates the presence of severe inflammatory reaction of nerve root, which means well-responsiveness to anti-inflammatory treatment such as transforaminal epidural steroid injection, even if patients' symptom is very severe.

Effect of Intensive Conservative Treatment on Extraforaminal Lumbar Disc Herniations - 1 Year Prospective Follow-up Study

OBJECTIVE: To evaluate the outcomes of intensive conservative treatment on extraforaminal lumbar disc herniations. METHOD: Twenty five patients with extraforaminal lumbar disc herniations with symptomatic radicular pain were included. Under fluoroscopic guidance, 40 mg of triamcinolone was infused around the nerve root after provocation of patient's usual radicular pain. Lumbosacral dynamic stabilization exercise, thermal and electrical therapy, and education of posture correction were added. The clinical outcomes were measured by visual analogue scale (VAS) and Oswestry disability index (ODI) before treatment, one, three, six, and twelve months after the treatment. After twelve months, patients' satisfaction was classified to four categories: excellent, good, fair, or poor. Four patients were dropped out. RESULTS: Follow-up VAS and ODI significantly decreased since post-treatment one month (p<0.0001). The average score of VAS for lower extremity and back pain reduced significantly from 6.6, 4.5 at pretreatment to 1.5, 1.9 at 12 months post-treatment, respectively (p<0.0001). The averages of ODI reduced significantly from 65.4% at pretreatment to 25.4% at post-treatment 12 months (p<0.0001). In patients' satisfaction, seventeen patients (81.0%) were recorded as excellent or good after post-treatment 12 months. CONCLUSION: Intensive conservative treatment was effective on patients who underwent extraforaminal lumbar disc herniation. Pain relief and functional improvement sustained for 12 months.

The Prevention and Management of the Complications of translaminar Microendoscopic Discectomy / 中国微创外科杂志

Objective To study the complications of translaminar microendoscopic discectomy and their prevention and management. Methods The complications of translaminar microendoscopic discectomy performed on 487 cases of lumbar disc herniations were retrospectively analyzed. Results Most of the complications were seen in the first 50 cases, which included intraoperative CSF leak (8 cases, 1.64% ), cauda equina damage (1 case,0.21%) nerve root damage (1 case,0.21%) and inflammation of intervertebral disc (1 case,0.21%). Three patients (0.62%) converted into standard open lumbar disc surgery because epidural bleeding was difficult to control under endoscope. Conclusions There is a direct correlation between the compliations and the clinical experience in this technique. The complications of translaminar microendoscopic discectomy at the early stage are significantly higher than those of open techniques, but they are rarely seen at the later stage.

Clinical Study of Percutaneous Laser Disc Decompression (A Report of 66 Cases) / 实用放射学杂志

Objective To study of percutaneous laser disc decompression(PLDD)in the patients of lumbar disc herniations.Methods 66 patients were treated with PLDD.The mean age of the 48 male and 18 female patients was 39.3 years old.Results 58 patients of all,or 87.9% showed excellent or good result.15 patients(78.9%)showed excellent and 2 patients(10.5%) were good,2 patients(10.6%) were fair or poor under 30 year old.15 patients(44.1%)showed excellent and 17(50.5%)patients were good,2(5.9%)patients were fair in 31~50 years old.2(15.4%) patients showed excellent and 7(53.8%)patients were good,4(29.8%)patients were fair or poor over 51 years old.Conclusion PLDD is safe and convenient method of treating lumbar disc herniations.

Clinical Analysis of the Automated Percutaneous Discectomy

A retrospective study was performed in order to evaluate the efficacy of automated percutaneous discectomy in lumbar disc herniations that were treated in our institute between May, 1992 and December, 1994. Of the 68 patients that were followed up for 12 weeks, the success rate was 82% according to Onik classification. No serious complications, vascular or nerve damage and discitis, were noted except transient postoperative muscular spasms. The results of this study indicates that automated percutaneous discectomy can be used successfully to treat lumbar disc herniations with minimal morbidity and also emphasized the need for proper patient selection prior to performing the automated percutaneous discectomy.

Clinical application of percutaneous lumbar puncture to treat sciatica caused by lumbar disc herniation under CT guidance / 介入放射学杂志

Objective To evaluate the effect of the percutaneous lumbar puncture to treat sciatica caused by lumbar disc herniation.Methods 75 cases of lumbar disc herniation with significant clinical signs were confirmed by CT scan. The technique of the percutaneous lumbar puncture led the needle to approach nerve root and injected medicine diffusing into extraduramater, and then relieved the symptom of sciatica. Results The rate of success of percutaneous lumbar puncture guided by CT reached to 100%. After two weeks of follow up, the symptom of pain was obviously improved and disappeared in 63.3% cases. There were 23.0% cases needed a second proceduse, and no change was obsesved in 9.3% cases.Conclusions The percutaneous lumbar puncture guided by CT to treat sciatica resulted from lumbar disc herniation is one of the safe ,reliable,effective new methods with no complication. The long term effectiveness is still in need of investigation.