Lumbar disc reherniation after transforaminal lumbar endoscopic discectomy

Abstract

Background: Transforaminal lumbar endoscopic discectomy is a minimally invasive surgical procedure that can be performed in awake patients through an incision less than 1 cm. The procedure requires very little bony removal to access the herniated disc material because the approach is through the foramen, and only a small amount of the superior articulating process is removed to access Kambin's triangle. This study describes our experience with transforaminal endoscopic lumbar decompression (TELD) for the treatment of lumbar disc herniation. We evaluate the risk for reherniation in the first year after surgery and the characteristics of the patients who experience reherniation.

Methods: We describe the technique for the transforaminal endoscopic approach to treat lumbar disc herniations. Retrospectively, a series of 141 consecutive patients, who were operated on with lumbar radiculopathy, was analyzed. We excluded patients who had previous surgery at the lumbar level, surgeries done for disease adjacent to a fusion, and surgeries done for spondylolisthesis. A total of 84 consecutive patients were included who had single level lumbar non-revision surgery and at least 1-year follow up.

Results: A series of 46 consecutive male and 38 female patients with an average age of 57.4 years (range, 28-87 years old) who underwent transforaminal endoscopic treatment for lumbar disc herniations between 2014 and 2016 is presented. Four patients required microdiscectomy due to reherniation at 5 months, 8 months, 9 months, and 10 months postoperatively. All the patients in the series improved immediately following their endoscopic procedures, and no patients presented with symptoms suggestive of reherniation until 5 months after their initial endoscopic surgery. Patients with reherniation tended to be young: 31, 45, 48, and 49 years of age: all less than the average patient age who underwent endoscopic surgery.

Conclusions: Transforaminal endoscopic surgical access to lumbar disc herniations is an ultra-minimally invasive approach for the treatment lumbar degenerative disc disease. It allows for neural decompression by removing disc and foraminal pathology with minimal bone removal. This minimal bone removal prevents iatrogenic destabilization. However, the 1-year reherniation rate presented here is 4.7%. This suggests that the benefit of this technique may be that it is ultra-minimally invasive, but it may only be equal, not superior to microdiscectomy in its rate of reherniation.

Keywords: Reherniation; TESSYS; endoscopic spine surgery; lumbar disc herniation; transforaminal.

Figure 1

Left lumbar 4–5 foraminal disc herniation in a patient with left L5 radicular symptoms. (A) Axial T2 MRI shows the L4–5 foraminal disc herniation; (B) lateral fluoroscopic view shows the beveled tubular retractor positioned in the L4–5 foramen; (C) AP fluoroscopic view shows the beveled tubular retractor in the left L4–5 foramen with a ball probe over the pedicle of L5; (D) endoscopic view of the L5 nerve root and L4–5 foraminal disc herniation (a portion of the SAP has been removed with reamers to expose the nerve and disc pathology); (E) endoscopic view of the ball probe under the nerve and over the L5 pedicle as pictured in (C); (F) endoscopic view of the Joimax semi-bendable grasper underneath the L5 nerve root removing the disc herniation.