The modified transforaminal endoscopic technique in treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniations

Abstract

Background: To develop a modified transforaminal endoscopic spine system (TESSYS^®) technique for treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniation (ICFE-LDH), and evaluate the technical efficacy and safety.

Methods: Twenty-three patients with ICFE-LDH underwent the modified TESSYS technique were enrolled. Magnetic resonance imaging (MRI) was used to verify the reduction of herniated disc. Pre- and post-operative neurological functions were compared by visual analogue scale (VAS) score, Oswestry disability index (ODI) and the modified MacNab criteria. The technical safety was evaluated by surgical complications.

Results: MRI demonstrated reductions of disc herniations in 22 patients (95.7%) after surgeries. The VAS scores were significantly improved at 1 year follow-up (low back: P=0.001, lower limbs: P<0.001), as well as ODI scores (P<0.001). 22 patients had achieved excellent and good recovery postoperatively according to the modified MacNab criteria. One patient (4.3%) underwent a reoperation due to postoperative recurrence of disc herniation. Another patient complained postoperative causalgia in 8 weeks, the symptom alleviated after conservative treatment at 1 year follow-up (VAS: back, 3, lower limbs, 0; ODI: 20%). The incidence rate of surgical complication was 8.7%.

Conclusions: The modified TESSYS technique is a minimally-invasive, effective and safe surgery for treating ICFE-LDHs in selected patients.

Keywords: Modified transforaminal endoscopic spine system (modified TESSYS); efficacy; lumbar disc herniation; safety.

Figure 1

The modified TESSYS technique in treating ICFE-LDH. (A-C) The ICFE-LDH occurs at L4/5; (D,E) the fluoroscopic trajectory of working cannula for removing foraminal and/or extraforaminal herniated disc; (F,G) the fluoroscopic trajectory of working cannula for removing intracanalicular herniated disc. TESSYS, transforaminal endoscopic spine system; ICFE-LDH, intracanalicular combining foraminal and/or extraforaminal lumbar disc herniation.

Figure 2

The intracanalicular combining foraminal lumbar herniated discs are removed by the modified TESSYS approach. A: puncture trajectory of the modified TESSYS technique; B: the trajectory of working cannula to remove foraminal herniated disc; C: the trajectory of working cannula to remove intracanalicular herniated disc. TESSYS, transforaminal endoscopic spine system.

Figure 3

Intraoperative endoscopic imaging. (A) An existing nerve root is compressed by extraforaminal herniated disc. Arrowhead is pointing to the position of nerve root, same hereinafter; (B) revealing the existing nerve root after removal of the extraforaminal herniated disc; (C) a traversing nerve root is compressed and covered by intracanalicular herniated disc (blue-stained); (D) the traversing nerve root is free after removal of the intracanalicular herniated disc.

Figure 4

Recurrence of lumbar disc herniation after surgery. (A) Preoperative intracanalicular combining foraminal disc herniation at L4/5; (B) an existing nerve root is compressed by the postoperative recurrent herniated disc.

Figure 5

Neurofunctional outcomes at postoperative 3 months and 1 year follow-up. D-values are defined as measurement value difference, positive value is considered as improvement, negative value is considered as deterioration. At postoperative 3 months and 1 year follow-up: (A) D-value of VAS scores shows the improvements in lower limbs pain; (B) D-value of VAS scores indicates the remissions in most patients with low back pain; (C) D-value of ODI scores reveals the relief in most patients with lumbar dysfunctions; (D) 22 patients achieve neurofunctional improvements according to the modified MacNab criteria. VAS, visual analogue scale; ODI, Oswestry disability index.