The Evolution of Transforaminal Endoscopic Spine Surgery

A prospective randomized study involving 280 consecutive cases of lumbar disc herniation managed either by an endoscopic discectomy alone or an endoscopic discectomy combined with an intradiscal injection of a low dose (1000 U) of chymopapain. To compare outcome, complications, and reherniations of both techniques. Despite a low complication rate, posterolateral endoscopic nucleotomy has made a lengthy evolution because of an assumed limited indication. Chemonucleolysis, however, proven to be safe and effective, has not continued to be accepted by the majority in the spinal community as microdiscectomy is considered to be more reliable. A total of 280 consecutive patients with a primary herniated, including sequestrated, lumbar disc with predominant leg pain, was randomized. A clinical follow-up was performed at 3 months, and at 1 and 2 years after the index operation with an extensive questionnaire, including the visual analog scale for pain and the MacNab criteria. The cohort integrity at 3 months was 100%, at 1 year 96%, and at 2 years 92%. At the 3-month evaluation, only minor complications were registered. At 1-year postoperatively, group 1 (endoscopy alone) had a recurrence rate of 6.9% compared to group 2 (the combination therapy), with a recurrence rate of 1.6%, which was a statistically significant difference in favor of the combination therapy (P = 0045). At the 2-year follow-up, group 1 reported that 85.4% had an excellent or good result, 6.9% a fair result, and 7.7% were not satisfied. At the 2-year follow-up, group 2 reported that 93.3% had an excellent or good result, 2.5% a fair result, and 4.2% were not satisfied. This outcome was statistically significant in favor of the group including chymopapain. There were no infections or patients with any form of permanent iatrogenic nerve damage, and no patients had a major complication. A high percentage of patient satisfaction could be obtained with a posterior lateral endoscopic discectomy for lumbar disc herniation, and a statistically significant improvement of the results was obtained when an intradiscal injection of 1000 U of chymopapain was added. There was a low recurrence rate with no major complications. The method can be applied in any type of lumbar disc herniation, including the L5-S1 level.

Removal of a sequestered lumbar disk; in instances of foraminal stenosis a decompression (foraminoplasty) can also be performed. The objective is to restore the best possible pain-free function of the spinal column. Prolapsed lumbar vertebral disk, sequestered caudally or cranially, that is no longer responding to nonoperative treatment. Cauda equina syndrome. Sequestered herniated lumbar disk posterior to the dura mater. Lateral decubitus on a radiolucent table allowing the use of an image intensifier. The usual access to a sequester at segments L5/S1 and L4/5 is approximately 12-14 cm lateral to the midline, at segments L3/4 and L2/3 approximately 10 cm lateral to the midline. In the case of sequestration in a cranial direction a somewhat smaller angle of access should be chosen, for caudal displacement the angle should be greater. Reaming of a lateral transforaminal approach to the spinal canal. The sequester is removed endoscopically through a working cannula. The patient remains in the recovery room for approximately 2 h, is fitted with a brace and transferred to the ward. No medicinal thrombosis prophylaxis. Follow-up examination the next morning. Physiotherapy after 1 week. The brace is worn for approximately 2-6 weeks. MRI checkup and after 3 months evaluation of the development of strength and the state of the back musculature. Between January 1999 and January 2002, 611 patients underwent surgery, 32% women and 68% men, age between 18 and 65 years (average age 43.8 years). Clinical follow-up examinations were carried out after 3 months, follow-ups with questionnaire after 1 and 2 years. The evaluation criteria were based on an own questionnaire, and also on MacNab's score and the visual analog scale (VAS). After 2 years 558 patients (91.2%) responded to the questionnaires. Excellent or good results were achieved in 95.3% of the patients. 74.7% were very satisfied, 20.6% satisfied. The result was judged unsatisfactory by 4.7% of patients (less satisfied 3.9%, unsatisfied 0.8%). The numbness of the leg, present in 448 patients preoperatively, was either no longer present (63.9%) or had improved (30.3%). There were no serious complications, in particular no infections. The recurrence rate was 3.6%.