Application of a targeted and quantificational foraminoplasty device in percutaneous transforaminal endoscopic discectomy for L5–S1 disc herniation: preliminary clinical outcomes

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Abstract

Objective

Percutaneous transforaminal endoscopic discectomy (PTED) is minimally invasive and has been widely used to treat patients with lumbar disc herniation (LDH) due to its safety and efficiency. However, due to the unique anatomy of the L5–S1 level, the PTED procedure is often difficult to perform in the region. ZESSYS, a targeted and quantificational foraminoplasty device, may help to overcome these anatomical limitations. In this study, we assessed the efficiency and the short-term effects of PTED with ZESSYS at the L5–S1 level.

Methods

Between January and August of 2018, fifty-six patients with lumbar disc herniation at the single level of L5–S1 and who underwent percutaneous transforaminal endoscopic discectomy were enrolled in this retrospective cohort study. They were segregated into the transforaminal endoscopic surgical system (TESSYS) group and the ZESSYS group. The puncture time, foraminoplasty time, decompression time, and fluoroscopy time were evaluated for operation efficiency. Clinical outcomes were assessed by the visual analog scale (VAS) score and Oswestry Disability Index (ODI) score. The MacNab criteria were used to evaluate patient subjective satisfaction at 12-month follow-up postoperatively.

Results

The average puncture time (5.29 ± 2.05 min), foraminoplasty time (12.82 ± 2.52 min), and fluoroscopy time (26.29 ± 5.96 s) were all significantly shorter in the ZESSYS group than in the TESSYS group (average puncture time 8.07 ± 3.13 min, p < 0.01; foraminoplasty time, 17.18 ± 2.92 min, p < 0.01; fluoroscopy time, 34.73 ± 6.86 s; p < 0.01). No significant differences were observed between the 2 groups in the decompression time ( p = 0.057). The VAS score of low back pain and leg pain, as well as the ODI score, improved at all time points postoperatively compared with preoperative, in both the TESSYS group and the ZESSYS group ( P < 0.05). There were no significant differences in the VAS score of low back pain, VAS score of leg pain, and ODI score between the TESSYS group and the ZESSYS group at the same time points ( P > 0.05). According to the MacNab criteria, the excellent and good rate at 12-month follow-up postoperatively was 85.7% in the TESSYS group and 89.3% in the ZESSYS group ( P > 0.05).

Conclusion

The targeted and quantificational foraminoplasty device named ZESSYS was more efficient in the puncture and foraminoplasty procedures, effectively protecting the exiting nerve and minimizing the level of radiation exposure. The device is efficient and safe for PTED in treating lumbar disc herniation at the L5–S1 level.

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Most cited references 28

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A practical MRI grading system for lumbar foraminal stenosis.

Seunghun Lee, Jee-Yeon Kim, Richard W J Lee … (2010)

This study aimed to evaluate the reproducibility of a new grading system for lumbar foraminal stenosis. Four grades were developed for lumbar foraminal stenosis on the basis of sagittal MRI. Grade 0 refers to the absence of foraminal stenosis; grade 1 refers to mild foraminal stenosis showing perineural fat obliteration in the two opposing directions, vertical or transverse; grade 2 refers to moderate foraminal stenosis showing perineural fat obliteration in the four directions without morphologic change, both vertical and transverse directions; and grade 3 refers to severe foraminal stenosis showing nerve root collapse or morphologic change. A total of 576 foramina in 96 patients were analyzed (from L3-L4 to L5-S1). Two experienced radiologists independently assessed the sagittal MR images. Interobserver agreement between the two radiologists and intraobserver agreement by one reader were analyzed using kappa statistics. According to reader 1, grade 1 foraminal stenosis was found in 33 foramina, grade 2 in six, and grade 3 in seven. According to reader 2, grade 1 foraminal stenosis was found in 32 foramina, grade 2 in six, and grade 3 in eight. Interobserver agreement in the grading of foraminal stenosis between the two readers was found to be nearly perfect (kappa value: right L3-L4, 1.0; left L3-L4, 0.905; right L4-L5, 0.929; left L4-L5, 0.942; right L5-S1, 0.919; and left L5-S1, 0.909). In intraobserver agreement by reader 1, grade 1 foraminal stenosis was found in 34 foramina, grade 2 in eight, and grade 3 in seven. Intraobserver agreement in the grading of foraminal stenosis was also found to be nearly perfect (kappa value: right L3-L4, 0.883; left L3-L4, 1.00; right L4-L5, 0.957; left L4-L5, 0.885; right L5-S1, 0.800; and left L5-S1, 0.905). The new grading system for foraminal stenosis of the lumbar spine showed nearly perfect interobserver and intraobserver agreement and would be helpful for clinical study and routine practice.

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Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases.

T Hoogland, A. Ramirez, Boris Miklitz … (2006)

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.

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Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases.

Christopher A Yeung, Paul Tsou (2002)

A retrospective review involving 307 consecutive cases of lumbar disc herniation managed by posterolateral endoscopic discectomy was conducted. To describe a contemporary posterolateral endoscopic decompression technique for radiculopathy secondary to lumbar disc herniation; to evaluate the efficacy of the technique as it is applied to lumbar disc herniation including primary herniation, reherniation, intracanal herniation, and extracanal herniation; and to report outcome and complications. The concept of percutaneous posterolateral nucleotomy was introduced in 1973. The development of the related equipment and technique had witnessed a slow and lengthy evolution. A retrospective assessment of 307 patients was performed at least 1 year after their index operation. The outcome was graded according to a modified MacNab method. A patient-based outcome questionnaire also was incorporated into the study. The surgeon-performed assessment showed satisfactory results in 89.3% of the cases. The rate of response to the questionnaire was 91%. The responses indicated that 90.7% of the respondents were satisfied with their surgical outcome and would undergo the same endoscopic procedure again if faced with a similar herniation in the future. The poor outcome occurred in 10.7% of the primary group and 9.7% of the questionnaire group. The combined major and minor complication rate was 3.5%. The surgical outcome of posterolateral endoscopic discectomy for lumbar disc herniation is comparable with that for the traditional open transcanal microdiscectomy. Intracanal and extracanal herniations, reherniations, and incidental lateral recess stenosis can be addressed by the same approach.

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Author and article information

Contributors

Chao Zhang:

ORCID: http://orcid.org/0000-0003-2315-3491

czspine11@163.com

Journal

Journal ID (nlm-ta): J Orthop Surg Res

Journal ID (iso-abbrev): J Orthop Surg Res

Title: Journal of Orthopaedic Surgery and Research

Publisher: BioMed Central (London )

ISSN (Electronic): 1749-799X

Publication date (Electronic): 22 June 2021

Publication date PMC-release: 22 June 2021

Publication date Collection: 2021

Volume: 16

Electronic Location Identifier: 398

Affiliations

[1 ]GRID grid.415912.a, ISNI 0000 0004 4903 149X, Department of Spine Surgery, , People’s Hospital of Liaocheng, ; Liaocheng, 252000 Shandong China

[2 ]Department of Orthopaedics, The 941th Hospital of Joint Logistics Support Force of Chinese PLA, Xining, 810000 Qinghai China

[3 ]Department of Orthopaedics, The Hospital of People Liberation Army Hong Kong Garrison, Hong Kong, 999077 China

[4 ]GRID grid.410570.7, ISNI 0000 0004 1760 6682, Department of Spine Surgery, , Xinqiao Hospital, Army Medical University, ; Chongqing, 400037 China

Author information

Chao Zhang http://orcid.org/0000-0003-2315-3491

Article

Publisher ID: 2533

DOI: 10.1186/s13018-021-02533-z

PMC ID: 8218444

PubMed ID: 34158087

SO-VID: 285d4770-0740-4ccf-8060-25d041289d8b

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 25 March 2021

Date accepted : 8 June 2021

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ScienceOpen disciplines: Surgery

Keywords: percutaneous transforaminal endoscopic discectomy,lumbar disc herniation at the l5–s1 level,foraminoplasty,preliminary clinical outcomes

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ScienceOpen disciplines: Surgery

Keywords: percutaneous transforaminal endoscopic discectomy, lumbar disc herniation at the l5–s1 level, foraminoplasty, preliminary clinical outcomes

Application of a targeted and quantificational foraminoplasty device in percutaneous transforaminal endoscopic discectomy for L5–S1 disc herniation: preliminary clinical outcomes

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Most cited references 28

A practical MRI grading system for lumbar foraminal stenosis.

Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases.

Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases.

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