Low complication rate in percutaneous endoscopic lumbar discectomy via an interlaminar approach

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The lumbar spine

Percutaneous endoscopic lumbar discectomy via an interlaminar approach is effective for lumbar disc herniation, with few complications, reported Jiancheng Zeng (West China Hospital, Sichuan University, Department of Orthopaedics, Chengdu, China), speaking at the 18th annual conference of the International Society for the Advancement of Spine Surgery (11–13 April, Toronto, Canada).

Zeng presented this research during the General session on endoscopic surgery, and he and his team were awarded 1st place for the best abstract presented on minimally invasive surgery. Zeng and his colleague T Xie (Sichuan University, department of Orthopaedics, Chengdu, China) set out to analyse the complications associated with performing percutaneous endoscopic lumbar discectomies via an interlaminar approach, as well as the causes of these complications.

Percutaneous endoscopic lumbar discectomy is an advanced minimally invasive spine surgery done to achieve decompression of the lumbar disc space and removal of nucleus pulposus. It is a minimally invasive surgical technique, and is also used in the management of spinal tumours and structural deformities. The technique was first introduced in Germany by H Michael Mayer and Mario Brock (both Department of Neurosurgery, Klinikum Steglitz, Free University of Berlin, Germany) in April 1987. They listed “The atraumatic extraspinal approach, the reduced time of hospitalisation and postoperative morbidity, as well as the reduced time of work incapability” as the main advantages of this method.

This current study followed the 479 patients with lumbar disc herniation at West China Hospital treated between January 2010 and December 2012 with percutaneous endoscopic lumbar discectomy via an interlaminar approach. The patients all had the procedure under general anaesthetic; there were 252 males (52.6%) and 227 females, with a mean age of 43 years (range 13–70 years). Over a mean follow-up period of 36 months (ranging from 25–59 months), complications were found in 38 cases, an incidence rate of 7.93%. Those cases with complications in the intraoperative and/ or postoperative period were studied retrospectively.

The complications

Nucleus pulposus omissions were found in three cases; these patients suffered from central protrusion lumbar disc herniation, and all three were amongst the first percutaneous endoscopic lumbar discectomy cases performed by the practising surgeon. Following three to six weeks of conservative treatment, the symptoms were alleviated for all three of these patients.

Of the 479 patients followed, two suffered nerve root injury (an incidence rate of 0.4%). Both cases were an L4/L5 lumbar disc herniation combined with lumbar stenosis, but through one to three months of functional training and a course of neurotrophic drugs, both patients made a full recovery.

Twenty-four cases experienced postoperative dysesthesia. The symptoms were improved in all 24 patients by taking mecobalamin and gabapentin, combined with three to six weeks of rehabilitation exercises.

Recurrent disc herniation occurred in nine cases (1.9%); six of these patients released their symptoms after conservative treatment, and the remaining three patients underwent subsequent fenestration discectomy, making a complete recovery three to six months after the operation.

Effective ways to decrease and prevent operative related complications

Preoperatively, all patients suffered from low back pain and leg pain, with the latter often more severe, and there was no confirmed evidence of lumbar instability. The levels of herniation were L4/L5 in 196 cases, and L5/S1 in 286 cases. There were 476 cases of monosegment lumbar disc herniation, three cases of double-level lumbar disc herniation, 46 cases of lumbar disc herniation combined with calcification, and 15 cases of lumbar  disc herniation combined with lumbar stenosis.

Zeng and Xie explained how to minimise intraoperative complications: “Strict selection of the indication, sophisticated arrangements of surgical plan and skillful manipulation are effective ways to decrease and prevent operative related complications.”

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