Transforaminal percutaneous endoscopic lumbar discectomy: technical tips to prevent complications

Figures & data

Figure 1. Schematic drawings demonstrating the adequate transforaminal approach in different situations.

According to the zone of herniation, the landing point and approach angle should be adjusted; for central and subarticular disc herniation, the horizontal approach to the medial pedicular line is recommended (A). For foraminal and far-lateral disc herniation, the steep approach angle to the lateral pedicular line is recommended (B). The landing point and approach angle can be changed according to the level. For upper lumbar levels, such as L1-L2 and L2-L3, a steeper approach and lateral landing are recommended (C). For lower lumbar levels, such as L4-L5 and L5-S1, a more horizontal approach and medial landing are recommended (D).

Figure 2. Regardless of the approach angle and landing point, the exiting nerve root should be protected during the approach.

The leading edge of any instrument should be located away from the trajectory of the exiting nerve root. A more caudal approach along the superior facet surface is a useful technique to avoid the exiting nerve root injury.

Figure 3. Schematic drawings demonstrating the importance of annular release and complete herniotomy.

The herniated fragment should be separated from the tight annular anchorage and freed before removal. The releasing procedure can be performed using a side-firing laser and annulus cutter (A). Then, complete removal of the whole hernia fragment in both the epidural and the intradiscal space should be performed to prevent recurrence (B).

Figure 4. The ideal end point is free mobilization of neural tissue with complete herniotomy, not full exposure of the nerve root.

An attempt to achieve wide exposure of the neural tissue involves the risk of neural damage. (A) In the intradiscal view, we can identify the annular fissure (arrow heads), decompressed dural sac through the undersurface of the annulus (a) and intradiscal space (b). (B) In the lateral view, we can see the anatomical layers such as the dural sac in the epidural space (a), the remaining annulus (b) and the intradiscal space (c).Reproduced with permission from [14].

Ahn Y, Lee SH, Park WM, Lee HY, Shin SW, Kang HY. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine 29(16), E326–E332 (2004).

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