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BACKGROUND: Thirty years have passed since Kambin's first clinical series of lumbar disc herniations (LDH) treated by arthroscopic microdiscectomy. Despite several advances in this interim, sequestrated LDHs over the dorsal aspect of the dura, and high-grade up- or downward disc migration have been a relative limitation of the transforaminal endoscopic technique. The interlaminar window was the next step to deal with such highly migrated LDHs. Favorable outcomes were obtained in 70-90% of the patients in the long-term, but recurrence rates remained high (approximately 12%), and the approach could be limited by the size of the interlaminar window. Few relevant studies have addressed the role of translaminar full endoscopic technique for migrated LDHs. To describe an innovative modification of the translaminar full endoscopic approach with Tom Shidi needles. METHODS: This technical modification is presented in a detailed fashion for treating these challenging LDHs and illustrated through a clinical case. RESULTS: The patient underwent successful translaminar full endoscopic technique with complete pain resolution postoperatively. The postprocedural course was uneventful. A follow-up imaging showed no evidence of residual LDHs fragments. CONCLUSIONS: Translaminar full endoscopic technique with Tom Shidi needles is a promising modification of the previously presented interlaminar and translaminar endoscopic routes in the treatment of migrated LDHs to fasten surgical procedures and increase the safety of spinal canal manipulation.
Assuntos
Discotomia Percutânea , Deslocamento do Disco Intervertebral , Humanos , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Deslocamento do Disco Intervertebral/cirurgia , Discotomia Percutânea/métodos , Resultado do Tratamento , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Endoscopia/métodos , Estudos RetrospectivosRESUMO
Background: Transforaminal endoscopic lumbar discectomy (TELD) has well-recognized advantages and disadvantages in the literature. Some of the mentioned disadvantages are insufficient discectomy, higher recurrence rate and long learning curve (LC). The objective of this study is to describe the LC and analyze the survival rate of patients operated through TELD. Methods: Retrospective study of 41 cases operated through TELD by the same surgeon from June 2013 to January 2020, with a minimum follow-up of 6 months. Demographic data and information on operative time (OT), complications, hospital stay, hernia recurrence and reoperations were collected. LC of the TELD was analyzed using a cumulative sum (CUSUM) test for parameter stability for linear regression coefficients, using the CUSUM from recursive residuals. Results: Thirty-nine patients, 24 men (61.54%) and 15 women (38.46%), were included in the present cohort, and a total of 41 TELD were performed. The average OT was 96 minutes (SD =30) and the CUSUM of the recursive residuals shows learning of the TELD in the case 20. The mean OT in the first 20 cases was 114 minutes (SD =30) versus 80 minutes (SD =17) in the last 21 cases (P=0.0001). The rates of recurrent Dh were 17%, and 12% need reoperation. Conclusions: We consider that the LC of TELD requires operating 20 cases to perform the procedure with a significant reduction in OT, with minimal rates of reoperation and complications.
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BACKGROUND: Why are intradural disc herniations (IDHs) (0.3% of all discs) so infrequent? One explanation has been the marked adherence of the posterior longitudinal ligament (PLL) to the ventral wall of the dura. Variability in symptoms and difficulty in interpreting magnetic resonance (MR) images with/without contrast make the diagnosis of an IDH difficult. Here, we reported a patient with an L1-L2 IDH and appropriately reviewed the relevant literature. CASE DESCRIPTION: A 57-year-old male presented with chronic low back and 1 month's duration of the left thigh pain. The lumbar MR with/without contrast demonstrated an IDH at the L1-L2 level, resulting in spinal cord compression. At surgery, the disc herniation was appropriately resected, the dura was closed, and an interbody fusion with pedicle screw fixation was performed. Postoperatively, the patient clinically improved. CONCLUSION: IDHs are rare, being seen in only 0.3% of all cases. MR findings, performed with/without contrast, may help signal the presence of an IDH. MR findings include a hypointense structure inside the dura; the "hawk beak" sign (e.g., beak-like mass with ring enhancement at the intervertebral disc space); the Y sign (e.g., ventral dura split into ventral dura and arachnoid by disc material); an abrupt loss of continuity of the PLL; a diffuse annular bulge with a large posterocentral extrusion; and an typical crumbled appearance of disc (e.g., "crumble disc sign"). At surgery, both the extradural and intradural components of the disc must be excised.
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INTRODUCTION: Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive technique that has been used in different countries since the late eighties for the treatment of herniated discs. OBJECTIVE: The objective of this study was to describe the results of PELD in a series of awake patients, treated with epidural anesthesia and mild sedation. MATERIALS AND METHODS: In a group of 60 patients, who together had 77 discs operated on between April 2016 and March 2018, data were collected on patient age and gender, clinical presentation, and MRI abnormalities. The main outcome of interest was the difference between preoperative and postoperative Oswestry (Oswestry disability index [ODI]) scores 8 weeks after the procedure. Macnab criteria, operation duration, length of hospitalization, surgical complications, and the need for reoperation were other outcomes evaluated. All patients received epidural anesthesia and mild sedation. RESULTS: The average reduction in ODI at 8 weeks was 48 points (standard deviation [SD] = 5), representing an average percentage reduction of 85% (SD = 8). By Macnab's criteria, 85% of patients experienced either an excellent or good result, while 10% and 5% had a fair and poor result, respectively. Average surgery time was 50 min and in-hospitalization stay 8.6 h. CONCLUSIONS: In our series of surgical patients with lumbar disc herniations, PELD yielded very good results, manifest as significantly reduced pain, brief procedural durations, no complications, and short hospital stays. Patients accepted the option of being awake and immediately ambulatory, and the approach proved highly feasible to execute.
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La Discectomía Percutánea Endoscópica Lumbar es una técnica mínimamente invasiva para el tratamiento de las hernias discales lumbares con resultados comparables a la microdiscectomía lumbar. La principal complicación, los fragmentos discales remanentes, son en gran parte producidos por la limitación de movimiento del endoscopio una vez realizada la punción. Presentamos una nota técnica y aplicación en un caso ejemplo de lo que hemos llamado "libre flotación foraminal": un acceso al espacio epidural por vía transforaminal que mantiene la libertad de movimiento y permite una exploración endoscópica en busca de fragmentos remanentes.
Percutaneous endoscopic lumbar discectomy is a minimally-invasive surgical approach for the treatment of lumbar disc herniation, with outcomes similar to open micro-discectomy. The main complication residual disc fragments is largely caused by a rigid endoscopic trajectory once the puncture has been made. We present a technical note of a surgery performed in a patient who underwent what we have called a "free foraminal flotation technique": accessing the epidural space through a transforaminal approach that maintains freedom of movement and allows for endoscopic exploration to locate residual disc fragments.