Clinical Results of Combined Interlaminar and Transforaminal Endoscopic Discectomy for Central Lumbar Disc Herniation — The International Society for the Study of the Lumbar Spine
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Clinical Results of Combined Interlaminar and Transforaminal Endoscopic Discectomy for Central Lumbar Disc Herniation (#1250)

Kanthika Dr. Wasinpongwanich 1 2 , Verapan Dr. Kuansongtham 1 , Khin Myat Myat Lwin Dr. - 1
  1. Spine, Bumrungrad International Hospital, Bangkok, --None--, Thailand
  2. Orthopaedics, Suranaree University of Technology, Nakhon Ratchasima, -, Thailand

Introduction

Herniated nucleus pulposus of the lumbar spine is the most common indication for surgery [1]. The herniated nucleus pulposus can be classified into 3 types: central, paramedian, foraminal herniation according to location [2]. The incidence of central large disc herniation is about 3.6% [3]. However, central large disc herniation type is the most common cause of cauda equina syndrome, resulting in severe disability [4].

The use of endoscopy has been extensively expanded to other areas rather than simple lumbar discectomy e.g., large central disc herniation [4], migrated lumbar disc herniation [6], Lumbar endoscopic fusion etc. Some studies have used the benefits and overcome the limitation of each approach by combining transforaminal and interlaminar in one patient but at different levels [5,6].

Methods

From January 2015 to December 2020, 9 cases were diagnosed with Central large disc herniation and treated with combined interlaminar and transforaminal approach were retrospectively reviewed.

Results

The study revealed 7 men and 2 women. The average age of patients was 42.33 ± 19.8 years old (18 - 83). The level of surgery reveal L3-4 2 cases, L4-5 7cases. The VAS Back and Leg were improved from pre-operative score from 5.0 ± 2.0, 4.42 ± 2.93 to 2.18 ± 1.97 and 2.55 ± 2.84 retrospectively at 1 week. The ODI score was improved pre-operative from 46.85 ± 15.61% to 14.94 ± 19.08% at 3 month follow up. There were 2 cases (2/9) diagnosed of recurrent disc herniation. No case of epidural hematoma, infection or permanent neurological deterioration.

Discussion

The Incidence of central disc herniation reported, varied from 1.2% to 44% [7]. The symptoms reported in previous study were different e.g. present of quada equina syndrome, bilateral radicular symptoms. In our study, all patients’ symptoms were not cauda equina syndrome but only bilateral radiculopathy.

The surgical technique combines the advantage of transforaminal approach and interlaminar approach. Via the transforaminal approach which is considered less invasive,we aim to gently remove some part of large disc to loosen the epidural tissue and widen space for the interlaminar approach discectomy. The interlaminar approach purpose to remove the remnant of herniated disc, remove the intra discal free fragments and manage the annular defect with eletrocoagulation(figure 1).

The VAS back, leg ODI score were improved significantly after surgery. The recurrent rate was 22.22% (2/9 cases), one of two cases needed surgery while the other was treated conservatively after recurrent symptoms. We assumed that the annular defect may be larger than paramedian or posterolateral herniation therefore after surgery recurrent is more likely.

Complications of the combined approach were similar to general endoscopic discectomy[8]. There were 2 cases of postoperative weakness and numbness which was completely resolved at 3 months follow up. The excessive nerve retraction was considered the cause of the temporary weakness in both cases. There are 2 cases diagnosed of recurrent disc herniation as patient had recurring symptoms on post-operative day 155 and 225. However, those two cases have improved postoperative VAS back and leg and ODI score.

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