Percutaneous endoscopic discectomy in adolescent lumbar disc herniation: a 3- to 5-year study

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OBJECTIVE

The authors sought to investigate the efficiency of percutaneous endoscopic discectomy (PED) in adolescent patients with lumbar disc herniation (LDH), compare PED outcomes in adolescent patients with those in young adult LDH patients as controls, and discuss relevant technical notes.

METHODS

This was a retrospective study involving 19 adolescent LDH patients (age > 13 and < 18 years, 20 discectomies) and 38 young adults (age < 40 years, 38 discectomies) who also had LDH and were matched to the adolescent group for sex and body mass index. The combined cohort included 51 male patients (89.5%) and 6 female patients (10.5%), with an average age of 26.7 years (range 14–39 years). The operated levels included L3–4 in 1 patient (1.7%), L4–5 in 22 patients (37.9%), and L5–S1 in 35 patients (60.4%). Two adolescents (10.5%) exhibited apophyseal ring separation and one (5.3%) had had previous PED. All patients underwent PED under local anesthesia. Outcomes were evaluated through a visual analog scale (VAS), the Japanese Orthopaedic Association (JOA) scoring system, and the modified MacNab grading system.

RESULTS

The mean duration of follow-up was 41.7 months (range 36–65 months). The outcomes in adolescents were satisfactory and comparable with previously reported outcomes of microsurgical discectomy (MD) and conventional open discectomy (COD). The adolescent patients had a faster and better recovery course than the adult patients (p < 0.01). One adolescent patient (5.3%) exhibited recurrence and 2 adults (5.3%) experienced transient dysesthesia; the complication rates were comparable in the 2 age groups (p = 0.47). Prolonged duration of symptoms (p < 0.01) and disc degeneration (p = 0.01) were correlated with lower postoperative JOA values; patients with extrusions had higher postoperative JOA values than those with protrusions (p = 0.01).

CONCLUSIONS

PED may yield favorable results in the treatment of adolescent LDH in terms of short- to medium-term follow-up; restricted discectomy and a conservative rehabilitation program might be advisable. Further long-term studies are warranted to address this rare disease entity.

ABBREVIATIONS BMI = body mass index; COD = conventional open discectomy; JOA = Japanese Orthopaedic Association; LDH = lumbar disc herniation; MD = microsurgical discectomy; PED = percutaneous endoscopic discectomy; VAS = visual analog scale.

Article Information

Correspondence Ruoxian Song: General Hospital of Jinan Military Commanding Region, Jinan, Shandong Province, China. zhongguozhiwangcy@163.com.

INCLUDE WHEN CITING Published online November 2, 2018; DOI: 10.3171/2018.8.PEDS18442.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Images from a representative case involving an adolescent with a herniated L5–S1 disc. This 16-year-old male patient presented with a 26-month history of pain in his back (VAS score of 2) and right lower extremity (VAS score of 6). Physical examination showed radiculopathy consistent with the imaging findings. A, B, and D: Sagittal (A) and axial (B and D) T2-weighted MR images demonstrating a soft central disc herniation. C: Anteroposterior fluoroscopic image showing the use of a trephine to perform foraminotomy in order to ensure that the working sheath could pass via the transforaminal approach. E and G: Anteroposterior fluoroscopic images showing that the working channel was targeted to the index segment. F: Endoscopic view of the surgical field. The traversing nerve root (white arrow) was compressed by the herniated disc fragment (black arrow). H: Photograph of the excised disc material (white arrow) and the part of the facet removed for foraminotomy (black arrow). At 42 months after PED, the patient had an excellent outcome as measured by the MacNab grading system. Figure is available in color online only.

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    Comparison of outcomes of PED in adolescent and adult age groups. A and B: Preoperative and postoperative JOA scores in the adolescent (A) and adult (B) groups. The adolescents had higher postoperative JOA scores than the adult group (p < 0.01). JOAs = JOA scores. C and D: Preoperative and postoperative VAS scores for leg pain in the adolescent (C) and adult (D) groups. The adolescent patients had more satisfactory improvement in VAS scores for leg pain (p < 0.01). E and F: Preoperative and postoperative VAS scores for back pain in the adolescent (E) and adult (F) groups showing comparable improvement in the 2 groups (p > 0.05). Overall, both groups exhibited significant improvement in functionality and pain relief (p < 0.01).

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    Images from a case involving an adolescent who underwent a revision PED. This 16-year-old male patient presented with back pain (VAS score of 3) and pain in his right leg (VAS score of 7) 6 months after a previous PED procedure that was performed at another institution. Physical examination revealed numbness in the right calf, and the results of a straight leg raise test were positive. A and B: Sagittal T2-weighted MR image (A) and axial CT image (B) obtained before the patient’s initial PED procedure demonstrating a centrolateral L4–5 disc herniation. C: Sagittal T2-weighted MR image obtained at the time of presentation to our institution (6 months after the initial surgery) indicating severe degeneration and recurrence. D: Axial CT image obtained 6 months after the initial surgery after the primary operation showing a residual bony fragment at the surgically treated level. E and G: Lateral (E) and anteroposterior (G) fluoroscopic images obtained during revision PED through the transforaminal approach. F: Endoscopic view of the surgical field. The nerve root was fully decompressed. H: Photograph of the excised disc fragment (black arrow) and the removed mobile bony fragment (white arrow) shown next to a 20-ml syringe for scale. At 40 months after surgery, the patient had a good outcome as measured by the MacNab grading system. Figure is available in color online only.

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