Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy

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✓ Percutaneous endoscopic discectomy is a new technique for removing “contained” lumbar disc herniations (those in which the outer border of the anulus fibrosus is intact) and small “noncontained” lumbar disc herniations (those at the level of the disc space and occupying less than one-third of the sagittal diameter of the spinal canal) through a posterolateral approach with the aid of specially developed instruments. The technique combines rigid straight, angled, and flexible forceps with automated high-power suction shaver and cutter systems. Access can thus be gained to the dorsal parts of the intervertebral space where the disc herniation is located. Percutaneous endoscopic discectomy is monitored using an endoscope angled to 70° coupled with a television and video unit and is performed with the patient under local anesthesia and an anesthesiologist available if needed. Its indication is restricted to discogenic root compression with a minor neurological deficit.

Two groups of patients with contained or small noncontained disc herniations were treated by either percutaneous endoscopic discectomy (20 cases) or microdiscectomy (20 cases). Both groups were investigated in a prospective randomized study in order to compare the efficacy of the two methods. The disc herniations were located at L2–3 (one patient), L3–4 (two patients), or L4–5 (37 patients). There were no significant differences between the two groups concerning age and sex distribution, preoperative evolution of complaints, prior conservative therapy, patient's occupation, preoperative disability, and clinical symptomatology. Two years after percutaneous endoscopic discectomy, sciatica had disappeared in 80% (16 of 20 patients), low-back pain in 47% (nine of 19 patients), sensory deficits in 92.3% (12 of 13 patients), and motor deficits in the one patient affected. Two years after microdiscectomy, sciatica had disappeared in 65% (13 of 20 patients), low-back pain in 25% (five of 20 patients), sensory deficits in 68.8% (11 of 16 patients), and motor deficits in all patients so affected. Only 72.2% of the patients in the microdiscectomy group had returned to their previous occupation versus 95% in the percutaneous endoscopic discectomy group. Percutaneous endoscopic discectomy appears to offer an alternative to microdiscectomy for patients with “contained” and small subligamentous lumbar disc herniations.

Article Information

Address reprint requests to: H. Michael Mayer, M.D., Department of Orthopedic Surgery, Freie Universitaet Berlin, Clayallee 229, 1000 Berlin 33, Germany.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Postdiscography computerized tomography scan showing a typical “contained” disc herniation located in the midline at L4–5.

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    Discogram demonstrating a disc protrusion with accumulation of contrast medium in the outer anulus fibrosus. No epidural or subligamentous leakage of contrast medium is seen.

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    Photograph of instruments used during percutaneous endoscopic discectomy: 1 = flexible forceps: 2 = reverse-opening forceps; 3 = blunt trocar; 4 = working cannula; 5 = anulus fibrosus trephine; 6 = angled forceps; 7 = straight forceps; 8 = shaver.

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    Schematic representation of an endoscope angled to 70° and introduced into the disc through a posterolateral approach.

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    Left: Endoscopic view of a partially removed nucleus pulposus. The dorsal aspect of the nucleus pulposus is seen at the top. Right: Endoscopic view of the forceps being introduced into the disc space from the opposite side (bilateral approach). The dorsal aspect of the nucleus pulposus is seen at the top.

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    Summary of symptoms in 20 patients undergoing percutaneous endoscopic discectomy. Black bars denote symptoms before the operation; cross-hatched bars denote symptoms at the 2-year follow-up examination. Sens. = sensory; Diff. = differences.

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    Results of percutaneous endoscopic discectomy in 20 patients (black bars), of an operation after percutaneous endoscopic discectomy in three (dark cross-hatched bars), and of microdiscectomy in 20 patients (light cross-hatched bars), according to the clinical score (at left, see Table 2).

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    Results of percutaneous endoscopic discectomy in 20 patients (black bars), of an operation after percutaneous endoscopic discectomy in three (dark cross-hatched bars), and of microdiscectomy in 20 patients (light cross-hatched bars), as evaluated by the patients themselves.

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    Postoperative percentage improvement of preoperative symptoms as evaluated by the patients themselves. Black bars denote those treated with percutaneous endoscopic discectomy; cross-hatched bars denote those undergoing microdiscectomy.

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    Summary of symptoms in patients undergoing microdiscectomy. Black bars denote symptoms before the operation; cross-hatched bars denote symptoms at the 2-year follow-up examination. Sens. = sensory; Diff. = differences.

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