Unilateral biportal endoscopic discectomy for high-grade migrated lumbar disc herniation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

CHEN Pan ¹ , ZHENG Danyang ¹ , DING Weiguo ² ,  XU Weixing ²

1. The Second Clinical Medical College of Zhejiang Chinese Medicine University, Hangzhou Zhejiang, 310053, P. R. China;
2. Department of Spine Surgery, Tongde Hospital of Zhejiang Province, Hangzhou Zhejiang, 310012, P. R. China;

Corresponding author：

XU Weixing, Email: xwxspine@163.com

Keywords：

Unilateral biportal endoscopy; discectomy; lumbar disc herniation; high-grade migration

DOI：

10.7507/1002-1892.202203047

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Objective To investigate the effectiveness of the unilateral biportal endoscopy (UBE) technique in the treatment of high-grade migrated lumbar disc herniation (LDH). Methods Between January 2020 and February 2021, 23 cases of high-grade migrated LDH were treated with discectomy via UBE. There were 14 males and 9 females, with a mean age of 48.7 years (range, 32-76 years). All patients had low back and leg pain. The disease duration ranged from 2 months to 7 years (median, 13 months). Lesion segments were L_{3, 4} in 2 cases, L_{4, 5} in 15 cases, and L₅, S₁ in 6 cases. The operation time, intraoperative blood loss, the time when the patients started to move off the floor, and postoperative complications were recorded. The effectiveness was evaluated using the visual analogue scale (VAS) score, the modified Oswestry disability index (ODI), and the modified MacNab criteria. Results All operations were completed successfully, and no complication such as dural tear, epidural hematoma, nerve injury, or vascular injury occurred. The operation time ranged from 53 to 96 minutes, with an average of 71.0 minutes. The intraoperative blood loss ranged from 32 to 56 mL, with an average of 39.3 mL. All patients were removed the drainage tube and wore a lumbar brace to move off the floor around 1 to 2 days after operation. All patients were followed up 3-12 months after operation, with an average of 5.7 months. The VAS scores of low back pain and leg pain and the modified ODI at all postoperative time points were lower than those before operation, and the differences were significant (P<0.05). The differences were significant (P<0.05) when comparing the above indexes between the time points after operation. At last follow-up, the effectiveness was evaluated according to the modified MacNab criteria, and 17 cases were excellent, 4 cases were good, and 2 cases were fair, with an excellent and good rate of 91.3%. There was no recurrence of LDH during follow-up. Conclusion Discectomy via UBE is an effective method for the treatment of high-grade migrated LDH because of its flexibility, clear view, and wide range of intraoperative exploration, which can effectively reduce the risk of residual nucleus pulposus after operation.

Citation： CHEN Pan, ZHENG Danyang, DING Weiguo, XU Weixing. Unilateral biportal endoscopic discectomy for high-grade migrated lumbar disc herniation. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(7): 860-865. doi: 10.7507/1002-1892.202203047 Copy

1.	Wu C, Lee CY, Chen SC, et al. Functional outcomes of full-endoscopic spine surgery for high-grade migrated lumbar disc herniation: a prospective registry-based cohort study with more than 5 years of follow-up. BMC Musculoskelet Disord, 2021, 22(1): 58-76.
2.	Lee S, Kim SK, Lee SH, et al. Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches. Eur Spine J, 2007, 16(3): 431-437.
3.	Choi KC, Lee DC, Shim HK, et al. A strategy of percutaneous endoscopic lumbar discectomy for migrated disc herniation. World Neurosurg, 2017, 99: 259-266.
4.	Ahn Y, Jeong TS, Lim T, et al. Grading system for migrated lumbar disc herniation on sagittal magnetic resonance imaging: an agreement study. Neuroradiology, 2018, 60(1): 101-107.
5.	Choi KC, Lee JH, Kim JS, et al. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10, 228 cases. Neurosurgery, 2015, 76(4): 372-380.
6.	Choi G, Lee SH, Lokhande P, et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976), 2008, 33(15): E508-E515.
7.	Zhao Y, Fan Y, Yang L, et al. Percutaneous endoscopic lumbar discectomy (PELD) via a transforaminal and interlaminar combined approach for very highly migrated lumbar disc herniation (LDH) between L_4/5 and L₅/S₁ level. Med Sci Monit, 2020, 26: e922777. doi: 10.1111/os.12862.
8.	Soliman HM. Irrigation endoscopic discectomy: a novel percutaneous approach for lumbar disc prolapse. Eur Spine J, 2013, 22(5): 1037-1044.
9.	Heo DH, Lee N, Park CW, et al. Endoscopic unilateral laminotomy with bilateral discectomy using biportal endoscopic approach: Technical report and preliminary clinical results. World Neurosurg, 2020, 137: 31-37.
10.	Li C, Ju F, Li W, et al. Efficacy and safety of unilateral biportal endoscopy compared with microscopic decompression in the treatment of lumbar spinal stenosis: A protocol for systematic review and meta-analysis. Medicine (Baltimore), 2021, 100(50): e27970.
11.	Kim SK, Kang SS, Hong YH, et al. Clinical comparison of unilateral biportal endoscopic technique versus open microdiscectomy for single-level lumbar discectomy: a multicenter, retrospective analysis. J Orthop Surg Res, 2018, 13(1): 22-29.
12.	Heo DH, Lee DC, Park CK. Comparative analysis of three types of minimally invasive decompressive surgery for lumbar central stenosis: biportal endoscopy, uniportal endoscopy, and microsurgery. Neurosurg Focus, 2019, 46(5): E9. doi: 10.3171/2019.2.FOCUS197.
13.	程继伟, 王振林, 刘伟, 等. Oswestry功能障碍指数的改良及信度和效度检验. 中国脊柱脊髓杂志, 2017, 27(3): 235-241.
14.	Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine: A preliminary report. Clin Orthop Relat Res, 1983, 174: 127-132.
15.	Ahn Y, Lee S H, Park W M, et al. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine (Phila Pa 1976), 2004, 29(16): E326-E332.
16.	Lee SH, Kang BU, Ahn Y, et al. Operative failure of percutaneous endoscopic lumbar discectomy: a radiologic analysis of 55 cases. Spine (Phila Pa 1976), 2006, 31(10): E285-E290.
17.	Wu XB, Fan GX, Guan XF, et al. Percutaneous endoscopic lumbar discectomy for far-migrated disc herniation through two working channels. Pain Physician, 2016, 19(4): E675-E680.
18.	Kim HS, Ju CI, Kim SW, et al. Endoscopic transforaminal suprapedicular approach in high grade inferior migrated lumbar disc herniation. J Korean Neurosurg Soc, 2009, 45(2): 67-73.
19.	Yan Y, Wang Y, Yang J, et al. Percutaneous endoscopic lumbar discectomy for highly upmigrated disc herniation through the transforaminal isthmus plasty approach. World Neurosurg, 2018, 120: 511-515.
20.	Kim JS, Choi G, Lee SH. Percutaneous endoscopic lumbar discectomy via contralateral approach: a technical case report. Spine (Phila Pa 1976), 2011, 36(17): E1173-1178.
21.	Du J, Tang X, Jing X, et al. Outcomes of percutaneous endoscopic lumbar discectomy via a translaminar approach, especially for soft, highly down-migrated lumbar disc herniation. Int Orthop, 2016, 40(6): 1247-1252.
22.	Ruetten S, Komp M, Merk H, et al. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976), 2008, 33(9): 931-939.
23.	Choi KC, Kim JS, Ryu KS, et al. Percutaneous endoscopic lumbar discectomy for L₅-S₁ disc herniation: transforaminal versus interlaminar approach. Pain Physician, 2013, 16(6): 547-556.
24.	Choi G, Prada N, Modi HN, et al. Percutaneous endoscopic lumbar herniectomy for high-grade down-migrated L₄-L₅ disc through an L₅-S₁ interlaminar approach: a technical note. Minim Invasive Neurosurg, 2010, 53(3): 147-152.
25.	Hwa Eum J, Hwa Heo D, Son SK, et al. Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results. J Neurosurg Spine, 2016, 24(4): 602-607.
26.	Xie X, Zhang G, Liu N. Clinical effect of unilateral biportal endoscopy in the treatment of lumbar diseases: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne, 2022, 17(1): 61-68.
27.	Park HJ, Kim SK, Lee SC, et al. Dural tears in percutaneous biportal endoscopic spine surgery: Anatomical location and management. World Neurosurg, 2020, 136: e578-e585.
28.	Kim JE, Choi DJ, Park EJ. Evaluation of postoperative spinal epidural hematoma after biportal endoscopic spine surgery for single-level lumbar spinal stenosis: clinical and magnetic resonance imaging study. World Neurosurg, 2019, 126: e786-e792.
29.	Choi DJ, Choi CM, Jung JT, et al. Learning curve associated with complications in biportal endoscopic spinal surgery: Challenges and strategies. Asian Spine J, 2016, 10(4): 624-629.
30.	朱斌, 田大胜, 陈磊, 等. 单边双通道内镜技术在腰椎疾病中的应用研究进展. 中华骨科杂志, 2020, 40(15): 1030-1038.

1. Wu C, Lee CY, Chen SC, et al. Functional outcomes of full-endoscopic spine surgery for high-grade migrated lumbar disc herniation: a prospective registry-based cohort study with more than 5 years of follow-up. BMC Musculoskelet Disord, 2021, 22(1): 58-76.
2. Lee S, Kim SK, Lee SH, et al. Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches. Eur Spine J, 2007, 16(3): 431-437.
3. Choi KC, Lee DC, Shim HK, et al. A strategy of percutaneous endoscopic lumbar discectomy for migrated disc herniation. World Neurosurg, 2017, 99: 259-266.
4. Ahn Y, Jeong TS, Lim T, et al. Grading system for migrated lumbar disc herniation on sagittal magnetic resonance imaging: an agreement study. Neuroradiology, 2018, 60(1): 101-107.
5. Choi KC, Lee JH, Kim JS, et al. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10, 228 cases. Neurosurgery, 2015, 76(4): 372-380.
6. Choi G, Lee SH, Lokhande P, et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976), 2008, 33(15): E508-E515.
7. Zhao Y, Fan Y, Yang L, et al. Percutaneous endoscopic lumbar discectomy (PELD) via a transforaminal and interlaminar combined approach for very highly migrated lumbar disc herniation (LDH) between L_4/5 and L₅/S₁ level. Med Sci Monit, 2020, 26: e922777. doi: 10.1111/os.12862.
8. Soliman HM. Irrigation endoscopic discectomy: a novel percutaneous approach for lumbar disc prolapse. Eur Spine J, 2013, 22(5): 1037-1044.
9. Heo DH, Lee N, Park CW, et al. Endoscopic unilateral laminotomy with bilateral discectomy using biportal endoscopic approach: Technical report and preliminary clinical results. World Neurosurg, 2020, 137: 31-37.
10. Li C, Ju F, Li W, et al. Efficacy and safety of unilateral biportal endoscopy compared with microscopic decompression in the treatment of lumbar spinal stenosis: A protocol for systematic review and meta-analysis. Medicine (Baltimore), 2021, 100(50): e27970.
11. Kim SK, Kang SS, Hong YH, et al. Clinical comparison of unilateral biportal endoscopic technique versus open microdiscectomy for single-level lumbar discectomy: a multicenter, retrospective analysis. J Orthop Surg Res, 2018, 13(1): 22-29.
12. Heo DH, Lee DC, Park CK. Comparative analysis of three types of minimally invasive decompressive surgery for lumbar central stenosis: biportal endoscopy, uniportal endoscopy, and microsurgery. Neurosurg Focus, 2019, 46(5): E9. doi: 10.3171/2019.2.FOCUS197.
13. 程继伟, 王振林, 刘伟, 等. Oswestry功能障碍指数的改良及信度和效度检验. 中国脊柱脊髓杂志, 2017, 27(3): 235-241.
14. Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine: A preliminary report. Clin Orthop Relat Res, 1983, 174: 127-132.
15. Ahn Y, Lee S H, Park W M, et al. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine (Phila Pa 1976), 2004, 29(16): E326-E332.
16. Lee SH, Kang BU, Ahn Y, et al. Operative failure of percutaneous endoscopic lumbar discectomy: a radiologic analysis of 55 cases. Spine (Phila Pa 1976), 2006, 31(10): E285-E290.
17. Wu XB, Fan GX, Guan XF, et al. Percutaneous endoscopic lumbar discectomy for far-migrated disc herniation through two working channels. Pain Physician, 2016, 19(4): E675-E680.
18. Kim HS, Ju CI, Kim SW, et al. Endoscopic transforaminal suprapedicular approach in high grade inferior migrated lumbar disc herniation. J Korean Neurosurg Soc, 2009, 45(2): 67-73.
19. Yan Y, Wang Y, Yang J, et al. Percutaneous endoscopic lumbar discectomy for highly upmigrated disc herniation through the transforaminal isthmus plasty approach. World Neurosurg, 2018, 120: 511-515.
20. Kim JS, Choi G, Lee SH. Percutaneous endoscopic lumbar discectomy via contralateral approach: a technical case report. Spine (Phila Pa 1976), 2011, 36(17): E1173-1178.
21. Du J, Tang X, Jing X, et al. Outcomes of percutaneous endoscopic lumbar discectomy via a translaminar approach, especially for soft, highly down-migrated lumbar disc herniation. Int Orthop, 2016, 40(6): 1247-1252.
22. Ruetten S, Komp M, Merk H, et al. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976), 2008, 33(9): 931-939.
23. Choi KC, Kim JS, Ryu KS, et al. Percutaneous endoscopic lumbar discectomy for L₅-S₁ disc herniation: transforaminal versus interlaminar approach. Pain Physician, 2013, 16(6): 547-556.
24. Choi G, Prada N, Modi HN, et al. Percutaneous endoscopic lumbar herniectomy for high-grade down-migrated L₄-L₅ disc through an L₅-S₁ interlaminar approach: a technical note. Minim Invasive Neurosurg, 2010, 53(3): 147-152.
25. Hwa Eum J, Hwa Heo D, Son SK, et al. Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results. J Neurosurg Spine, 2016, 24(4): 602-607.
26. Xie X, Zhang G, Liu N. Clinical effect of unilateral biportal endoscopy in the treatment of lumbar diseases: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne, 2022, 17(1): 61-68.
27. Park HJ, Kim SK, Lee SC, et al. Dural tears in percutaneous biportal endoscopic spine surgery: Anatomical location and management. World Neurosurg, 2020, 136: e578-e585.
28. Kim JE, Choi DJ, Park EJ. Evaluation of postoperative spinal epidural hematoma after biportal endoscopic spine surgery for single-level lumbar spinal stenosis: clinical and magnetic resonance imaging study. World Neurosurg, 2019, 126: e786-e792.
29. Choi DJ, Choi CM, Jung JT, et al. Learning curve associated with complications in biportal endoscopic spinal surgery: Challenges and strategies. Asian Spine J, 2016, 10(4): 624-629.
30. 朱斌, 田大胜, 陈磊, 等. 单边双通道内镜技术在腰椎疾病中的应用研究进展. 中华骨科杂志, 2020, 40(15): 1030-1038.

Chinese Journal of Reparative and Reconstructive Surgery

Unilateral biportal endoscopic discectomy for high-grade migrated lumbar disc herniation

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