Background: Percutaneous endoscopic lumbar discectomy (PELD) has been growing in popularity
for the treatment of lumbar disc herniation (LDH) due to its irreplaceable advantages over
conventional open surgery. Compared with common lumbar disc herniations, discectomy of highly
migrated LDH by PELD is known to be very difficult. Highly migrated lumbar disc herniation has
long been a challenge for its specific characteristics. Three approaches for PELD have been applied
to access a highly migrated LDH, including an interlaminar approach (IL), transforaminal approach
(TF), and contralateral transforaminal approach (CTF). However, none of the existing research has
systematically described the selection of the most appropriate procedure from the 3 approaches or
the individualization of an operative procedure in different cases.
Objectives: The purpose of this study was to present a detailed surgical approach selection and
individualization of procedure in the treatment of highly migrated LDH with PELD. We also mean to
compare the outcomes of patients with highly migrated LDH treated with PELD by the 3 approaches.
Study Design: Single-center retrospective observational study.
Setting: An interventional pain management practice, a medical center, major metropolitan city,
China.
Methods: In our retrospective analysis between March 2011 and March 2013, 73 patients with
single level highly migrated LDH received PELD. Clinical outcomes were assessed with the visual
analogue scale (VAS) score, the modified MacNab criteria, and the Oswestry disability index (ODI).
Relevant data such as operation duration and fluoroscopy frequency of the 3 operative approaches
were recorded.
Results: The mean operating time of IL was 56 minutes, compared with 64 minutes for TF and
112 minutes for CTF. The mean intraoperative fluoroscopy times were 5.5 for IL, 9.7 for TF, and
14.6 for CTF. In each group, the mean VAS and ODI after surgery and 3 months after surgery
improved dramatically compared with preoperative counterparts. However, the difference between
postoperative results and the results 3 months after surgery was not significant (P > 0.05). The
overall excellent rate was 90.4% according to the modified MacNab criteria; there was no significant
statistical difference between the 3 operative routes. Operative complications occurred in 3 patients
(2 after IL and one after CTF, 3 of 73, 4.1%).
Limitations: This study is limited by its sample size.
Conclusion: In our research, PELD with all 3 approaches was similarly effective to highly
migrated disc herniation. The CTF approach required the longest operation duration and the
most intraoperative times. On the contrary, the least operation time and radiographfrequency was
required with the IL approach. In addition, we came to a conclusion of surgery approach selection
when it comes to varied HM-LDH.
Key words: Highly migrated, lumbar disc herniation, percutaneous endoscopic lumbar discectomy,
minimally invasive treatment
Pain Physician 2017;
State of the Art: Transforaminal Approach for Percutaneous Endoscopic Lumbar Discectomy under Local Anesthesia
