Two Cases of Iatrogenic Lumbar Foraminal Disc Herniations

Study Design. A case report. Objective. We report two cases of iatrogenic deterioration of lumbar foraminal disc herniations following lumbar disc injections. Summary of Background Data. Complications associated with discography were reported. However, only a few reports have thus far referred to the iatrogenic deterioration of lumbar foraminal disc herniations. Cases. 60-year-old and 74-year-old men were treated with MR images of L4-5 foraminal disc herniations without fragment in the spinal canal. The patients underwent discography and disc block for its diagnosis and treatment. After disc injections, both patients complained of deterioration of L4 radiculopathy. Results. On disco-CT or reexamined MR images after disc injections, herniated fragment was migrated from neural foramen to cranial central spinal canal with was not shown in previous MR images. The herniated fragments were extirpated by means of osteoplastic laminoplasty or transforaminal lumbar interbody fusion with facetectomy. The herniated fragments were migrated from neural foramen to cranial central spinal canal. Conclusions. The injection of liquid medicine into the nucleus led the intradiscal pressure increased, and the disc fragment might prolapsed through the raptured region of annulus fibrosus and migrated to cranial central spinal canal by anatomical reason. The disc injection may have a risk for deterioration of foraminal disc herniation. Our report is instructive for the management of discography for the diagnosis of foraminal disc herniations.

Surgical Techniques Ensuring Success in Posterior Endoscopic Cervical Foraminotomy and Discectomy at C6-7 in Patients with Prominent Shoulders and Short Necks

Introduction: There is a steep learning curve for a successful posterior endoscopic cervical foraminotomy and discectomy (PECFD), an important surgery for cervical foraminal or lateral disc herniation, and cervical radiculopathy due to a small operation field. PECFD becomes even more challenging in patients who have prominent shoulders and/or short necks with C6–7-disc herniation, because of the difficulty to localize C6–7 vertebral structure under fluoroscopy. The study objective is to prove that the PECFD can be performed safely and successfully to C6–7-disc herniation on patients with prominent shoulders and/or short necks following our novel surgical techniques under fluoroscopic guidance. Materials and Methods: PECFD was performed on a patient who had an extruded foraminal disc herniation at C6–7 on the left with left arm pain and weakness. Due to his prominent shoulders and a short neck, the C6–7 anatomic site was not visible under traditional anterior-posterior (AP) and lateral fluoroscopic views. The authors inserted a reference needle to C4–5 facets between C4 and C5 pedicles under AP and lateral fluoroscopic views. Following the reference needle, the C6–7 facets were easily located with an oblique fluoroscopic view. A large endoscopic cannula was used initially for adequate resection of C6–7 facets, followed by a small cannula for nerve root handling with minimal pressure and discectomy. Results: The novel surgical techniques resulted in a complete resection of the C6–7-disc herniation and resolution of the patient’s radiculopathy with no postoperative complications. Conclusion: PECFD can be safely and successfully applied for C6–7-disc herniation in patients with prominent shoulders and/or short necks using our novel surgical techniques.

Minimally Invasive Laminotomy for Contralateral “Over-the-Top” Foraminal Decompression Using 3-Dimensional Total Navigation: 2-Dimensional Operative Video

This video demonstrates the step-by-step surgical technique for the minimally invasive laminotomy for contralateral “over-the-top” foraminal decompression. This technique allows for excellent decompression with clearance of the contralateral recess and foramen. In the video, we present the case of a 51-yr-old female patient with a past medical history of left L5-S1 microdiscectomy who presented in clinic with residual/recurrent foraminal disc herniation at L5-S1 compressing the left L5 nerve root. The patient had left lower extremity pain in the left hip and thigh that radiated down the front and side of the leg, as well as tingling and numbness in the left foot. The patient was treated via a L5-S1 microdiscectomy using a portable intraoperative computed tomography scanner, (Airo®, Brainlab AG, Feldkirchen, Germany), combined with 3-dimensional (3D) computer navigation. Patient consent was obtained prior to performing the procedure. The main advantage of this technique is the direct “over-the-top” trajectory to the foraminal pathology that minimizes the need of facet joint resection. The use of 3D navigation facilitates surgical planning and further minimizes facet joint compromise. Particularly, the inferior facet contralateral to the approach side as well as its outer capsular surroundings can be preserved. Recent biomechanical studies have shown that “over-the-top” decompression produces significantly less instability than a traditional open midline laminectomy.

Posterolateral Endoscopic Lumbar Decompression Rotate-to-Retract Technique for Foraminal Disc Herniation: A Technical Report

Background and Study Aim. Foraminal disc herniations present the unique surgical challenge for exiting nerve root retraction and decompression. The aim of current study is to describe an innovative maneuver and evaluate its usefulness for endoscopic decompression of foraminal disc herniations.Material and Methods. A retrospective review was performed including cases of foraminal disc herniations who underwent endoscopic discectomy utilizing the rotate-to-retract technique. Data on patient demographics and improvement in VAS/ODI scores were collected and analyzed statistically.Results. There were ten patients (three male; seven female) in the final analysis. Seven procedures were done at the L4-L5 level, two were done at the L5-S1 level, and one was done at the L3-L4 level. The average VAS scores improved from preoperatively 7.5 to postoperatively 4.4 (p= 0.001). The mean preoperative ODI was 67.8 and improved to 26.6 postoperatively (p< 0.001). None of the cases reported any neurological or dural complication.Conclusion. Foraminal disc herniations can be safely and adequately addressed endoscopically with the use of rotate-to-retract technique.

Minimally Invasive Full-Endoscopic Posterior Cervical Foraminotomy Assisted by O-Arm-Based Navigation

Background: Navigated percutaneous endoscopic cervical discectomy (PECD) is a promising minimally invasive surgery for treating cervical spondylotic radiculopathy. PECD has been described as a safe, effective, and minimally invasive method for patients with radiculopathy, but it comes with a steep learning curve. Due to the limited field of vision, anatomic localization is difficult for surgeons until using the O-arm based navigation. In this study, patients with radiculopathy due to foraminal disc herniation or foraminal stenosis in the lower cervical spine underwent the single level full endoscopic posterior cervical foraminotomy procedure assisted by O-arm-based navigation. Objective: The purpose of this study was to evaluate the clinical, radiological outcome and the factors predicting an excellent outcome of patients who underwent full endoscopic posterior cervical foraminotomy procedure assisted by O-arm-based navigation. Study Design: A retrospective analysis of consecutively prospectively collected data. Setting: This study was conducted by a university-affiliated hospital in a major Chinese city. Methods: Forty-two patients who had single-level foraminal disc herniation or foraminal stenosis were retrospectively reviewed. Radicular arm pain was the most common presenting symptom in patients. All patients underwent full-endoscopic posterior cervical foraminotomy assisted by O-arm-based navigation. Clinical outcomes were assessed by the visual analog scale (VAS) for neck and radicular arm pain, neck disability index (NDI), and the short form-36 health survey questionnaire (SF-36) in the immediate preoperative period, immediately postoperative, and at the final follow-up. The clinical parameters and radiological parameters included cervical curvature (CA), segmental angle (SA), and range of motion (ROM), which were assessed preoperatively and at the last follow-up. Results: The mean follow-up for the patients was 15 months. There were no perioperative complications. The VAS score for radicular arm pain and neck pain and the NDI score improved significantly in all of the patients. The SF-36 score reflected significant improvement in all 8 domains. Excellent and good outcomes were achieved in 38 out of 42 patients. The cervical curvature range of motion (CA-ROM) statistically and significantly improved at the final follow-up period compared with the preoperative period. The SA was less kyphotic after PECD at the final follow-up. The postoperative CA and CA-ROM improved but did not significantly change. On the univariate analysis, patients with a symptom duration of less than 3 months had a better outcome than patients with a symptom duration of more than 3 months (excellent, 83.33% vs. 50.00%). Limitations: This was a retrospective study with medium follow-up outcomes (mean 15 months). Conclusions: The results of this study show that the full endoscopic posterior foraminotomy assisted by O-arm-based navigation is a safe and effective option for cervical radiculopathy, with the advantages of a minimally invasive method. Patients with symptom duration less than 3 months had a better outcome than patients with symptom duration more than 3 months. Key words: Minimally invasive, cervical foraminotomy, endoscopic, navigation, O-arm, percutaneous endoscopic cervical discectomy