Two-level percutaneous endoscopic lumbar discectomy for highly migrated upper lumbar disc herniation: A case report

BACKGROUND The technique of percutaneous endoscopic lumbar discectomy(PELD)as a transforaminal approach has been used to treat highly migrated lower lumbar disc herniations.However,due to the different anatomic characteristics of the upper lumbar spine,conventional transforaminal PELD may fail to remove the highly migrated upper lumbar disc nucleus pulposus.Therefore,the purpose of this study was to describe a novel surgical technique,two-level PELD,for the treatment of highly migrated upper lumbar disc herniations and to report its related clinical outcomes.CASE SUMMARY A 60-year-old male presented with a complaint of pain at his lower back and right lower limb.The patient received 3 mo of conservative treatments but the symptoms were not alleviated.Physical examination revealed a positive femoral nerve stretch test and a negative straight leg raise test for the right leg,and preoperative visual analog scale(VAS)score for the lower back was 6 points and for the right leg was 8 points.Magnetic resonance imaging(MRI)demonstrated L2-L3 disc herniation on the right side and the herniated nucleus pulposus migrated to the upper margin of L2 vertebral body.According to physical examination and imaging findings,surgery was the primary consideration.Therefore,the patient underwent surgical treatment with two-level PELD.The pain symptom was relieved and the VAS score for back and thigh pain was one point postoperatively.The patient was asymptomatic and follow-up MRI scan 1 year after operation revealed no residual nucleus pulposus.CONCLUSION Two-level PELD as a transforaminal approach can be a safe and effective procedure for highly migrated upper lumbar disc herniation.

Learning curves of percutaneous endoscopic lumbar discectomy in transforaminal approach at the L4/5 and L5/S1 levels: a comparative study

Objectives： This study aimed to compare the learning curves of percutaneous endoscopic lumbar discectomy （PELD） in a transforaminal approach at the L4/5 and L5/S1 levels. Methods： We retrospectively reviewed the first 60 cases at the L4/5 level （Group I） and the first 60 cases at the L5/S1 level （Group II） of PELD performed by one spine surgeon. The patients were divided into subgroups A, B, and C （Group I： A cases 1-20, B cases 21-40, C cases 41-60; Group I1： A cases 1-20, B cases 21-40, C cases 41-60）. Operation time was thoroughly analyzed. Results： Compared with the L4/5 level, the learning curve of transforaminal PELD at the L5/S1 level was flatter. The mean operation times of Groups IA, IB, and IC were （88.75±17.02）, （67.75±6.16）, and （64.85±7.82） min, respectively. There was a significant difference between Groups A and B （P〈0.05）, but no significant difference between Groups B and C （P=-0.20）. The mean operation times of Groups IIA, liB, and IIC were （117.25±13.62）, （109.50±11.20）, and （92.15±11.94） rain, respectively. There was no significant difference between Groups A and B （P=0.06）, but there was a significant difference between Groups B and C （P〈0.05）. There were 6 cases of postoperative dysesthesia （POD） in Group I and 2 cases in Group IIA （P=-0.27）. There were 2 cases of residual disc in Group I, and 4 cases in Group II （P=0.67）. There were 3 cases of recurrence in Group I, and 2 cases in Group II （P〉0.05）. Conclusions： Compared with the L5/S1 level, the learning curve of PELD in a transforaminal approach at the L4/5 level was steeper, suggesting that the L4/5 level might be easier to master after short-term professional training.