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.

Segmental artery injury during transforaminal percutaneous endoscopic lumbar discectomy:Two case reports

BACKGROUND Since Kambin experimentally induced arthroscopy to treat herniated nucleus pulposus,percutaneous endoscopic lumbar discectomy(PELD)has been developed.The branch of the segmental artery around the neural foramen may be damaged during PELD using the transforaminal approach.We report 2 rare cases in which segmental artery injury that occurred during PELD was treated with emergency embolization.CASE SUMMARY In case 1,a 31-year-old man was transferred to our emergency department with left lower quadrant abdominal pain after PELD at a local hospital.Lumbar spine magnetic resonance imaging after the surgery showed a hematoma of the left retroperitoneal area and the psoas muscle area.Under suspicion of vascular injury,arteriography was performed.Pseudoaneurysm and blood leakage from the left 4th lumbar segmental artery into the abdominal cavity were identified.Emergency transarterial embolization was performed using fibered microcoils for bleeding of the segmental artery.In case 2,a 75-year-old woman was transferred to our emergency department with low blood pressure,right flank pain,and drowsy mental status after PELD at a local hospital.When the patient arrived at the emergency room,the blood pressure decreased from 107/55 mmHg to 72/47 mmHg.Low blood pressure persisted.Under suspicion of vessel injury,arteriography was performed,and the right 4th lumbar segmental artery rupture was confirmed.Emergency transarterial embolization was performed for bleeding of segmental artery.CONCLUSION We were able to find the bleeding focus by angiography and treat the injury of the segmental artery successfully through emergency transarterial embolization.

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.

Postoperative discal pseudocyst and its similarities to discal cyst:A case report

BACKGROUND Postoperative discal pseudocyst(PDP)is a rare condition that presents after surgery for lumbar disc herniation.Due to the lack of information,the diagnosis and treatment of PDP remain controversial.Herein,we report a PDP case that occurred following percutaneous endoscopic lumbar discectomy and received conservative treatment.Additionally,we review all the published literature regarding PDP and propose our hypothesis regarding PDP pathology.CASE SUMMARY A 23-year-old man presented with a relapse of low back pain and numbness in his left lower extremity after undergoing percutaneous endoscopic lumbar discectomy for lumbar disc herniation.Repeat magnetic resonance imaging demonstrated a cystic lesion at the surgical site with communication with the inner disc.The patient was diagnosed as having PDP.The patient received conservative treatment,which resulted in rapid improvement and spontaneous regression of the lesion,and had a favorable outcome in follow-up.CONCLUSION PDP and discal cyst(DC)exhibit similarities in both histological and epidemiological characteristics,which indicates the same pathological origin of PDP and DC.The iatrogenic annular injury during discectomy might accelerate the pathological progression of DC.For patients with mild to moderate symptoms,conservative treatment can lead to great improvement,even inducing spontaneous regression.However,surgical cystectomy is necessary in patients with neurological deficits and where conservative treatment is ineffective.