|Year : 2022 | Volume
| Issue : 4 | Page : 193-194
Endoscopic techniques for lumbar degenerative disc disease: The problem of plenty!
Chandrashekhar Gendle, Sivashanmugam Dhandapani
Department of Neurosurgery, PGIMER, Chandigarh, India
|Date of Submission||17-Dec-2022|
|Date of Acceptance||19-Dec-2022|
|Date of Web Publication||30-Dec-2022|
Department of Neurosurgery, PGIMER, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gendle C, Dhandapani S. Endoscopic techniques for lumbar degenerative disc disease: The problem of plenty!. J Spinal Surg 2022;9:193-4
Lumbar degenerative disc disease is a common condition that can lead to low backache, radicular pain, sensory symptoms, and/or motor deficits. While many patients get stabilized on conservative management with motor control exercises, refractory symptoms or motor deficits warrant surgical intervention. A plethora of surgical options are available to tackle lumbar disc disease, such as open surgery, microsurgery, microendoscopy, full endoscopy, and biportal endoscopy, through interlaminar or transforaminal corridors.
Postoperative complications and prolonged hospital stay following open surgery have become obsolete due to rapidly growing technology, continuous refinements in surgical techniques, and popularity aiding in progressive minimalism. The undisputed advantages of these minimally invasive techniques noted in literature over open surgery are smaller incisions, lesser paravertebral soft-tissue injury, preservation of bony and ligamental structures, minimal blood loss, speedy recovery, early mobilization, and fewer wound infections.
The interlaminar corridor has been the gold standard for lumbar disc surgery, utilized by open surgery, microsurgery, microendoscopy (Destandau, EasyGo, and other modifications), biportal endoscopy, and full-endoscopic interlaminar surgery. While the access ports and instruments differ, the primary surgical concept is similar, making these relatively familiar and easy to learn and practice. Other advantages of the interlaminar approach are the feasibility of decompressing thickened ligamentum flavum, short access to large posteriorly extruded discs, and lesser radiation exposure. Moreover, it can be utilized at any spinal level with no anatomical restrictions. The differences in outcome measures between different interlaminar techniques have been minor and of uncertain relevance till good prospective comparative data become available.
The full-endoscopic transforaminal surgery is founded on the concept of Kambin's triangle at each side of the intervertebral area, formed by exiting nerve root, superior articular process, and superior endplate. It was revolutionary, opening up an unconventional corridor, making the surgery less disruptive and almost stitchless. The two schools of Yeung (inside-out) and Hoogland (outside-in) have their own merits and can be individualized. However, the proximity of transforaminal access to the exiting root mandated awake surgery, which can be simultaneously both convenient and uncomfortable. The transforaminal approach is the least invasive, especially for foraminal and extraforaminal discs, and has the least risk for a dural tear. However, it has a steep learning curve, difficult with L5-S1 level, high iliac crest, vertically migrated discs, extremely narrow foramen, bulky articular processes, large extruded discs at the axilla, and low-lying segmental vessel. The most significant disadvantage of the transforaminal approach is the need for frequent imaging and attendant radiation exposure.
Comparative meta-analyses between transforaminal and interlaminar endoscopies have not shown a significant difference in terms of postoperative dysesthesia, nerve root injury, surgical site complication, recurrence, hospital stay, disability and pain scores, conversion to open surgery, incomplete decompression, and cost-effectiveness., While an increasing number of poor-quality studies are being conducted to compare different surgical methods, the technical obsession is probably pushing the need for good-quality evidence on when to do surgery to the rear.
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