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Fully Endoscopic Uniportal Interlaminar Microdiscectomy

The conventional approach to the lumbar discectomy requires significant tissue dissection to obtain a sufficient working space and is known to cause possible complications and injuries. The minimally invasive, fully endoscopic uniportal interlaminar discectomy provides numerous advantages to the typical open procedure. Some advantages include: good visualization of anatomical structures utilizing continuous lavage; lower rates of operative complications such as dural injury, bleeding, and infection; and shorter hospitalization, with increased post-operative rehabilitation. Surgical procedure utilizes guided fluoroscopy to gain access to the interlaminar window, with subsequent placement of the working channel endoscope. Microscopic debridement of herniated lumbar disc and decompression of nerve roots is conducted.

This case highlights a patient with significant disc herniation at the L5-S1 level with concurrent mild to moderate cervicothoracic scoliosis. The patient elected for the minimally invasive, fully endoscopic interlaminar microdiscectomy.

Authors: William Fuell, Eylem Ocal M.D., Salih Aydin M.D.

Institutions: Emsey Hospital-Istanbul, Arkansas Children’s Hospital

Fully endoscopic uniportal interlaminar microdiscectomy.
- A case deemed inoperable via the conventional open procedure due to interlaminar access being required. - Recurrent herniation after prior conventional procedure. - Spinal canal stenosis.
The main complication that arises when deciding to elect for a fully endoscopic uniportal procedure is the surgeon’s lack of experience with the technique. In addition, conditions limiting interlaminar access such as multisegmented fusions and extensive central spinal canal stenosis are contraindicated.
The patient was placed under general anesthesia while prone and in flexion to gain access to the interlaminar window.
A full patient history, MRI, and X-ray imaging was obtained to confirm a significant lumbar disc herniation at the L5-S1 level. Mild to moderate scoliosis in the cervicothoracic was noted, and there was no spondylolisthesis.
Initial skin incision markings were made at the L5-S1 level as medial as possible to spinous process line on the right side. Fluoroscopic guidance was used to aid the insertion of an 18-gauge spinal needle below the zygapophyseal joint, lateral to the S1 traversing nerve root to gain access to the interlaminar window.
The advantages of a minimally invasive procedure are numerous in comparison to the conventional open procedure. - Reduced ligamentous and bony resection required for visualization. - Lower incidence of intraoperative complications such as dural injury, infection, and bleeding. - Decreased hospitalization time and increased rate of rehabilitation. - Reduced trauma to the surrounding tissue. The disadvantages associated with the interlaminar procedure is that it requires a defect in the ligamentum flavum and the possible inexperience of the surgeon.
With the endoscopic technique, if a dural injury were to occur, a switch to the open procedure would be required to suture the dura. Long-term medial retraction of the thecal sac is to be avoided, with intermittent retraction with the operating sheath being optimal for reducing the risk of neurological damage. Conventional risks that accompany any surgical procedure such as infection and bleeding are possible.
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[1] Ruetten, S. (2010). Full-endoscopic interlaminar lumbar discectomy and spinal decompression. Minimally Invasive Percutaneous Spinal Techniques E-Book, 351. [2] Schick U, Dohnert J, Richter A, et al. Microendoscopic lumbar discectomy versus open surgery: An intraoperative EMG study. Eur Spine J 2002;11:20–26 [3] Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome and complications in 307 consecutive cases. Spine 2002;27:722–731. [4] Ruetten S. The full-endoscopic interlaminar approach for lumbar disc herniations. In: Mayer HM, editor. Minimally Invasive Spine Surgery: A Surgical Manual. 2nd ed. New York: Springer; 2005. p. 346–355 [5] Mathews HH. Transforaminal endoscopic microdiscectomy. Neurosurg Clin N Am 1996;7:59–63.

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