A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

The treatment model it is for combating degenerative rheumitis. It has been continuously evolving from open surgery and fixation to microdiscectomy to endoscopy as demonstrated here in. The advantages of full endoscopic spine surgeries are less soft tissue dissection, reduce the blood loss, and half the remission or the functional recovery, and the quality of life the next month.

Adjust the patient in the prone position on the radiolucent operating table with the spine in slight flexion and use a marking pen and an image intensifier to mark the midline of the spine as well as the extent of the iliac crest. To indicate the paraspinal skin entry point along the center of the disc space, use the manual back assessment method to check the borderline between the back muscles and the abdominal muscles and mark the skin entry points just medial to this borderline at the mid disc level in both anteroposterior and lateral x-rays. Next, infiltrate two milliliters of subcutaneous local anesthetic around the entry point and make a one centimeter skin incision in the desensitized skin.

Insert an 18 gauge spinal needle through the incision at a 25 to 35 degree horizontal angle passing the needle under the image intensifier through the fascia and the back muscles and docking the needle at Camben's triangle near the intervertebral disc. Then, deliver 1.5 milliliters of contrast dye through the needle tip to check the free epidural space within the triangle. Using fluoroscopy, insert the needle into the discal space followed by a delivery of 2 milliliters of 0.8%indigo carmine mixed with contrast agent.

For insertion of the endoscope, first insert a guide wire over the needle into the discal space and remove the needle. Slide an obturator through the guide wire into Camben's triangle and anchor the obturator over the surface of the disc space. Then, insert the working cannula through the obturator followed by the introduction of the endoscope into the triangle.

Observe the epidural fat and soft tissues from the triangle to the entry into the disc space and use the radio frequency coagulator to clear the soft tissue and blood vessels over the annulus. Use an annular cutter to perform an annular fenestration and enter the annulus under endoscopic vision. Insert the bevel of the working cannula into the fenestrated annulus and lever the cannula downward to obtain an exact half and half view of the epidural and disc spaces.

After sufficient decompression of the protruded disc change the trajectory of the cannula toward the symptomatic disc area and check the free floating dural sack exiting route and traversing route to confirm that all free fragments of the disc are removed. Then, rotate the working channel and the endoscope to free the epidural space and image the patient by MRI on the day after the surgery. In this representative clinical study, the age of the study group was 50 plus or minus 16 years and the male to female ratio was two to one.

The patients were further divided by type of disc prolapse with over 97%of patients reporting good to excellent MacNab criteria at surgical follow up, and recurrence observed in only 15 out of the 190 levels operated on. More, improvement in the visual analog scale and Oswestry Disability Index scores was noted immediately after the surgery, remaining statistically significant through follow up. The future applications of the described technique are for all wide area of disc lumbar prolapses.

Even patients with high canal compromise and a down migrated disc can be adequately managed by percutaneous endoscopic transformal lumbar discectomy or PTLD. By precisely targeting the compressing element of the disc this technique can provide an optimal region within the frame to help achieve the desired results. The mobile outside and PTLD technique can be used to treat all types of lumbar disclination including high canal compromise due to the mobility of the working canal toward the target point.

This technique can be applied to all types of lumbar disclination at all lumbar levels.