Name: Full-Endoscopic Transforaminal Approach for Lumbar Discectomy (Video) | JoVE Journal
Uploaded: 2023-09-08T13:50:00.000+00:00
Duration: 1 min 24 s
Description: Learn a minimally invasive full-endoscopic transforaminal approach for lumbar discectomy that avoids muscle retraction and bone removal. This technique enables safe decompression of nerve roots with faster patient recovery.

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5 minutes

There is no funding source for this study.

This study protocol has been approved by the Institutional Review Board of Istanbul University, Faculty of Medicine, ensuring adherence to ethical guidelines and patient safety. Additionally, prior to their participation in the study, informed consent was obtained from all patients.
1. Preoperative procedures
<ol>
	<li>Perform the surgery under general anesthesia, adhering to the institutionally approved protocol for anesthetization. Set the endoscope, optic instruments, and C-arm devices in the operating room (see Table of Materials).</li>
	<li>Check the tools before starting the procedure. 
	&#8203;NOTE: The necessary tools are: the dilator, beveled working sleeve, an endoscope with 20 degrees angle and 177 mm length with a 9.3 diameter oval shaft with a 5.6 mm diameter working channel, rongeur 3-4 mm, Kerrison punch 5.5 mm, punch 5.4 mm, burr round, fluid control irrigation and suction pump device, tip control radioablator applying a radiofrequency current of 4 MHz, 5.5 mm oval burr with lateral protection, and the diamond round (see Table of Materials).</li>
</ol>
2. Surgical technique
<ol>
	<li>Place the patient in a prone position with thorax and pelvis support pillows. One surgeon can perform the surgery, but an assistant would ease the procedure.</li>
	<li>Place the C- arm and obtain a lateral X-ray view to mark the posterior line of the facet. Obtain the anteroposterior (AP) view to mark the middle of the intervertebral disc space where the discectomy is intended. 
	NOTE: While obtaining the X-rays, ensure the end plates are parallel. The endplates are parallel when there is no double contour in the scan and only a superimposed single line.</li>
	<li>Perform a 1 cm skin incision by an 11-blade at the intersection of the lines.</li>
	<li>Place the 10-inch long 18 G spinal needle under the AP X-ray view until the medial border of the pedicle. Check the lateral X-ray view to be in the inferior border of the intervertebral foramen and dorsal and caudal to the dorsal border of the annulus fibrosis.</li>
	<li>Place the guide wire inside the spinal needle. Remove the spinal needle, and then introduce the dilator over the guide wire. While introducing the dilator, ensure its direction is the same as the guide wire.</li>
	<li>Obtain AP X-ray views while advancing the dilator for safe entry. Remove the guide wire when the dilator is in the foramen&#39;s caudal part and the pedicle&#39;s medial border in the AP view. Check the lateral view, so the dilator is dorsal to the annulus and not in the disc space.</li>
	<li>Introduce the beveled working sleeve over the dilator. Ensure that the handle of the beveled working sleeve is on the same side as the long edge of the instrument&#39;s tip.
	<ol>
		<li>When introducing the working sleeve, ensure the handle is in the dorsal aspect to protect the exiting nerve root. When the working sleeve is in place, rotate the working sleeve 180 degrees from the caudal side. 
		NOTE: Rotation from the caudal side is again to protect the exiting nerve root since the nerve root is superior to the working sleeve. On the inferior side is the caudal pedicle, which is the safer place to rotate the long edge of the beveled working sleeve.</li>
	</ol>
	</li>
	<li>Remove the dilator, and introduce the endoscope through the working sleeve.</li>
	<li>Visualize the annulus fibrosis, posterior longitudinal ligament (PLL), and epidural fat tissue. Do not enter the spinal canal since the pathology is not there.</li>
	<li>Coagulate bleeding to have clear visualization throughout the procedure. Here, one will see the ascending facet in the dorsal part, and in the inferior part, one will see the caudal pedicle.</li>
	<li>Rotate the working sleeve and the endoscope to the cranial aspect. This maneuver allows for a clear view of the vessels, fat tissue, and ligaments within the intervertebral foramen. Utilize the bipolar radioablator to coagulate these structures, and subsequently, remove them with the 3 mm rongeur.</li>
	<li>After removing the soft tissues, ensure that the disc fragment becomes visible, positioned superior to the annulus defect. Above the disc material, the exiting nerve root can be observed, which is being compressed by the disc fragment.</li>
	<li>Remove the disc fragment with the Kerrison punch and the rongeur. The disc fragment can appear larger during the surgery than it appears in preoperative magnetic resonance imaging (MRI) due to compression in a confined area. However, upon removal of the disc material, the nerve root is effectively decompressed. 
	NOTE: If bony stenosis exists in the intervertebral foramen, bone removal can be achieved by a 5.5 mm oval burr with lateral protection, burr round, or diamond round.</li>
	<li>Evacuate the disc space by using the existent annulus defect by rongeur. Especially for high intervertebral disc space, the evacuation of the disc space is recommended to prevent recurrent disc herniation.</li>
	<li>Seal the evacuated area and the annulus defect margins by coagulation to prevent recurrence.</li>
	<li>After hemostasis, complete the procedure by removing the endoscopic system. Use a single 3-0 suture for closure; no drainage is necessary.</li>
</ol>
3. Postoperative procedures and follow-up
<ol>
	<li>Ask the patients to begin oral intake in 6 h postoperatively. Mobilize the patients on the next day of the operation. 
	NOTE: Postoperative pain levels are minimal, eliminating the necessity for prolonged painkiller usage. To address any discomfort at the operation site, nonsteroidal anti-inflammatory drugs (NSAIDs) can be administered.</li>
	<li>Do not recommend physical therapy and rehabilitation or a lumbar corset.</li>
	<li>If the patient&#39;s symptoms have resolved after the surgery, do not perform a postoperative MRI.</li>
	<li>Remove the suture in the first week of operation.</li>
	<li>Recommend the patients to be admitted to the outpatient clinic in the first and fourth weeks of operation.</li>
</ol>

<ol><li>Eustacchio, S., Flaschka, G., Trummer, M., Fuchs, I., Unger, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+percutaneous+transforaminal+treatment+for+herniated+lumbar+discs%5BTitle%5D)+AND+%22Acta+Neurochirurgica%22%5BJournal%5D)">Endoscopic percutaneous transforaminal treatment for herniated lumbar discs.</a> Acta Neurochirurgica. 144 (10), 997-1004 (2002).</li>
<li>Haag, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+endoscopic+microdiscectomy.+Indications+and+short-term+to+intermediate-term+results%5BTitle%5D)+AND+%22Orthopade%22%5BJournal%5D)">Transforaminal endoscopic microdiscectomy. Indications and short-term to intermediate-term results.</a> Orthopade. 28 (7), 615-621 (1999).</li>
<li>Ebeling, U., Reichenberg, W., Reulen, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Results+of+microsurgical+lumbar+discectomy.+Review+on+485+patients%5BTitle%5D)+AND+%22Acta+Neurochirurgica%22%5BJournal%5D)">Results of microsurgical lumbar discectomy. Review on 485 patients.</a> Acta Neurochirurgica. 81 (1-2), 45-52 (1986).</li>
<li>Holtas, S., Jonsson, B., Strornqvist, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((No+relationship+between+epidural+fibrosis+and+sciatica+in+the+lumbar+postdiscectomy+syndrome.+A+study+with+contrast-enhanced+magnetic+resonance+imaging+in+symptomatic+and+asymptomatic+patients%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">No relationship between epidural fibrosis and sciatica in the lumbar postdiscectomy syndrome. A study with contrast-enhanced magnetic resonance imaging in symptomatic and asymptomatic patients.</a> Spine (Phila Pa 1976). 20 (4), 449-453 (1995).</li>
<li>Kim, S. S., Michelsen, C. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Revision+surgery+for+failed+back+surgery+syndrome%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">Revision surgery for failed back surgery syndrome.</a> Spine (Phila Pa 1976). 17 (8), 957-960 (1992).</li>
<li>Fritsch, E. W., Heisel, J., Rupp, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+failed+back+surgery+syndrome%3A+reasons%2C+intraoperative+findings%2C+and+long-term+results%3A+a+report+of+182+operative+treatments%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments.</a> Spine (Phila Pa 1976). 21 (5), 626-633 (1996).</li>
<li>Ruetten, S., Komp, M., Merk, H., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Full-endoscopic+interlaminar+and+transforaminal+lumbar+discectomy+versus+conventional+microsurgical+technique%3A+a+prospective%2C+randomized%2C+controlled+study%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study.</a> Spine (Phila Pa 1976). 33 (9), 931-939 (2008).</li>
<li>Ruetten, S., Komp, M., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((An+extreme+lateral+access+for+the+surgery+of+lumbar+disc+herniations+inside+the+spinal+canal+using+the+full-endoscopic+uniportal+transforaminal+approach-technique+and+prospective+results+of+463+patients%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients.</a> Spine (Phila Pa 1976). 30 (22), 2570-2578 (2005).</li>
<li>Kambin, P., Casey, K., O'Brien, E., Zhou, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+arthroscopic+decompression+of+lateral+recess+stenosis%5BTitle%5D)+AND+%22Journal+of+Neurosurgery%22%5BJournal%5D)">Transforaminal arthroscopic decompression of lateral recess stenosis.</a> Journal of Neurosurgery. 84 (3), 462-467 (1996).</li>
<li>Lew, S. M., Mehalic, T. F., Fagone, K. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+percutaneous+endoscopic+discectomy+in+the+treatment+of+far-lateral+and+foraminal+lumbar+disc+herniations%5BTitle%5D)+AND+%22Journal+of+Neurosurgery%22%5BJournal%5D)">Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations.</a> Journal of Neurosurgery. 94 (2 Suppl), 216-220 (2001).</li>
<li>Hua, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Full-endoscopic+discectomy+via+the+interlaminar+approach+for+disc+herniation+at+L4-L5+and+L5-S1%3A+An+observational+study%5BTitle%5D)+AND+%22Medicine%22%5BJournal%5D)">Full-endoscopic discectomy via the interlaminar approach for disc herniation at L4-L5 and L5-S1: An observational study.</a> Medicine. 97 (17), e0585(2018).</li>
<li>Ruetten, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+full-endoscopic+interlaminar+approach+for+lumbar+disc+herniations%5BTitle%5D)+AND+%22Minimally+Invasive+Spine+Surgery+%28Second+Edition%29%3A+A+Surgical+Manual%22%5BJournal%5D)">The full-endoscopic interlaminar approach for lumbar disc herniations.</a> Minimally Invasive Spine Surgery (Second Edition): A Surgical Manual. , 346-355 (2006).</li>
<li>Ruetten, S., Komp, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+Lumbar+Decompression%5BTitle%5D)+AND+%22Neurosurgery+Clinics+of+North+America%22%5BJournal%5D)">Endoscopic Lumbar Decompression.</a> Neurosurgery Clinics of North America. 31, 25-32 (2020).</li>
<li>Haag, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+endoscopic+microdiscectomy.+Indication+and+results%5BTitle%5D)+AND+%22Orthopade%22%5BJournal%5D)">Transforaminal endoscopic microdiscectomy. Indication and results.</a> Orthopade. 28 (7), 615-621 (1999).</li>
<li>Hoogland, T., Van Den Brekel-Dijkstra, K., Schubert, M., Miklitz, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+transforaminal+discectomy+for+recurrent+lumbar+disc+herniation%3A+a+prospective%2C+cohort+evaluation+of+262+consecutive+cases%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases.</a> Spine (Phila Pa 1976). 33 (9), 973-978 (2008).</li>
<li>Jang, J. S., An, S. H., Lee, S. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+percutaneous+endoscopic+discectomy+in+the+treatment+of+foraminal+and+extraforaminal+lumbar+disc+herniations%5BTitle%5D)+AND+%22Journal+of+Spinal+Disorders+and+Techniques%22%5BJournal%5D)">Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations.</a> Journal of Spinal Disorders and Techniques. 19 (5), 338-343 (2006).</li>
<li>Yeung, A. T., Tsou, P. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Posterolateral+endoscopic+excision+for+lumbar+disc+herniation%3A+Surgical+technique%2C+outcome%2C+and+complications+in+307+consecutive+cases%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases.</a> Spine (Phila Pa 1976). 27 (7), 722-731 (2002).</li>
<li>Tsou, P. M., Yeung, A. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+endoscopic+decompression+for+radiculopathy+secondary+to+intracanal+noncontained+lumbar+disc+herniations%3A+Outcome+and+technique%5BTitle%5D)+AND+%22Spine+Journal%22%5BJournal%5D)">Transforaminal endoscopic decompression for radiculopathy secondary to intracanal noncontained lumbar disc herniations: Outcome and technique.</a> Spine Journal. 2 (1), 41-48 (2002).</li>
<li>Kambin, P., Casey, K., O'Brien, E., Zhou, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+arthroscopic+decompression+of+lateral+recess+stenosis%5BTitle%5D)+AND+%22J+Neurosurg%22%5BJournal%5D)">Transforaminal arthroscopic decompression of lateral recess stenosis.</a> J Neurosurg. 84, 462-467 (1996).</li>
<li>Ruetten, S., Komp, M., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+New+full-endoscopic+technique+for+the+interlaminar+operation+of+lumbar+disc+herniations+using+6-mm+endoscopes%3A+prospective+2-year+results+of+331+patients%5BTitle%5D)+AND+%22Minim+Invasive+Neurosurg%22%5BJournal%5D)">A New full-endoscopic technique for the interlaminar operation of lumbar disc herniations using 6-mm endoscopes: prospective 2-year results of 331 patients.</a> Minim Invasive Neurosurg. 49, 80-87 (2006).</li>
<li>Ruetten, S., Komp, M., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((An+extreme+lateral+access+for+the+surgery+of+lumbar+disc+herniations+inside+the+spinal+canal+using+the+full-endoscopic+uniportal+transforaminal+approach-technique+and+prospective+results+of+463+patients%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients.</a> Spine (Phila Pa 1976). 30, 2570-2578 (2005).</li>
<li>Ruetten, S., Komp, M., Merk, H., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Full-endoscopic+interlaminar+and+transforaminal+lumbar+discectomy+versus+conventional+microsurgical+technique%3A+a+prospective%2C+randomized%2C+controlled+study%5BTitle%5D)+AND+%22Spine+%28Phila+Pa+1976%29%22%5BJournal%5D)">Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study.</a> Spine (Phila Pa 1976). 33, 931-939 (2008).</li>
<li>Mayer, H. M., Brock, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+endoscopic+discectomy%3A+surgical+technique+and+preliminary+results+compared+to+microsurgical+discectomy%5BTitle%5D)+AND+%22Journal+of+Neurosurgery%22%5BJournal%5D)">Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy.</a> Journal of Neurosurgery. 78 (2), 216-225 (1993).</li>
<li>Hermantin, F. U., Peters, T., Quartararo, L., Kambin, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+prospective%2C+randomized+study+comparing+the+results+of+open+discectomy+with+those+of+video-assisted+arthroscopic+microdiscectomy%5BTitle%5D)+AND+%22Journal+of+Bone+and+Joint+Surgery%22%5BJournal%5D)">A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy.</a> Journal of Bone and Joint Surgery. 81 (7), 958-965 (1999).</li>
<li>Ahn, Y., Lee, U., Kim, W. K., Keum, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Five-year+outcomes+and+predictive+factors+of+transforaminal+full-endoscopic+lumbar+discectomy%5BTitle%5D)+AND+%22Medicine%22%5BJournal%5D)">Five-year outcomes and predictive factors of transforaminal full-endoscopic lumbar discectomy.</a> Medicine. 97 (48), e13454(2018).</li>
<li>Park, H. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+Comparisons+of+surgical+outcomes+and+clinical+characteristics+between+the+far+lateral+lumbar+disc+herniations+and+the+paramedian+lumbar+disc+herniations%5BTitle%5D)+AND+%22Korean+Journal+of+Spine%22%5BJournal%5D)">The Comparisons of surgical outcomes and clinical characteristics between the far lateral lumbar disc herniations and the paramedian lumbar disc herniations.</a> Korean Journal of Spine. 10 (3), 155(2013).</li>
<li>O'Hara, L. J., Marshall, R. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Far+lateral+lumbar+disc+herniation.+The+key+to+the+intertransverse+approach%5BTitle%5D)+AND+%22Journal+of+Bone+and+Joint+Surgery%22%5BJournal%5D)">Far lateral lumbar disc herniation. The key to the intertransverse approach.</a> Journal of Bone and Joint Surgery. 79 (6), 943-947 (1997).</li>
<li>Nellensteijn, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+endoscopic+surgery+for+symptomatic+lumbar+disc+herniations%3A+a+systematic+review+of+the+literature%5BTitle%5D)+AND+%22European+Spine+Journal%22%5BJournal%5D)">Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature.</a> European Spine Journal. 19 (2), 181-204 (2010).</li>
<li>Kambin, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Arthroscopic+microdiscectomy%5BTitle%5D)+AND+%22Arthroscopy%22%5BJournal%5D)">Arthroscopic microdiscectomy.</a> Arthroscopy. 8 (3), 287-295 (1992).</li>
<li>Kim, M. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Targeted+percutaneous+transforaminal+endoscopic+diskectomy+in+295+patients%3A+comparison+with+results+of+microscopic+diskectomy%5BTitle%5D)+AND+%22Surgical+Neurology+International%22%5BJournal%5D)">Targeted percutaneous transforaminal endoscopic diskectomy in 295 patients: comparison with results of microscopic diskectomy.</a> Surgical Neurology International. 68 (6), 623-631 (2007).</li>
<li>Kafadar, A., Kahraman, S., Akbörü, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+endoscopic+transforaminal+lumbar+discectomy%3A+a+critical+appraisal%5BTitle%5D)+AND+%22Minimally+Invasive+Neurosurgery%22%5BJournal%5D)">Percutaneous endoscopic transforaminal lumbar discectomy: a critical appraisal.</a> Minimally Invasive Neurosurgery. 49 (2), 74-79 (2006).</li>
</ol>

The authors report no conflict of interest concerning the materials or methods used in this study.

In cases of spinal disc herniation, achieving complete decompression is essential and can be optimally accomplished under visual control17,18,19. Technical advancements have made it possible to achieve such decompression even through a full-endoscopic approach. The development of improved optics, endoscopes, and instruments introduced through the working channel has expanded the safe usage of this technique20</...

The full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity as a minimally invasive technique in various medical centers. It offers the advantage of requiring less muscular retraction and bone removal compared to conventional techniques1,2. Over time, the technique has undergone advancements since its initial description. Conventional surgeries have shown good results; however, epidural fibrosis occurs in around 10% of cases, leading to symptoms3,4.
The transforaminal approach provides lateral access, eliminating the risk of disrupting spinal canal structures, making it a more physiological route and reducing the risk of operation-induced destabilization. It also facilitates easier revision surgery if needed5,6,7,8. ETALD is effective in removing both intra- and extraforaminal disc herniations, and it allows for the removal of disc material from the spinal canal by approaching the disc space9,10.
Despite its advantages, ETALD does have limitations, such as limited access due to abdominal and pelvic structures, and obstruction by a high iliac crest8,11,12,13. Initially, disc space evacuation was required for adequate decompression, but with advancements in surgical tools and optics, direct visualization enables the removal of the disc fragment from its location14,15,16.
The primary goal of this new procedure is to minimize tissue damage and reduce negative long-term outcomes. This study aims to describe the current technique for ETALD in detail.

<table><tbody><tr><td>BURR OVAL &amp;Oslash; 5.5 mm</td><td>RiwoSpine</td><td>899751505</td><td>PACK=1 PC, WL 290 mm, with lateral protection</td></tr><tr><td>C-ARM</td><td>ZIEHM SOLO</td><td></td><td>C-arm with integrated monitor</td></tr><tr><td>DILATOR ID 1.1 mm OD 9.4 mm</td><td>RiwoSpine</td><td>892209510</td><td>For single-stage dilatation, TL 235 mm, reusable</td></tr><tr><td>ENDOSCOPE</td><td>RiwoSpine</td><td>892103253</td><td>20 degrees viewing angle and 177 mm length with a 9.3 mm diameter oval shaft with a 5.6 mm diameter working channel</td></tr><tr><td>KERRISON PUNCH 5.5 x 4.5 mm WL 380 mm</td><td>RiwoSpine</td><td>892409445</td><td>60&lt;sub&gt;&amp;deg;&lt;/sub&gt;, TL 460 mm, hinged pushrod, reusable</td></tr><tr><td>PUNCH &amp;Oslash; 3 mm WL 290 mm</td><td>RiwoSpine</td><td>89240.3023</td><td>TL 388 mm, with irrigation connection, reusable</td></tr><tr><td>PUNCH &amp;Oslash; 5.4 mm WL 340 mm</td><td>RiwoSpine</td><td>892409020</td><td>TL 490 mm, with irrigation connection, reusable</td></tr><tr><td>RADIOABLATOR RF BNDL</td><td>RiwoSpine</td><td>23300011</td><td></td></tr><tr><td>RF INSTRUMENT BIPO &amp;Oslash; 2.5 mm WL 280 mm</td><td>RiwoSpine</td><td>4993691</td><td>for endoscopic spine surgery, flexible insert, integrated connection cable WL 3 m&lt;br/&gt; with device plug to Radioblator RF 4 MHz, sterile, for single use&amp;nbsp;</td></tr><tr><td>RONGEUR &amp;Oslash; 3 mm WL 290 mm</td><td>RiwoSpine</td><td>89240.3003</td><td>TL 388 mm, with irrigation connection, reusable</td></tr><tr><td>WORKING SLEEVE ID 9.5 mm OD 10.5 mm</td><td>RiwoSpine</td><td>8922095000</td><td>TL 120, distal end beveled, graduated, reusable</td></tr></tbody></table>

full-endoscopic transforaminal approach for lumbar discectomy

Full-Endoscopic Transforaminal Approach for Lumbar Discectomy

With technical advancements, the full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity. This technique utilizes various tools and instruments, including a dilator, a beveled working sleeve, and an endoscope with a 20-degree angle and 177 mm length, equipped with a 9.3-diameter oval shaft and a 5.6 mm diameter working channel. Additionally, the procedure involves using a Kerrison punch (5.5 mm), rongeur (3-4 mm), punch (5.4 mm), tip control radioablator applying a radiofrequency current of 4 MHz, fluid control irrigation and suction pump device, 5.5 mm oval burr with lateral protection, burr round, and the diamond round. During the surgery, it is essential to identify significant landmarks, including the caudal pedicle, ascending facet, annulus fibrosis, posterior longitudinal ligament, and the exiting nerve root. The steps of the technique are relatively easy to follow, especially when utilizing the appropriate instruments and having a good understanding of the anatomy. Research studies have demonstrated comparable outcomes to open microdiscectomy techniques. ETALD presents itself as a safe option for lumbar discectomy, as it minimizes tissue disruption, results in low postoperative surgical site pain, and allows for early mobilization.

The preoperative Magnetic Resonance Imaging (MRI) scans reveal a left paracentral extruding disc herniation that was causing compression on the left L5 nerve root. However, the postoperative MRI scans demonstrate successful decompression of the left L5 nerve root, as depicted in Figure 1. Throughout the procedure, continuous irrigation was utilized, making it challenging to precisely measure the exact amount of blood loss. Nonetheless, it is noteworthy that none of the patients required sign...

The present protocol describes the full-endoscopic transforaminal approach for lumbar discectomy, which is a safe technique that does not require muscle retraction or bone removal.

With technical advancements, the full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity. This technique utilizes ...

full-endoscopic-transforaminal-approach-for-lumbar-discectomy

Research

JoVE Journal

Neuroscience

Here we present a protocol of a novel outside-in technique of transforaminal endoscopic discectomy for lumbar disc herniations. The technical aspects of the technique, the wide indications of use, and the results of the treatment in 184 patients are described in detail.

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

Presented here is a novel technique of C-arm free transtubular posterolateral decompression for lumbar foraminal stenosis and lateral disc herniation under O-arm navigation.

Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation

Here, we present a protocol to describe the full endoscopic interlaminar approach (FEILA) technique, including every cutoff step required to reach technical proficiency. FEILA is a surgery with a relatively steep learning adaptation. Despite this, any surgeon capable of microdiscectomy can perform FEILA with enough practice and suitable patient selection.

Full Endoscopic Interlaminar Approach for Paracentral L5-S1 Disc Herniation

This protocol provides a step-by-step guide for performing transforaminal full-endoscopic foraminotomy under local anesthesia. This motion-preserving technique is presented as a minimally invasive surgical alternative to fusion extension for treating L5/S1 foraminal stenosis in patients with adjacent segment disease.

Transforaminal Full-Endoscopic Lumbar Foraminotomy Under Local Anesthesia for L5/S1 Adjacent Segment Foraminal Stenosis

Phosphenes are transient percepts of light that can be induced by applying Transcranial Magnetic Stimulation (TMS) to visually sensitive regions of cortex. We demonstrate a standard protocol for determining the phosphene threshold value and introduce a novel method for quantifying and analyzing perceived phosphenes.

A Novel Approach for Documenting Phosphenes Induced by Transcranial Magnetic Stimulation

The VisioTracker is an automated system for the quantitative analysis of visual performance of larval and small adult fish based on the recording of eye movements. It features full control over visual stimulus properties and real-time analysis, enabling high-throughput research in fields such as visual system development and function, pharmacology, neural circuit studies and sensorimotor integration.

VisioTracker, an Innovative Automated Approach to Oculomotor Analysis

Subretinal injection is a surgical technique for effective gene delivery to retinal pigment epithelium in the mouse eye.  Here we describe an easy and replicable method for subretinal injection of viral vectors to retinal pigment epithelium in experimental mice.

Limbal Approach-Subretinal Injection of Viral Vectors for Gene Therapy in Mice Retinal Pigment Epithelium

During fruit fly fights, the behavioral patterns observed, fight dynamics, and associated learning and memory are influenced by experimental conditions. The protocol presented here describes a novel procedure that entirely eliminates handling of flies during experiments. This improves fight dynamics and allows formation of strong "loser" effects.

A New Approach that Eliminates Handling for Studying Aggression and the "Loser" Effect in Drosophila melanogaster

Subretinal injections are the most common technique for delivering large therapeutic agents such as proteins and viral vectors to photoreceptors and the retinal pigment epithelium. An alternative method in mice that successfully targets the subretinal space with minimal collateral damage and fast recovery times is described here.

An Alternative and Validated Injection Method for Accessing the Subretinal Space via a Transcleral Posterior Approach

The aim of this paper is to describe the different steps of the endoscopic endonasal approach to the sella turcica.

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

Learn a minimally invasive full-endoscopic transforaminal approach for lumbar discectomy that avoids muscle retraction and bone removal. This technique enables safe decompression of nerve roots with faster patient recovery.

Full-Endoscopic Transforaminal Approach for Lumbar Discectomy

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