A Suture Technique for Ruptured Annulus Fibrosus Following Decompression Under Percutaneous Transforaminal Endoscopic Discectomy

This protocol describes an innovative suture technique for ruptured annular fibrosus during percutaneous transforaminal endoscopic discectomy.

This research describes an innovative suture technique for ruptured annular fibrosis during percutaneous transforaminal endoscopic discectomy. We proposed a method of suturing the annular fibrosis tear by pulling up the posterior longitudal ligament under lumbar for endoscopic. To perform the surgical technique of endoscopic operations for lumbar herniation, surgeons must possess extensive experience.

However, not every patient with lumbar herniation is suitable for this technique. In some cases, suturing may not be necessary if the annular tear becomes too narrow after decompression. This technique offers a new solution that tackle the insufficient tension that occurs due to the conventional single stitch suturing method, following endoscopic decompression of the lumbar spine.

Moreover, the posterior longitudinal ligament was tightly seen above the annular fibrosis tear, which helped increase the lumbar canal volume at the compressed segment. To begin, position the patient in a prone position, and mark the skin puncture point under fluoroscopic guidance. Puncture the marked point with an 18 gauge needle while adjusting the position under fluoroscopy.

Gradually insert a dilation cannula, ensuring an ideal position is achieved. Use trephine saws of varying diameters to remove bone from the cranial, dorsal, and coddle aspects of the superior articular process of L5 for for aminoplasty. Next, expose and remove soft tissues step-by-step.

Identify the targeted herniated disc, and the compressed nerve root. Then, identify and excise the herniated and loose disc, including the annulus fibrosis, nucleus pulposus, and cartilage end plate. Check the decompressed nerve root to ensure no residual discs remain.

Use a disposable annular stapler for endoscopic suture. Locate the AF tear, and insert the first stitch. Then, insert a second stitch into the PLL, making sure it also penetrates the medial intact AF.Securely anchor the stitch, and tie the first and second stitches with a square knot.

Now, cut the first stitch, and insert a third stitch laterally on the intact AF, above the position of the second stitch. Cut both stitches after tying the square knot. Re-examine the nerve root to confirm that there is no compression.

Postoperative MRI showed successful left L4 or five nerve root decompression. After six months, a lumbar MRI was performed, and no evidence of recurrence was observed.