Three approaches of percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation with high iliac crest

YANG Jin; KONG Qing-quan; SONG Yue-ming

doi:10.3969/j.issn.2095-252X.2014.08.008

Abstract：Objective To retrospectively analyze the safety and effectiveness of 3 approaches of percutaneous endoscopic lumbar discectomy ( PELD ) in the treatment of L5-S1 disc herniation combined with high iliac crest in 51 patients, and to explore the proper indications of these approaches. Methods From August 2010 to April 2013, 51 consecutive patients with L5-S1 disc herniation combined with high iliac crest were included in the study and treated with PELD through interlaminar, transforaminal and transiliac approaches respectively. There were 20 females and 31 males, whose average age was 39 years old ( range:29-72 years ). The average duration of symptoms was 6.7 months ( range:3-23 months ). The selection of treatment plans and the switching of surgical approaches, operation time, intraoperative X-ray exposure time and intraoperative and postoperative complications were recorded. The Visual Analogue Scale ( VAS ) was used to evaluate low back pain and sciatica, and the Oswestry Disability Index ( ODI ) to assess the functional recovery preoperatively and at 3 months, 6 months and 12 months after the operation. The functional status of the irritated nerve roots was evaluated at 12 months after the operation. Results The operation was completed in all the patients. A transforaminal approach was planned for 2 patients, which was switched to a transiliac approach at last. The average operation time was 75 min ( range:65-110 min ) in the transiliac group, 45 min ( range:35-80 min ) in the transforaminal group and 50 min ( range:40-90 min ) in the interlaminal group, and it was longer in the transiliac group than that in other groups. The X-ray exposure times were 33.4 in the transiliac group, 16.5 in the transforaminal group and 2.6 in the interlaminal group. There were no nerve injuries or infections. A patient with injuries on the superior surface of the sacroiliac joint was found in the transiliac group. Reoccurrence was not noticed so far. The postoperative ODI scores and VAS scores of low back pain and sciatica were signiifcantly decreased at each time point when compared with the preoperative scores in 3 groups ( P<0.05 ). The VAS score of low back pain in the transforanminal group was reduced from ( 28.1±5.9 ) points preoperatively to ( 3.3±2.5 ) points at 1 year after the operation. The VAS score of sciatica was reduced from ( 71.8±7.5 ) points preoperatively to ( 4.4±4.6 ) points at 1 year after the operation. The ODI score was reduced from ( 38.6±4.5 ) points preoperatively to ( 7.2±2.6 ) points at 1 year after the operation ( P<0.05 ). The VAS score of low back pain in the interlaminal group was reduced from ( 28.5±5.2 ) points preoperatively to ( 7.0±3.6 ) points at 1 year after the operation. The VAS score of sciatica was reduced from ( 71.0±5.8 ) points preoperatively to ( 4.7±4.7 ) points at 1 year after the operation. The ODI score was reduced from ( 37.7±4.3 ) points preoperatively to ( 8.1±4.2 ) points at 1 year after the operation ( P<0.05 ). The VAS scores of low back pain and sciatica and ODI score in the transiliac group were reduced from 28.5±4.5, 69.7±6.2 and 38.4±4.3 points preoperatively to 5.0±3.4, 5.5±5.1 and 8.3±4.2 points at 1 year after the operation respectively ( P<0.05 ). Obvious recovery was achieved in the sensation and muscle strength of the irritated nerve roots at 1 year after the operation in 3 groups ( P<0.01 ). The L5 nerve root in a patient with lateral lumbar disc herniation was affected in the interlaminal group, and no significant improvement was found in the ankle reflex ( P>0.05 ). But obvious recovery was achieved in the ankle reflex in the other 2 groups ( P>0.05 ). A patient who underwent interlaminal PELD had more severe low back pain. The MRI and dynamic X-ray showed that there was no reoccurrence or the proof of unstablization or spondylolisthesis of the lumbar spine. The patient was still supervised. Conclusions The 3 approaches of PELD for L5-S1 disc herniation with high iliac crest are safe and effective, but the proper indications of these approaches may be different. The transforaminal surgery (targeted biopsy) may treat extraforaminal type more effectively. The interlaminal method may be more effective in the treatment of central, paracentral and central with paracentral L5-S1 disc herniation with or without mild prolapse. The transiliac approach can well deal with intraforanminal, intraforanminal with extraforaminal and intraforanminal with paracentral types, but we should be more cautious for migrated disc herniation when using this method.