Elsevier

World Neurosurgery

Volume 145, January 2021, Pages 612-620
World Neurosurgery

Endoscopic Spine Surgery Special Section
Technical Considerations of Interlaminar Approach for Lumbar Disc Herniation

https://doi.org/10.1016/j.wneu.2020.06.211Get rights and content

With the evolution of endoscopic instruments and techniques, full-endoscopic spine surgery has attracted more attention worldwide in recent years. At the initial stage, surgeons conducted endoscopic lumbar discectomy using the transforaminal approach. Next, interlaminar endoscopic lumbar discectomy was developed to treat a herniation disc at the L5-S1 level. The progression in interlaminar endoscopic techniques has further broadened the indications for full-endoscopic spine surgery. However, the steep learning curve of endoscopic procedures has remained challenging. The use of interlaminar endoscopic lumbar discectomy entails many essential skills to manage the different anatomical structures of the spine. From the perspective of successful and safe interlaminar endoscopic lumbar discectomy, we have discussed the technical considerations for endoscopic procedures.

Introduction

Full-endoscopic spine surgery (FESS) has evolved continuously, with the progression of instruments and techniques for the past three decades. Recently, increasing evidence has drawn attention to the advancement and benefits of FESS.1 The early randomized trial from Germany showed that the clinical outcomes of patients who had undergone full-endoscopic lumbar discectomy (FELD) were comparable with the outcomes after conventional microdiscectomy.2 In addition, FELD has been shown to be superior to microdiscectomy in enhancing postoperative recovery and decreasing complication rates. With the advancement of FESS in Asia, the progression of the endoscopic techniques and instruments has improved the clinical results and applications of FELD. The 2018 comparative meta-analysis in Korea also showed advantages for both clinical outcomes and postoperative recovery.3 Although the systemic review was mainly retrospective and nonrandomized with small sample size, it suggested that FELD has been well-developed and is a reliable treatment at the current stage.

FELD was initially developed for use with a posterolateral or transforaminal approach.4,5 However, some limitations exist at the L5-S1 level for the posterolateral corridor, including a high iliac crest, the smallest intertransverse space, and a narrow foramen compared with the other levels cranially.6,7 Therefore, interlaminar endoscopic lumbar discectomy (IELD) was introduced as an alternative for the challenging situation disc herniation at the L5-S1 level.8,9 The use of IELD will usually result in one encountering a neural structure before the herniated disc. In contrast, the transforaminal approach will often reach the nerve after removal of the herniation. Thus, IELD demands meticulous techniques to avoid neural complications and recurrence. The learning curve for IELD is flat, and the technique is difficult to master.10 In the present review, we have elaborated on the technical considerations for IELD at the corresponding anatomical structures.

Section snippets

Local or General Anesthesia

The anesthesia for patients undergoing IELD can be local, regional (epidural), or general.11 The choice of anesthesia depends on the complexity of the surgery, extent of the root manipulation, and surgeon experience. General anesthesia can allow one to secure the airway when the patient is in the prone position. A complicated procedure such as extensive bone work or multilevel surgery could increase the operative time, especially for inexperienced surgeons. Therefore, local anesthesia should be

Conclusion

The technique of IELD has evolved with clinical evidence and well-developed tools for the past decade. IELD can provide minimal injury to the collateral soft tissue and enhance postoperative recovery.43 Meticulous techniques have been proposed to achieve structural preservation. Thus, the learning curve for IELD is flat and difficult to master due to its complexity.10,44 The technical considerations for each anatomical structure can help surgeons recognize the advantages and difficulties of

CRediT authorship contribution statement

Kuo-Tai Chen: Writing - original draft. Chun Tseng: Writing - review & editing. Li-Wei Sun: Data curation, Software. Kai-Sheng Chang: Investigation, picture editing. Chien-Min Chen: Conceptualization, Supervision.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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