Journal ofHead Neck & Spine Surgery
ISSN: 2577-2864

Case Report

J Head Neck Spine Surg

Volume 3 Issue 1 - April 2018
DOI: 10.19080/JHNSS.2018.02.555596

Copyright © All rights are reserved by Yoshihiro Kitahama

Posterolateral Percutaneous Endoscopic Discectomy
with Partial Pediculotomy for the L1-L2 High-Grade
Downward Migrated Disc Herniation
Yoshihiro Kitahama1,5*, Hisashi Koga2, Kawaoka Taigo3, Manabu Minami1,4, Hideaki Miyake5 and Seiji Yamamoto5
1Omaezaki Municipal Hospital, Spine Center, Japan2Iwai Orthopedic Surgery Hospital, Spine Center, Japan

3

Kawasaki Hospital, Neurosurgery, Japan

4

Heisei Memorial Hospital, Spine Disorder Treatment Center, Japan

5Hamamatsu University School of Medicine, Cooperative Major of Medical Photonics, Japan

Submission: March 19, 2018; Published: April 11, 2018

*Corresponding author: Yoshihiro Kitahama Omaezaki Municipal Hospital, Spine Center, 2060 Ikeshinden, Omaezaki, Shizuoka 437-1696, Japan,
Tel: +81-537-86-8511; Email:
Abstract
Background: Percutaneous endoscopic discectomy (PED) is one of the most useful minimally invasive surgical techniques for lumbar discherniation (LDH). However, high-grade migrated disc is difficult to treat with only the standard posterolateral approach (posterolateral PED,PLPED).

Purpose: To overcome this difficulty, we combined the pediculotomy with PLPED for the treatment of high-grade migrated LDH. The
pediculotomy is the recent technic for PED that has been explored with development of high-speed drill.
Case report: A 72-year-old man had a 6-month history of left L2 radiculopathy. His general state was too poor to perform general anesthesia
and invasive surgery. The left L1-L2 downward migrated fragment compressed his L2 nerve root axial portion on magnetic resonance imaging.
PLPED with partial pediculotomy was used for complete total removal, which cured his symptoms without any complications. Thirty minutes
after fragmentectomy, we needed to control 100-ml bleeding from the anterior epidural venous plexus (AEVP).
Discussion: Upper-level migrated large lumbar disc fragments often require facetectomy with some fusion in conventional microscopic
surgery. This case was too complicated for indicating the conventional technique. Only the flexible bipolar device helps control hemostasis in thePED system, but some bleeding cannot be controlled easily.
Conclusion: PLPED with partial pediculotomy was useful for a migrated fragment in patients with poor general conditions. Although the PED
system requires a new device to control the bleeding from the AEVP.
Keywords: Lumbar disc herniation; Posterolateral percutaneous endoscopic discectomy

Introduction

Percutaneous endoscopic discectomy (PED) is one of
the most useful minimally invasive surgery for lumbar discherniation (LDH) (1,2). Especially, high-grade migrated
fragments are difficult to treat with the standard posterolateral
PED (PLPED) technique (3,4). PED with a high-speed drill is aminimally invasive method of approaching the deep narrow
lumbar space (5-8). This paper presents a successful case of
PLPED with partial pediculotomy for a high-grade downward
migrated fragment and discusses a hemostatic technique forsevere bleeding.

Case Report

A 72-year-old man had severe untreatable lumbago and left
femoral radicular pain for 6 months. His health condition was

J Head Neck Spine Surg J 3(1): JHNSS.MS.ID.555596 (2018)

poor with chronic renal failure requiring dialysis 3 times per
week, hypertrophic cardiomyopathy, and obstructive ventilation
impairment .The initial physician referred the patient to us toundergo a minimally invasive spine surgery.

During his first visit, the patient’s numeric rating scale(NRS) scores were 8/10 for low back pain and 8/10 for left front
femoral pain. His leg pain increased after 10 minutes of slow
walking, so he needed a wheelchair. Neurological examination
revealed normal deep tendon reflexes. His thigh circumference
was asymmetrical (right, 35.5cm; left, 35.0cm). Owing to hispain, he could not get into a prone position for examination withthe femoral nerve stretch test. The straight leg raising test result
was negative bilaterally.
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Journal of Head Neck & Spine Surgery
On sagittal T2-weighted magnetic resonance imaging (MRI),ahigh-grade downward migrated disc was observed at the L1-L2
level on the left side (Figure 1a). The axial view at the L2 pedicle

midline level showed a large fragment impinging the L2 nerve
root (Figure 1b).

Figure 1: Magnetic resonance imaging (MRI) scans before and after posterolateral percutaneous endoscopic discectomy (PLPED).
a: Left para-sagittal MRI scan before PLPED. The herniated fragment migrated over the L2 vertebral body at the midline level.
b: Axial view of a MRI scan through the L2 pedicle level before PLPED. A large fragment impinged the left L2 nerve root.
c: Axial view of a MRI scan through the L2 pedicle level after PLPED. Note the total removal of the migrated fragment and decompressionof the left L2 nerve root and cauda equina.

Figure 2a: When the partial pediculotomy started, we could confirm the head of the electrical high-speed drill located in the crossing part ofsuperior facet and transverse process under lateral fluoroscopy.
Figure 2b: The reconstructed three-dimensional computed tomography scan clearly shows the minimal cortical bone resection of a quarterof the craniomedial part (yellow arrow) performed as partial pediculotomy. *1:L2 cranial endoplate, *2: L2 left pedicle, *3: superior facet, *4:transverse process.

002

How to cite this article: Yoshihiro K, Hisashi K, Kawaoka T, Manabu M, Hideaki M. Posterolateral Percutaneous Endoscopic Discectomy with
Partial Pediculotomy for the L1-L2 High-Grade Downward Migrated Disc Herniation. J Head Neck Spine Surg. 2018; 3(1): 555596. DOI: 10.19080/
JHNSS.2018.02.555596.

Journal of Head Neck & Spine Surgery

Figure 2c: After the partial pediculotomy, the migrated fragment is removed using the punch under endoscopic view with lateral
fluoroscopy.Figure 2d: After the fragmentectomy, the decompressed state of the L2 nerve root could be confirmed using the flexible bipolardevice.

PLPED with partial pediculotomy under local anesthesia wasplanned to decompress the left L2 nerve root. Our anesthesiologist
performed deep sedation of the patient. The patient was placedin a prone position, and the puncture point under fluoroscopy
was simulated prior to the calculation of data (9). An 8mm skinincision was made 5cm to the left of the midline. The standard
PLPED procedure was started after local anesthesia. Owing tothe L1-L2 foraminal severe stenosis, we selected the outsidein technique. The adverse walking technique could be used toapproach the crossing point of the superior facet and transverse
process (Figure 2a). Partial pediculotomy was started from thispoint, and a quarter of the craniomedial portion was drilled(Figure 2b) for the total fragmentectomy (Figure 2c) (10). We
could decompress the L2 nerve root from the L1 endoplate levelto under the midline of the L2 pedicle (Figure 2d).

The operative time was 2 hours; 100ml of bleeding from theL1 AEVP due to injury by the tip of the Beak-type cannula took
30min to control. We first attempted the standard hemostatic
techniques of increasing the irrigation pressure (100 to 110cm
H2O for 3min) several times and compression the bleeding pointwith rigid dissector but did not succeed the hemostasis. We thenattempted the techniques for such a vigorous bleeding situation
include slow cannula rolling and bleeding point compression bya flexible bipolar device with hemostatic cotton materials. We
finally achieved the hemostasis and placed a drainage tube. Little
outflow stayed only in the tube, which was withdrawn the nextmorning without hematoma formation.
The patient did not have any dysesthesia and paresis. The
time to ambulation was 2 hours, and his hospital stay was 7 days.
The NRS score of his affected leg improved from 8 to 1 after 2003

months. In the next morning, his wound pain NRS score was
1. The axial view of the MRI scan (Figure 1c) showed that themigrated fragment was completely removed.

Discussion

The standard treatment for higher-level lumbar discherniation is conventional discectomy with some fusion after
facetstomy (11). Nowadays, many types of minimally invasive
percutaneous pedicle screw systems are available (12). Owing
to the poor general condition of our patient, we selected theoperative procedures suitable for local anesthesia were limited.
Interlaminar PED (ILPED) with partial laminectomy (7,8)
and PLPED with partial pediculotomy are the best minimally
techniques for patients with poor general conditions.
The major difference between ILPED and PLPED with partial
pediculotomy is the direction of the operative approaches.
ILPED accesses from dorsal side of vertebral laminae, thereby
even combined with laminectomy the migrated fragment is still
covered with neural structures. On the other hand, PLPED withpartial pediculotomy can directly expose the migrated fragment
covering neural structures. In other words, as the migrated
fragment protects underneath neural structures, we can safely
drill the inner cortical bone layer of the pedicle. Additionally,
the width of spinal canal at high vertebral level (ex. L1-L2)
is narrower than that at low vertebral level (ex. L5-S1) (13).
Consequently ILPED at high vertebral level requires more skillful
technic. Our case was affected at L1-L2 vertebral level and themigrated fragment extended lateral part of the spinal canal(Figure 1b), we therefore planned to perform the PLPED withpartial pediculotomy.

How to cite this article: Yoshihiro K, Hisashi K, Kawaoka T, Manabu M, Hideaki M. Posterolateral Percutaneous Endoscopic Discectomy with
Partial Pediculotomy for the L1-L2 High-Grade Downward Migrated Disc Herniation. J Head Neck Spine Surg. 2018; 3(1): 555596. DOI: 10.19080/
JHNSS.2018.02.555596.

Journal of Head Neck & Spine Surgery
The disadvantages of PLPED under the situation of severe
foraminal stenosis include the possibility of complicating theexiting nerve injury and bleeding from the AEVP. As the beaktype cannula has a wider view than the square-type cannula, wechanged the square-type cannula with the beak-type cannula
to complete the decompression of the L2 nerve root. Whenthe joystick maneuver was used to observe the narrow discspace, the tip of the beak-type cannula injured the L1 AEVP.
The flexible bipolar unit is the only instrument for hemostasiswith the PED system. We needed 30min to control 100ml of
bleeding from the AEVP. The robotic general surgery systemalready has many useful instruments developed for dissection
and coagulation (14). One of the urgent needs of PED surgeons isthe development of a bipolar dissector for fine manipulation likeunder microscopic surgery.
On the basis of this case of higher-level migrated lumbar
disc herniation, PLPED with partial pediculotomy is a usefulprocedure for patients with poor general conditions. For theappropriate development of this procedure, the PED system
requires new devices to control the bleeding from the AEVP.

Acknowledgment

All the authors made a significant contribution to this casereport.

References

1. Yeung AT, Yeung CA (2007) Minimally invasive techniques for themanagement of lumbar disc herniation. Orthop Clin North Am 38(3):363-372.
2. Sairyo K, Egawa H, Matsuura T, Takahashi M, Higashino K, et al. (2014)
State of the art: transforaminal approach for percutaneous endoscopic
lumbar discectomy under local anesthesia. J Med Invest 61(3-4): 217225.

3. Lee S, Kim SK, Lee SH, Kim WJ, Choi WC, et al. (2007) Percutaneousendoscopic lumbar discectomy for migrated disc herniation:
classification of disc migration and surgical approaches. Eur Spine J16(3): 431-437.
This work is licensed under Creative
Commons Attribution 4.0 Licens
DOI: 10.19080/JHNSS.2018.02.555596

4. Kitahama Y, Sairyo K, Dezawa A (2013) Percutaneous endoscopictransforaminal approach to decompress the lateral recess in an elderly
patient with spinal canal stenosis, herniated nucleus pulposus andpulmonary comorbidities. Asian J Endosc Surg 6(2): 130-133.

5. Ying J, Huang K, Zhu M, Zhou B, Wang Y, et al. (2016) The effect andfeasibility study of transforaminal percutaneous endoscopic lumbar
discectomy via superior border of inferior pedicle approach for downmigrated intracanal disc herniations. Medicine (Baltimore) 95(8):e2899.
6. Li Z, Hou S, Shang W, Cao Z, Zhao H (2016) Percutaneous lumbar
foraminoplasty and percutaneous endoscopic lumbar decompression
for lateral recess stenosis through transforaminal approach: techniquenotes and 2 years follow-up. Clin Neurol Neurosurg 143: 90-94.

7. Dezawa A, Sairyo K (2011) New minimally invasive discectomy
technique through the interlaminar space using a percutaneousendoscope. Asian J Endosc Surg 4(2): 94-98.
8. H Koga (2017) Improved percutaneous endoscopic translaminar
approach for lumbar foraminal stenosis at L5/S1. Mini-invasive Surg
1: 3-5.

9. Kitahama Y, Matsui G, Minami M, Kawaoka T, Otome K, et al. (2017)
Posterolateral percutaneous endoscopic discectomy with free-runningelectromyography monitoring under general anesthesia. Mini-invasiveSurg 1: 109-114.
10. Kitahama Y (2017) Percutaneous endoscopic lumbar foraminotomy.
Spine & Spinal Cord 30(12): 1037-1045.

11. Hoffman RM, Wheeler KJ, Deyo RA (1993). Surgery for herniatedlumbar discs: a literature synthesis. J Gen Intern Med 8(9): 487-496.

12. Harris EB, Massey P, Lawrence J, Rihn J, Vaccaro A, et al. (2008)
Percutaneous techniques for minimally invasive posterior lumbarfusion. Neurosurg Focus 25(2): E12.

13. Kitahama Y (2017) Posterolateral Approach. In: Supervised byMizuno J, Nishimura Y (Eds.), Chapter 5.04, Irasuto Jutsuchu-shashin
Karamanabu: Sekitsui Naisikyougeka No Zissai (Spinal endoscopic
surgical procedure:Learn from the Intraoperative image). Medical
Review, Tokyo, Japan, pp: 30-35.
14. Camarillo DB, Krummel TM, Salisbury JK (2004) Robotic technology
in surgery: Past, present, and future. Am J Surg 188 (4A Suppl):
2S-15S.

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How to cite this article: Yoshihiro K, Hisashi K, Kawaoka T, Manabu M, Hideaki M. Posterolateral Percutaneous Endoscopic Discectomy with
Partial Pediculotomy for the L1-L2 High-Grade Downward Migrated Disc Herniation. J Head Neck Spine Surg. 2018; 3(1): 555596. DOI: 10.19080/
JHNSS.2018.02.555596.