Full-Endoscopic Posterior Apophyseal Ring Fracture Resection in Adolescent Lumbar Disc Herniation
Article information
Abstract
A lumbar posterior apophyseal ring separation (PARS) is characterized by the detachment of bony fragments from the posterior edge of the lumbar vertebral endplate, leading to protrusion into the spinal canal. In recent years, endoscopic surgery has gained increasing popularity in the management of PARS because it minimizes damage to surrounding healthy tissues and facilitates faster postoperative recovery. In this case, full endoscopy was performed using a transforaminal approach. The author presents the surgical technique of full-endoscopic discectomy combined with PARS resection.
WRITTEN TRANSCRIPT
0:07 Case Presentation
I’m presenting the case of a 15-year-old male patient with recurrent back pain with radiculopathy in his right leg. Upon examination, he is neurologically intact, but has a positive straight leg raising test on his right leg. His symptoms did not improve despite conservative treatment including epidural blocks and surgical management was chosen.
0:25 Preoperative Imaging
The preoperative magnetic resonance imaging (MRI) and computed tomography (CT) show a large bilateral posterior apophyseal ring separation and L3–4 level lumbar with disc herniation and central and paracentral area. The patient has symptoms predominantly more on right side and right-side approach was chosen for this procedure.
0:45 Endoscope Docking
Skin incision was made at approximately 15 cm from the midline and a 6.3-mm transforaminal 30° endoscope docking was done at SAP using outside-in technique. The disc has been stained with methylene blue dye prior to scope insertion. Circumferential bone resection around SAP was done and ligamentum flavum was removed to expose the dura and disc space.
1:16 Decompression of Apophysis.
The protruded apophysis on the cranial aspect is removed. Further removal of the apophysis was done and the contralateral apophysis was accessed and decompress.
1:37 Caudal Disc Access
Further SAP and partial removal of pedicle was done to access the apophysis caudally. The apophysis and bone fragments were completely resected using a high-speed burr and pituitary rongeur. Contralateral lesion was accessed ventral to the dura and decompressed.
1:57 Completion of Decompression
The decompression was completed by removal of the remaining protruded disc and bone fragment.
2:14 Postoperative Imaging
Postoperative MRI and CT demonstrated thorough removal of protruded disc and apophysis in both ipsilateral and contralateral sides. The sagittal images also show good decompression of the dural sac.
2:28 Discussion
The patient has significant improvement of axial back pain and radicular pain after surgery. The use of percutaneous transforaminal full-endoscopic discectomy represents a more minimally invasive approach compared to microsurgery or conventional open surgery [1,2]. Utilizing a single portal, a 6.3-mm endoscope is inserted right into the area of pathology, minimizing soft tissue trauma and blood loss [3]. This approach also results in less postoperative pain and enhanced postoperative recovery [4,5]. The endoscopy via transforaminal approach provides an excellent view of the pathology intraoperatively, allowing ipsilateral and contralateral decompression within single approach. The advantages of this technique include small skin incision, less damage to surrounding soft tissue, faster recovery and less blood loss. However, it is a technically demanding procedure and requires extensive endoscopic experience.
Notes
Conflicts of interest
The first and last authors serve as editors of this journal. The authors have nothing to disclose.
Funding/Support
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Informed Consent
Written informed consent was obtained from the patient for the publication of the video material.