J Korean Neurosurg Soc.  2012 Mar;51(3):182-186. 10.3340/jkns.2012.51.3.182.

The Obturator Guiding Technique in Percutaneous Endoscopic Lumbar Discectomy

• Han IH
• Choi BK
• Cho WH
• Nam KH

• KMID: 2018197
• DOI: http://doi.org/10.3340/jkns.2012.51.3.182

Abstract

In conventional percutaneous disc surgery, introducing instruments into disc space starts by inserting a guide needle into the triangular working zone. However, landing the guide needle tip on the annular window is a challenging step in endoscopic discectomy. Surgeons tend to repeat the needling procedure to reach an optimal position on the annular target. Obturator guiding technique is a modification of standard endoscopic lumbar discectomy, in which, obturator is used to access triangular working zone instead of a guide needle. Obturator guiding technique provides more vivid feedback and easy manipulation. This technique decreases the steps of inserting instruments and takes safer route from the peritoneum.

Keyword

Diskectomy; Percutaneous; Intervertebral disc disease; Endoscope

MeSH Terms

Diskectomy
Endoscopes
Intervertebral Disc Degeneration
Intervertebral Disc Displacement
Needles
Peritoneum
Intervertebral Disc Degeneration
Intervertebral Disc Displacement

Figure

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  Fig. 1 a : New guide wire with 1.22 mm diameter. b : Conventional guide needle. c : Obturator.

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  Fig. 2 An obturator (O) is slid in while a new guide wire (G) is anchored on the target area (T) on the lateral facet.

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  Fig. 3 Once bony contact along the facet is established, the tip of the obturator should be directed towards the ventral border of the facet by elevating the other end of the obturator. The obturator is slid into the safe triangle by twisting back and forth while pushing it against the facet.

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  Fig. 4 Difference of redirection methods in two techniques. A : For the conventional technique, a guide needle has to be withdrawn first (dotted arrow), redirected, and then advanced again (arrow). B : For an obturator, it can be redirected without withdrawing it.

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  Fig. 5 When a needle (or new guide wire) is aimed at a more dorsal target (O) than a target in conventional technique (C), the chance of violating the peritoneum can be decreased by the distance, d.

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  Fig. 6 Relationship between the size of the neural foramen and the chance of violating the epidural space. A : A needle track (N) is always closer to the epidural space than the tip of a working cannula (C). When the needle track (N) can be eliminated, the chance of violating the epidural space could be decreased. The access angle (a) could be decreased to have a shallower approach without increasing the risk of violating the epidural space. B : When the height of a neural foramen, d, is smaller than the diameter of an obturator, it is engaged between the annulus and pedicle before the tip enters the epidural space.

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