J Korean Neurosurg Soc.  2020 Sep;63(5):614-622. 10.3340/jkns.2020.0050.

What Is the Ideal Entry Point for Transforaminal Endoscopic Lumbar Discectomy?

• Lee JU
• Park KJ
• Choi MK
• Lee YH
• Kim DH
• Kim KH

• KMID: 2506025
• DOI: http://doi.org/10.3340/jkns.2020.0050

Abstract

Objective
: The method of approach during transforaminal endoscopic lumbar discectomy (TELD) has been the subject of repeated study. However, the ideal entry point during TELD has not been studied in detail. Therefore, this study investigated the ideal entry point for avoiding complications using computed tomography (CT) scans obtained from patients in the prone position.
Methods
: Using CT scans obtained from patients in the prone position, we checked for retroperitoneal or visceral violations and measured the angles of approach with five conventional approach lines drawn on axial CT scans at each disc space level (L2–3, L3–4, and L4–5). We also determined the ideal entry point distance and approach angles for avoiding retroperitoneal or visceral violations. Correlation analysis was performed to identify the patient characteristics related to the ideal entry point properties.
Results
: We found that the far lateral approach at the L2–3 level resulted in high rates of visceral violation. However, rates of visceral violation at the L3–4 and L4–5 levels were remarkably low or absent. The ideal angles of approach decreased moving caudally along the spine, and the ideal entry point distances increased moving caudally along the spine. Weight, body mass index (BMI), and the depth of the posterior vertebral line from the skin were positively associated with the distance of the ideal entry point from the midline.
Conclusion
: We reviewed the risk of the extreme lateral approach by analyzing rates of retroperitoneal and visceral violations during well-known methods of approach. We suggested an ideal entry point at each level of the lumbar spine and found a positive correlation between the distance of the entry point to the midline and patient characteristics such as BMI, weight, and the depth of the posterior vertebral line from the skin.

Keyword

Endoscopy; Diskectomy; Percutaneous

Figure

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  Fig. 1. Patients were positioned on an operating frame (Wilson’s Frame) with their abdomens relaxed. Computed tomography images were reconstructed parallel to each disc space (L2–3, L3–4, and L4–5) at 2 mm intervals.

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  Fig. 2. Five conventional lines of approach (A) and the ideal lines of approach for avoiding visceral or retroperitoneal violations (B). a : Another line is horizontally extended line from the midpoint between the tip of the spinous process and the dorsal edge of the inferior articular process to the intersection of the medial pedicular line and the posterior vertebral line. b : The line from the intersection of the skin and the line horizontally extended from the dorsal edge of the inferior articular process to the intersection of the medial pedicular line and the posterior vertebral line. c : The tangential line from the intersection of the posterior vertebral line and the medial pedicular line to the posterior margin of the retroperitoneum. d : The tangential line from the intersection of the posterior vertebral line and the medial pedicular line to the posterior margin of the abdominal organs. e : The depth of the posterior vertebral line from the skin.

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  Fig. 3. The percentages of retroperitoneal and visceral violations according to the five lines of approach at each level of the lumbar spine. RP-V : retroperitoneal violation, V-V : visceral violation, 10DA : 10 cm distance approach, 11DA : 11 cm distance approach, 12DA : 12 cm distance approach, mFLA : modified far lateral approach, FLA : far lateral approach.

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  Fig. 4. Scatter graphs for the correlation between the distance of the entry point and body mass index (BMI), weight, and the depth of the posterior vertebral line from the skin (DPVS) at the L2–3, the L3–4, and L4–5 levels.

Reference

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