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Purpose: Treatment of adjacent segment disease (ASD) is still controversial. The aim of this study was to evaluate the short-term efficacy and safety and to analyze the technical advantages, surgical approach, and indications of percutaneous full endoscopic lumbar discectomy (PELD) in the treatment of ASD after lumbar fusion in elderly patients., Methods: A retrospective of 32 patients with symptomatic ASD were accepted for PELD from October 2017 to January 2020. All patients used the transforaminal approach and recorded the operation time and intraoperative conditions. Preoperative, 3, 12, 24 months of postoperative and at the last follow-up, the pain of back and leg of visual analog scale (VAS), Oswestry dysfunction index (ODI), and Japanese Orthopaedic Association Assessment Treatment Score (JOA) were performed, and the paired student's t test was used to the compare the continuous variables preoperatively and postoperatively. The clinical efficacy was evaluated according to MacNab standards. The lumbar MRI was performed to evaluate the decompression of the nerve roots, and the lumbar lateral and dynamic X-rays were performed to evaluate the stability of the surgical segment., Results: A total of 32 patients were included in the study, including 17 males and 15 females. The follow-up time ranged from 24 to 50 months, with an average of (33.2 ± 8.1) months and an average operation time of (62.7 ± 28.1) minutes. Compared to preoperatively, the VAS score of the back and leg pain (p < 0.05), ODI (p < 0.05), and JOA (p < 0.05) postoperatively were significantly improved. At the last follow-up, according to the modified MacNab standard assessment, 24 cases were excellent, five cases were good, and three cases were fair, the excellent and good rate was 90.65%. As for complications, one case had a small rupture of the dural sac during the operation, which was found but not repaired during the operation, and one case recurred after the operation. At the last follow-up, there were three cases of intervertebral instability., Conclusion: PELD showed satisfactory short-term efficacy and safety in the management of ASD after lumbar fusion in elderly patients. Therefore, PELD might be an alternative choice for elderly patients with symptomatic ASD after lumbar fusion, but surgical indications must be strictly controlled., (© 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Objective: To explore the effect and safety of transforaminal percutaneous endoscopic decompression for lower thoracic spinal stenosis., Methods: We reviewed 6 patients receiving transforaminal percutaneous endoscopic thoracic decompression for sympathetic symptoms in the lower extremities. Pre- and postoperative Frankel grade and Japanese Orthopaedic Association scale (JOA) score, Oswestry Disability Index (ODI) score, and visual analog scale (VAS) scores of back and lower extremities were also evaluated and recorded. Wilcoxon signed-rank test was performed for statistical analysis., Results: All 6 patients completed the follow-up. Mean follow-up was 12.6 months. Frankel grade in all patients improved to normal at the third month after operation. JOA scores significantly increased from 4.4 (range, 3.5-5.0) preoperatively to 5.5 (range, 5.0-6.5) postoperatively, to 6.5 (range, 6.0-7.0) at 3 months, to 6.6 (range, 6.2-7.0) at 6 months, and to 6.6 (range, 6.2-7.1) at 12 months (P < 0.05). ODI scores significantly decreased from 71.2 (range, 65-78) preoperatively to 50.2 (range, 45-60) postoperatively, to 30.3 (range, 25-40) at 3 months, to 12.2 (range, 0-20) at 6 months, and to 10.2 (range, 0-15) at 12 months (P < 0.05). VAS back scores decreased from 7.8 (range, 7.0-9.0) preoperatively to 6.9 (range, 6.0-7.5) postoperatively, to 3.3 (range, 3.0-4.0) at 3 months, to 2.3 (range, 2.0-3.0) at 6 months, and to 1.9 (range, 1.5-3.0) at 12 months (P < 0.05). VAS lower extremity scores decreased from 8.7 (range, 8.0-9.0) preoperatively to 3.0 (range, 2.5-3.6) postoperatively, to 1.1 (range, 0.5-1.3) at 3 months, to 0.9 (range, 0.2-1.2) at 6 months, and to 0.3 (range, 0.1-1.0) at 12 months (P < 0.05). Four patients reported excellent results and 2 reported good results at the last follow-up., Conclusions: Percutaneous endoscopic transforaminal thoracic decompression is effective and safe in settling lower thoracic spinal stenosis., (Copyright © 2019 Elsevier Inc. All rights reserved.)

People's understanding of lumbar spinal stenosis has become more and more comprehensive and reasonable, however, there are still many controversies about the concepts of "central lumbar canal" and "lateral lumbar spinal canal", and there is no unified standard at present. In this paper, we redefine and differentiate the two concepts. We believe that some kinds of central canal stenosis caused by bilateral recess stenosis can be completely solved by bilateral percutaneous endoscopic transforaminal discectomy. At the same time, the concept of "lumbar lateral recess" is ambiguous. We redefine it as "lateral lumbar spinal canal" and propose "West China Hospital classification" to guide surgical decision-making, which has been widely recognized and applied.

Purpose: This study reports a new technique known as percutaneous endoscopic trans-articular discectomy (PETAD) for huge central/paracentral lumbar disc herniation (LDH)., Methods: Sixteen patients with huge central/paracentral LDH who underwent PETAD in our department from July 2015 to July 2016 were retrospectively analyzed. Clinical outcomes were evaluated according to pre-operative and post-operative visual analog scale (VAS) and Oswestry disability index (ODI) scores and the MacNab criteria. Immediate post-operative MRI and CT were conducted to confirm complete removal of LDH along with follow-up flexion-extension X-ray to observe lumbar stability., Results: The huge central/paracentral LDH was completely removed by PETAD in 16 patients, as confirmed by post-operative MRI and CT. Leg pain was eased after removal of the disc herniations. The satisfactory (excellent/good) results were 93.7%. The mean follow-up duration was 15.6 (range, 3-24) months. The mean pre-operative VAS and ODI scores were 5.72 ± 1.18 (range, 4-9) and 60.1 (range, 51-87), respectively, which decreased to 1.26 ± 0.81 (range, 0-3) and 18.1 (range, 10-31), respectively at the third month post-operatively and to 0.78 ± 0.62 (range, 0-1) and 7.2 (range, 0-15), respectively by the last follow-up visit. No recurrence and segmental instability was observed in any of the 16 patients during the follow-up period., Conclusion: PETAD could be a good alternative for treatment of huge central/paracentral LDH.

Background: Highly upmigrated herniation can be difficult to remove using percutaneous endoscopic lumbar discectomy (PELD) and the conventional transforaminal approach. Although many surgeons have constantly explored new techniques and approaches, we still lack a more effective, convenient, and economical technique to treat highly upmigrated herniation. We have described a novel approach, the transforaminal isthmus plasty approach, for PELD to treat highly upmigrated disc herniation., Case Description: A 72-year-old man with L3-L4 highly upmigrated disc herniation, who had experienced no relief after a long period of conservative treatment, underwent PELD through the transforaminal isthmus plasty approach. The operation was successful, and he experienced significant symptom relief after the surgery., Conclusions: The transforaminal isthmus plasty approach is an effective and viable alternative approach for PELD to treat highly upmigrated disc herniation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To evaluate the short-term effectiveness of percutaneous endoscopic lumbar discectomy (PELD) in treatment of buttock pain associated with lumbar disc herniation., Methods: Between June 2015 and May 2016, 36 patients with buttock pain associated with lumbar disc herniation were treated with PELD. Of 36 cases, 26 were male and 10 were female, aged from 18 to 76 years (mean, 35.6 years). The disease duration ranged from 3 months to 10 years (mean, 14 months). The location of the pain was buttock in 2 cases, buttock and thigh in 6 cases, buttock and the ipsilateral lower extremity in 28 cases. Thirty-four patients had single-level lumbar disc herniation, and the involved segments were L 4, 5 in 15 cases and L 5 , S 1 in 19 cases; 2 cases had lumbar disc herniation at both L 4, 5 and L 5 , S 1 . The preoperative visual analogue scale (VAS) score of buttock pain was 6.1±1.3. VAS score was used to evaluate the degree of buttock pain at 1 month, 3 months, 6 months, and last follow-up postoperatively. The clinical outcome was assessed by the modified MacNab criteria at last follow-up., Results: All patients were successfully operated and the operation time was 27-91 minutes (mean, 51 minutes). There was no nerve root injury, dural tear, hematoma formation, or other serious complications. The hospitalization time was 3-8 days (mean, 5.3 days). All incisions healed well and no infection occurred. Patients were followed up 12-24 months (median, 16 months). MRI examination results showed that the dural sac and nerve root compression were sufficiently relieved at 3 months after operation. Patients obtained pain relief after operation. The postoperative VAS scores of buttock pain at 1 month, 3 months, 6 months, and last follow-up were 1.1±0.6, 0.9±0.3, 1.0±0.3, and 0.9±0.4 respectively, showing significant differences when compared with preoperative VAS scores ( P <0.05); there was no significant difference in VAS score between the different time points after operation ( P >0.05). At last follow-up, according to the modifed MacNab criteria, the results were excellent in 27 cases, good in 9 cases, and fair in 2 cases, and the excellent and good rate was 94.4%., Conclusion: PELD can achieve satisfactory short-term results in the treatment of buttock pain associated with lumbar disc herniation and it is a safe and effective minimally invasive surgical technique.

Objective: To investigate the feasibility, effectiveness, and security of percutaneous endoscopic spine surgery for treatment of lumbar spine disorders with intraspinal ossification., Methods: Between July 2008 and June 2016, 96 patients with lumbar spine disorders (lumbar disc herniation or lumbar spinal stenosis) with intraspinal ossification were treated with percutaneous endoscopic spine surgery. There were 59 males and 37 females, aged from 13 to 57 years (mean, 29.5 years). The disease duration was 3-51 months (mean, 18.2 months). Fifty-one cases had trauma history. Ninety-two cases were single segmental unilateral symptom, 4 cases were bilateral symptom. The ossification property was posterior ring apophysis separation in 89 cases, and ossification of the fibrous ring or posterior longitudinal ligament in 7 cases. There were 32 cases of lateral type, 13 cases of central type, and 51 cases of mixed type. The pressure factors, such as nucleus pulposus, hyperplasia of the yellow ligament, joint capsule, or articular osteophyma, were removed under the microscope. Local anesthesia or continuous epidural anesthesia was performed in the transforaminal approach with 50 cases, and continuous epidural anesthesia or general anesthesia was performed in the interlaminar approach with 46 cases. The visual analogue scale (VAS) score was used to evaluate the degree of leg pain preoperatively and at last follow-up. The effectiveness was evaluated at last follow-up according to the modified Macnab criteria., Results: All patients were successfully operated. Via transforaminal approach, the mean operation time was 53 minutes and the mean intraoperative fluoroscopy times was 8 times; and via interlaminar approach was 58 minutes and 3 times, respectively. The mean bed rest time after operation was 6.5 hours and the mean hospitalization time was 4.7 days. All patients were followed up 6-18 months (median, 11 months). Postoperative lumbar CT scan and three-dimensional reconstruction after 3 days of operation showed that ossification tissues of 26 cases were not resected, 12 cases were resected partly, and 49 cases were resected completely. Postoperative lumbar MRI after 3 months of operation showed that spinal cord and nerve root were not compressed. At last follow-up, VAS score of leg pain was 0.7±1.1, which was significantly lower than preoperative score (5.8±1.1) ( t =1.987, P =0.025). At last follow-up, according to modified Macnab criteria, the results were excellent in 87 cases, good in 5 cases, and fair in 4 cases, and the excellent and good rate was 95.8%., Conclusion: Percutaneous endoscopic spine surgery for treatment of lumbar spine disorders with intraspinal ossification is an effective, safe, and minimal invasive alternative, and the short-term effectiveness is reliable. Accounting for the treatment of intraspinal ossification, comprehensive analysis should be made by combining clinical symptoms, imaging characteristics, and risk assessment.

To evaluate the feasibility and clinical efficacy of percutaneous endoscopic lumbar discectomy (PELD) for cauda equina syndrome (CES) caused by disc herniation. 16 patients with CES caused by LDH at the early and middle stages of Shi's classification were selected as the objects of study, who underwent PELD. Clinical outcomes were assessed using the Macnab criteria and the visual analogue scale (VAS). The VAS for leg pain and back pain significantly decreased from preoperative scores of 7.67 ± 1.23 and 7.52 ± 1.42, respectively, to postoperative scores of 1.71 ± 0.53 and 3.18 ± 0.72. Thirteen patients showed favorable results. Complications included one patient of motor weakness, and one patient developed an ipsilateral recurrent herniation who finally acquired satisfactory result after reoperation. Hence, PELD could be used as an alternative surgical method for the treatment of CES in properly selected cases and appropriate patient selection and a reasonable surgical approach will give rise to better outcomes.

Objective: To determine the feasibility and effectiveness of percutaneous endoscopic transforaminal discectomy (PETD) for recurrent lumbar disc herniation (RLDH)., Methods: Between June 2009 and December 2011, 56 patients with RLDH underwent PETD after local anesthesia, including 30 males and 26 females, with a mean age of 50 years (range, 24-70 years). The involved segments were L3, 4 in 3 cases, L4, 5 in 34 cases, and L5-S1 in 19 cases. Of 56 patients, 48 suffered from ipsilateral re-herniation, and 8 suffered from contralateral re-herniation. All the patients had a mean pain-free interval of 5.5 years (range, 6 months to 27 years). The visual analogue scale (VAS) score for back pain was 6.18 ± 1.44 and the VAS score for leg pain was 7.66 ± 1.03. Postoperative effectiveness was assessed based on the VAS score and modified MacNab criteria., Results: The mean operation time was 60.4 minutes (range, 30-100 minutes) and the mean duration of hospital stay was 5.1 days (range, 3-6 days). All patients were followed up 28.2 months on average (range, 24-56 months). Patients obtained immediate pain relief postoperatively. The postoperative VAS scores of back and leg pain at 1 month, 3 months, 12 months, and last follow-up were significantly decreased when compared with preoperative score (P < 0.05). Based on the modified MacNab criteria, the results were excellent in 39 cases, good in 9 cases, fair in 5 cases, and poor in 3 cases at 12 months after operation, and the excellent and good rate was 85.7%. Surgery-related complications were found in 5 cases (8.9%); one patient (1.8%) suffered from recurrence at 18 months postoperatively, and the symptom was relieved after open lumbar discectomy and intervertebral fusion surgery., Conclusion: PETD has several advantages in treating RLDH, such as avoiding from the old scar tissue, decreasing operation-related complications, shortening operation time, reducing trauma, and obtaining rapid postoperative recovery. This technique is feasible and effective for RLDH.

Objective: To investigate the feasibility and short-term effectiveness of percutaneous endoscopic spine surgery for treatment of lumbar disc herniation with posterior ring apophysis separation., Methods: Between July 2008 and January 2013, 57 patients with lumbar disc herniation and posterior ring apophysis separation were treated. There were 39 males and 18 females, aged from 13 to 46 years (mean, 26.7 years). Of 57 cases, 29 had a clear trauma history. All patients had single segmental unilateral lumbar disc herniation, and the location was at L4, 5 in 22 cases and at L5, S1 in 35 cases; there were 25 cases of lateral bone fragments and 32 cases of central cortical and cancellous fragments. While fracture located at posterior inferior edge of the vertebrae at L4 level in 9 cases and at Ls level in 8 cases, at posterior superior edge at L5 level in 13 cases and in S1 level in 27 cases. Percutaneous endoscopic surgeries were performed via interlaminar or transforaminal approach from unilaterally symptomatic side for discectomy of lumbar disc herniation and partial or complete resection of free bone fragments., Results: Accurate positioning was obtained in all patients during operation, and no complication of nerve root injury, hematoma formation, or dural tear occurred. The operation time was 20-85 minutes; the intraoperative fluoroscopy times were 2-15 times, and the blood loss was 3-10 mL. Postoperative radiographic examination showed that bone fragment was not removed in 16 cases, was partly removed in 32 cases, and was completely removed in 9 cases. Disc was completely removed. All patients were followed up 10-64 months (median, 16 months). According to modified Macnab criteria for the evaluation of effectiveness, the results were excellent in 48 cases, good in 6 cases, and fair in 3 cases, and the excellent and good rate was 94.7%., Conclusion: Percutaneous endoscopic spine surgery through unilaterally symptomatic approach has advantages of small tissue damage and lumbar structure damage, less bleeding, and shorter recovery time. It has a good short-term effectiveness, but long-term effectiveness need further follow-up.

Purpose: Percutaneous endoscopic interlaminar discectomy (PEID) is a widely used minimally invasive procedure which shows satisfying outcomes in the adult population. However, pediatric lumbar disc herniations (PLDH) occur in growing spines and are less related to degeneration, which makes them different from the adult disc herniations. This study evaluates the clinical outcomes of PEID in treating PLDH., Methods: A prospect study was done in the period from June 2010 to December 2012, which included 29 consecutive pediatric patients with a mean age of 16.4 years (range, 13 to 18 years) who underwent PEID for single level lumbar disc herniation. The following measuring tools were used: visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and Macnab criteria., Results: There were no severe complications such as dural tear or nerve root damage found in our study. The mean follow-up period was 19.7 months. The VAS score for leg and back pain decreased dramatically at 1 day postoperatively and kept decreasing until the follow-up visit at 3 months postoperatively, when it became stable at a low level. ODI kept improving until the follow-up visit at 6 months postoperatively when it reached a stable low level. Of the patients, 91% reported no longer having leg pain and 9% had occasional leg pain at last follow-up., Conclusions: PEID shows a satisfying outcome with a minimal rate of complications. It has the advantages of minimal traumatization and scar formation and is a safe and effective treatment for PLDH.