Modified Endoscopic Access for Migrated and Foraminal/Extraforaminal Disc Herniation

  • Kyung-Chul Choi
  • Dong Chan Lee
  • Choon-Keun Park


Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive spinal technique that has several advantages over open discectomy, including less paravertebral muscle injury, preservation of bony structure, and rapid recovery. PELD has gained popularity for removal of herniated disc (HD) material over the past few years since Kambin introduced the percutaneous posterolateral approach in 1983. Remarkable evolution of endoscopic techniques and instrumentation leads to successful outcomes comparable to conventional open surgery. PELD has been applied to various types of disc herniation and the indication has been expanded. I propose various strategies for PELD according to various types of disc herniation.

Herniated disc (HD) with migration was classified into four zones: low-grade up/down and high-grade up/down based on the extent and direction of migration. High-grade up HDs can be removed with the outside or outside-in techniques from L1-2 to L4-5. High-grade down HDs can be removed using the outside technique with additional foraminoplasty. Low-grade up/down HDs with disc space continuity can be removed using the inside-out technique. Without continuity, the outside technique or foraminoplasty may be needed. Meanwhile, at the L5-S1 level, interlaminar PELD is used to treat high-grade up/down HD with migration.
  • Foraminal/extraforaminal disc herniation

The approach angle is steeper than conventional posterolateral approach. The entry point is about 7–10 cm depending on disc location. The approach angle is about 30–50°. In case of foraminal/extraforaminal disc herniation, invading the axilla of the exiting root, the area available for cannula insertion increases due to the lateral displacement of the corresponding nerve root. It is concerned about postoperative dysesthesia with manipulation of exiting nerve root. We should use a radiofrequency probe, laser, and working cannula carefully.

Proper surgical indications and good working cannula position are important for successful PELD. PELD techniques should be specifically modified to remove the disc fragments in various types of HD.


Foraminoplasty Inside-out Interlaminar Outside-in migration 

Supplementary material

Video 13.1

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  1. 1.
    Hijikata S, Yamagishi M, Nakayama T, Oomori K. Percutaneous discectomy: a new treatment method for lumbar disc herniation. J Toden Hosp. 1975;5(5):39–44.Google Scholar
  2. 2.
    Kambin P, Sampson S. Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res. 1986;(207):37–43.Google Scholar
  3. 3.
    Choi G, Lee SH, Lokhande P, Kong BJ, Shim CS, Jung B, Kim JS. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine. 2008;33(15):E508–15. Scholar
  4. 4.
    Lee SH, Choi KC, Baek OK, Kim HJ, Yoo SH. Percutaneous endoscopic intra-annular subligamentous herniotomy for large central disc herniation: a technical case report. Spine. 2014;39(7):E473–9. Scholar
  5. 5.
    Osman SG, Sherlekar S, Malik A, Winters C, Grewal PK, Narayanan M, Gemechu N. Endoscopic trans-iliac approach to L5-S1 disc and foramen - a report on clinical experience. Int J Spine Surg. 2014;8. Scholar
  6. 6.
    Choi KC, Lee JH, Kim JS, Sabal LA, Lee S, Kim H, Lee SH. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10,228 cases. Neurosurgery. 2015;76(4):372–80. discussion 380-371; quiz 381. Scholar
  7. 7.
    Choi KC, Lee DC, Shim HK, Shin SH, Park CK. A strategy of percutaneous endoscopic lumbar discectomy for migrated disc herniation. World Neurosurg. 2017;99:259–66. Scholar
  8. 8.
    Fardon DF, Milette PC, Combined Task Forces of the North American Spine Society ASoSR, American Society of Neuroradiology. Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine. 2001;26(5):E93–E113.PubMedCrossRefGoogle Scholar
  9. 9.
    Schubert M, Hoogland T. Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation. Oper Orthop Traumatol. 2005;17(6):641–61. Scholar
  10. 10.
    Min JH, Kang SH, Lee JB, Cho TH, Suh JK, Rhyu IJ. Morphometric analysis of the working zone for endoscopic lumbar discectomy. J Spinal Disord Tech. 2005;18(2):132–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Choi KC, Park CK. Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: consideration of the relation between the iliac crest and L5-S1 disc. Pain Physician. 2016;19(2):E301–8.PubMedGoogle Scholar
  12. 12.
    Ruetten S, Komp M, Godolias G. A New full-endoscopic technique for the interlaminar operation of lumbar disc herniations using 6-mm endoscopes: prospective 2-year results of 331 patients. Minim Invasive Neurosurg. 2006;49(2):80–7. Scholar
  13. 13.
    Choi KC, Kim JS, Ryu KS, Kang BU, Ahn Y, Lee SH. Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: transforaminal versus interlaminar approach. Pain Physician. 2013;16(6):547–56.Google Scholar
  14. 14.
    Lee S, Kim SK, Lee SH, Kim WJ, Choi WC, Choi G, Shin SW. Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches. Eur Spine J. 2007;16(3):431–7. Scholar
  15. 15.
    Choi KC, Lee JH, Kim JS, Lee DC, Park CK. Combination of transforaminal and interlaminar percutaneous endoscopic lumbar diskectomy for extensive down-migrated disk herniation. J Neurol Surg A Cent Eur Neurosurg. 2018;79(1):60–5. Scholar
  16. 16.
    Epstein NE. Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg. 1995;83(4):648–56. Scholar
  17. 17.
    Reulen HJ, Muller A, Ebeling U. Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations. Neurosurgery. 1996;39(2):345–50. discussion 350-341.PubMedCrossRefGoogle Scholar
  18. 18.
    Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine. Spine. 1988;13(6):696–706.CrossRefGoogle Scholar
  19. 19.
    Choi G, Lee SH, Bhanot A, Raiturker PP, Chae YS. Percutaneous endoscopic discectomy for extraforaminal lumbar disc herniations: extraforaminal targeted fragmentectomy technique using working channel endoscope. Spine. 2007;32(2):E93–9. Scholar
  20. 20.
    Jang JS, An SH, Lee SH. Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. J Spinal Disord Tech. 2006;19(5):338–43. Scholar
  21. 21.
    Lew SM, Mehalic TF, Fagone KL. Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations. J Neurosurg. 2001;94(2 Suppl):216–20.PubMedGoogle Scholar
  22. 22.
    Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine. 2002;27(7):722–31.CrossRefGoogle Scholar
  23. 23.
    Kambin P, O'Brien E, Zhou L, Schaffer JL. Arthroscopic microdiscectomy and selective fragmentectomy. Clin Orthop Relat Res. 1998;347:150–67.CrossRefGoogle Scholar
  24. 24.
    Epstein NE. Different surgical approaches to far lateral lumbar disc herniations. J Spinal Disord. 1995;8(5):383–94.PubMedCrossRefGoogle Scholar
  25. 25.
    Hurday Y, Xu B, Guo L, Cao Y, Wan Y, Jiang H, Liu Y, Yang Q, Ma X. Radiographic measurement for transforaminal percutaneous endoscopic approach (PELD). Eur Spine J. 2017;26(3):635–45. Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  • Kyung-Chul Choi
    • 1
  • Dong Chan Lee
    • 1
  • Choon-Keun Park
    • 1
  1. 1.Department of NeurosurgeryThe Leon Wiltse Memorial HospitalAnyang CitySouth Korea

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