Outside-in Direct Fragmentectomy of TELD After Foraminoplasty

  • Tomoya Terai


As a minimally invasive surgery for lumbar disc herniation, full-endoscopic discectomy (FED) is gaining attention. There are three types of FED, transforaminal and posterolateral method with local anesthesia and interlaminar method with epidural anesthesia and general anesthesia. There are two methods of transforaminal endoscopic lumbar discectomy (TELD) for accessing the lumbar intervertebral discs in transforaminal approach: “inside-out technique” and “outside-in technique.” Following foraminoplasty, the cannula was moved into the epidural space with the outside-in technique. With epidural observation just beneath the nerve root, the extruded transligamentous fragment was confirmed. The direct fragmentectomy of TELD is possible from outside of the intradiscal space. In conclusion, the outside-in technique during the transforaminal approach for TELD is a useful and reliable technique to remove extruded transligamentous disc fragments. We describe the outside-in technique of TELD in this review.


Lumbar disc herniation Full-endoscopic discectomy Local anesthesia Transforaminal approach Outside-in technique 


  1. 1.
    Yeung AT. The evolution of percutaneous spinal endoscopy and discectomy: state of the art. Mt Sinai J Med. 2000;67:327–32.PubMedGoogle Scholar
  2. 2.
    Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine. 2002;27:722–31.CrossRefGoogle Scholar
  3. 3.
    Yeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am. 2007;38(3):363–72.CrossRefGoogle Scholar
  4. 4.
    Dezawa A, Sairyo K. New minimally invasive endoscopic discectomy technique through the interlaminar space using a percutaneous endoscope. Asian J Endosc Surg. 2011;4(2):94–8.CrossRefGoogle Scholar
  5. 5.
    Sairyo K, Egawa H, Matsuura T, Takahashi M, Higashino K, Sakai T, et al. State of the art: transforaminal approach for percutaneous endoscopic lumbar discectomy under local anesthesia. J Med Investig. 2014;61(3–4):217–25.CrossRefGoogle Scholar
  6. 6.
    Ruetten S, Komp M, Merk H, Godolias G. Use of newly developed instruments and endoscopes: full-endoscopic resection of lumbar disc herniations via the interlaminar and lateral transforaminal approach. J Neurosurg Spine. 2007;6(6):521–30.CrossRefGoogle Scholar
  7. 7.
    Dezawa A, Mikami H, Sairyo K. Percutaneous endoscopic translaminar approach for herniated nucleus pulposus in the hidden zone of the lumbar spine. Asian J Endosc Surg. 2011;5(4):200–3.CrossRefGoogle Scholar
  8. 8.
    Koga S, Sairyo K, Shibuya I, Kanamori Y, Kosugi T, Matsumoto H, et al. Minimally invasive removal of a recurrent lumbar herniated nucleus pulposus by the small incised microendoscopic discectomy interlaminar approach. Asian J Endosc Surg. 2012;5(1):34–7.CrossRefGoogle Scholar
  9. 9.
    Gore S, Yeung A. The “inside out” transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: results and a review of the literature. Int J Spine Surg. 2014;8:28.CrossRefGoogle Scholar
  10. 10.
    Kim HS, Adsul N, Kim KJ, Jang JS, Jang IT, Oh SH. Get ready for 100 years of active spine life using percutaneous endoscopic spine surgery (PESS). J Minim Invasive Spine Surg Tech. 2018;3(1):1–8.CrossRefGoogle Scholar
  11. 11.
    Yoshinari H, Tezuka F, Yamashita K, Manabe H, Hayashi F, Ishihama Y, et al. Transforaminal full-endoscopic lumbar discectomy under local anesthesia in awake and aware condition: the inside-out and outside-in techniques. Curr Rev Musculoskelet Med. 2019;12(3):311–7.CrossRefGoogle Scholar
  12. 12.
    Henmi T, Terai T, Hibino N, Yoshioka S, Kondo K, Goda Y, et al. Percutaneous endoscopic lumbar discectomy utilizing ventral epiduroscopic observation technique and foraminoplasty for transligamentous extruded nucleus pulposus: technical note. J Neurosurg Spine. 2016;24(2):275–80.CrossRefGoogle Scholar
  13. 13.
    Sairyo K, Chikawa T, Nagamachi A. State-of-the-art transforaminal percutaneous endoscopic lumbar surgery under local anesthesia: discectomy, foraminoplasty, and ventral facetectomy. J Orthop Sci. 2018;23(2):229–36.CrossRefGoogle Scholar
  14. 14.
    Henmi T, Terai T, Nagamachi A, Sairyo K. Morphometric changes of the lumbar intervertebral foramen after percutaneous endoscopic foraminoplasty under local anesthesia. J Neurol Surg A Cent Eur Neurosurg. 2018;79(1):19–24.CrossRefGoogle Scholar
  15. 15.
    Choi G, Kang HY, Modi HN, Prada N, Nicolau RJ, Joh JY, et al. Risk of developing seizure after percutaneous endoscopic lumbar discectomy. J Spinal Disord Tech. 2011;24(2):83–92.CrossRefGoogle Scholar
  16. 16.
    Choi I, Ahn JO, So WS, Lee SJ, Choi IJ, Kim H. Exiting root injury in transforaminal endoscopic discectomy: preoperative image considerations for safety. Eur Spine J. 2013;22(11):2481–7.CrossRefGoogle Scholar
  17. 17.
    Sairyo K, Matsuura T, Higashino K, Sakai T, Takata Y, Goda Y, et al. Surgery related complications in percutaneous endoscopic lumbar discectomy under local anesthesia. J Med Investig. 2014;61(3–4):264–9.CrossRefGoogle Scholar
  18. 18.
    Kitahama Y, Sairyo K, Dezawa A. Percutaneous endoscopic transforaminal approach to decompress the lateral recess in an elderly patient with spinal canal stenosis, herniated nucleus pulposus and pulmonary comorbidities. Asian J Endosc Surg. 2013;6(2):130–3.CrossRefGoogle Scholar
  19. 19.
    Sairyo K, Kitagawa Y, Dezawa A. Percutaneous endoscopic discectomy and thermal annuloplasty for professional athletes. Asian J Endosc Surg. 2013;6(4):292–7.CrossRefGoogle Scholar
  20. 20.
    Lee SH, Kang HS, Choi G, Kong BJ, Ahn Y, Kim JS, et al. Foraminoplastic ventral epidural approach for removal of extruded herniated fragment at the L5–S1 level. Neurol Med Chir (Tokyo). 2010;50(12):1074–8.CrossRefGoogle Scholar
  21. 21.
    Lewandrowski KU. “Outside-in” technique, clinical results, and indications with transforaminal lumbar endoscopic surgery: a retrospective study on 220 patients on applied radiographic classification of foraminal spinal stenosis. Int J Spine Surg. 2014;8:26.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2021

Authors and Affiliations

  • Tomoya Terai
    • 1
  1. 1.Department of Orthopedic SurgeryShikoku Central HospitalShikokuchuoJapan

Personalised recommendations