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Complications of Percutaneous Spinal Lumbar Endoscopy (PELD)

Ricardo Ruiz-López MD¹, Ovidiu Palea MD, FIPP², and Teodor Cristea MD³

¹ Clinica Vertebra, Spine and Pain Surgery Centers, Barcelona / Madrid, Spain
² Pain Centre, Provita, Bucharest, Hungary
³ Saint Pantalion Hospital and Provita Clinic, Bucharest, Romania

Introduction

Percutaneous spinal endoscopy (PSE) was first reported by Kambin [1–3] and Hijikata [4], more than 50 years ago. This technique has evolved since then due to major technologic improvements in optics, high-resolution cameras, as well as the imaging modality. Even although initial indications were about disc herniations, nowadays, PSE covers a wide range of degenerative spine pathology, and – not only that – practitioners are more and more comfortable with indications such as discitis or tumors.

PSE has similar indications proposed to those for open spine surgery and similar outcomes, as demonstrated by several randomized-controlled trials (RCTs) and meta-analyses [5–9].

Additionally, PSE offers better visualization, decreased damage to musculoskeletal tissues and preservation of spinal stability, a lower risk for reherniation, a lesser incidence for epidural scar tissue, less blood loss, diminished post-operative pain, reduced hospitalization and faster rehabilitation [10, 11].

Rationale for Minimally Invasive Spine Surgery

Minimally invasive spine surgery (MISS) encompasses techniques and innovative devices to reduce approach-related morbidity by sparing normal anatomic spinal structures during spine surgery.

Minimally invasive techniques can be performed for treatment of the vast majority of pathologic conditions of the spine and offer a compelling alternative to traditional approaches.

MISS is simply res ipsa loquitur (i.e., the thing speaks for itself).

Goals of PELD

Identify the patho-anatomy of pain
Treat pain generator in a step-by-step algorithmic rationale
Recognize personal surgical limitations
Leave spinal fusion just for deformity and progressive instability.

Anatomy

PTE is solely based on the thorough 3D understanding of the structure called The Kambin’s triangle (Figure 64.1). This is presented as a 2D plane, which is actually confusing for the interventionist and makes the learning curve steep or even wrong. From a 2D perspective, the boundaries of Kambin’s triangle are the superior end plate of the inferior vertebral body (base of the triangle), the superior articulating facet (the height of the triangle), and the exiting superior nerve root (the hypotenuse of the triangle) [1]. It is used to access critical structures in a variety of lumbar and thoracic spine procedures being a so-called “safety zone” as it is absent of vascular and neural structures of importance.

**Figure 64.1** Kambin’s safety triangle (shaded area) at L4/L5 [1].

Discography

This step is important in order to delineate the degenerated fragment for easy identification and removal during endoscopy. It can be done with a colored solution (indigo carmine/methylene blue) and contrast agent so that the visibility is ensured both endoscopically and fluoroscopically. It is almost always done the same way for all endoscopic techniques.

Indications

Any kind of herniated discs (Figure 64.2):

central canal
lateral recess
foraminal or extraforaminal
foraminal spinal stenosis
spinal canal stenosis.

**Figure 64.2** Various types of lumbar disc herniation.

Disc herniations can be accompanied by radicular and lumbar pain, neurologic symptoms which are refractory to rehabilitation, physical therapy and pharmacologic treatment [12–14].

Various approaches have been developed whether transforaminal or interlaminar according to the segmental lumbar level and type of pathologic conditions.

Contraindications

Absolute Contraindications

Coaguloptahy
Local or systemic infection.

Relative Contraindications

Motor deficit
Severe spinal canal stenosis
Spondilolisthesis
Far lateral disc herniations
Fibrotic adhesions
Calcified discs
Sequestered migrated disc herniations
Large L5–S1 disc herniations in patient with high iliac crests
Patient’s age
Co-morbidities.

Limitations of PSE

Narrow operating space
Surgeon’s learning curve (Table 64.1).

Table 64.1 Summary of factors affecting the learning curve.

	Case No.	Mean age (range), yrs	Male/female	Operating time (range), min	Failure rate, %	Complication rate, %	1-Year clinical success rate, %^*	1-Year reherniation rate, %^*
Group I	1–17	33.9 (24–52)	10/7	62.1 (30–90)	0	5.9	82.4	17.6
Group II	18–34	35.6 (18–49)	10/7	47.6 (30–105)	17.6	5.9	92.9	7.1
Group III	35–51	39.8 (15–55)	12/5	37.9 (30–60)	5.9	0	93.8	6.3
p Value		0.20	0.72	0.0004	0.31	1.0	0.51	0.60
^*The 1-year clinical success rate and 1-year reherniation rate were assessed in 47 patients with initial success of percutaneous endoscopic lumbar discectomy.[6]

Recommendations

Be aware of the different endoscopic systems and techniques
The learning curve is slow and on an individual basis
Mastering anatomy and access in pathological conditions.

Technique

The patient must be placed in ventral decubitus. Analgosedation is necessary for both the patient’s comfort and their pain response when the nervous structures are injured. After localizing the vertebral level using C-arm anesthesia is done on the skin, a 5-mm incision is made, through which, a spinal needle is inserted in order to inject the anesthetic throughout the muscle and bony plane (facet or lamina depending on the technique).

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