Name: a mobile outside-in technique of transforaminal lumbar endoscopy for lumbar disc herniations
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The protocol follows the guidelines of Nanoori Hospital&#39;s human research ethics committee. A written informed consent was obtained from all the patients with unilateral lower limb radiculopathy due to lumbar disc prolapse. The exclusion criteria were the presence of segmental instability, spondylolisthesis (more than grade 1), and the presence of significant spinal stenosis.
1. Patient Position and Skin Marking
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	<li>Place the patient in the prone position on the radiolucent operatin...

<ol>
	<li>Tzaan, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transforaminal+percutaneous+endoscopic+lumbar+discectomy.">Transforaminal percutaneous endoscopic lumbar discectomy.</a> Chang Gung medical journal. 30 (3), 226 (2007).</li><li>Morgenstern, R., Morgenstern, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+Transforaminal+Lumbar+Interbody+Fusion+(pTLIF)+with+a+Posterolateral+Approach+for+the+Treatment+of+Degenerative+Disk+Disease:+Feasibility+and+Preliminary+Results.">Percutaneous Transforaminal Lumbar Interbody Fusion (pTLIF) with a Posterolateral Approach for the Treatment of Degenerative Disk Disease: Feasibility and Preliminary Results.</a> International journal of spine surgery. 9, (2015).</li><li>Ying, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+and+feasibility+study+of+transforaminal+percutaneous+endoscopic+lumbar+discectomy+via+superior+border+of+inferior+pedicle+approach+for+down-migrated+intracanal+disc+herniations.">The effect and feasibility study of transforaminal percutaneous endoscopic lumbar discectomy via superior border of inferior pedicle approach for down-migrated intracanal disc herniations.</a> Medicine. 95 (8), (2016).</li><li>Schubert, M., Hoogland, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+transforaminal+nucleotomy+with+foraminoplasty+for+lumbar+disk+herniation.">Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation.</a> Operative Orthopadie und Traumat.ologie. 17 (6), 641-661 (2005).</li><li>Telfeian, A. E., Jasper, G. P., Francisco, G. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transforaminal+endoscopic+treatment+of+lumbar+radiculopathy+after+instrumented+lumbar+spine+fusion.">Transforaminal endoscopic treatment of lumbar radiculopathy after instrumented lumbar spine fusion.</a> PainPhysician. 18 (2), 179-184 (2015).</li><li>Kim, H. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Analysis+of+clinical+results+of+three+different+routes+of+percutaneous+endoscopic+transforaminal+lumbar+discectomy+for+lumbar+herniated+disk.">Analysis of clinical results of three different routes of percutaneous endoscopic transforaminal lumbar discectomy for lumbar herniated disk.</a> Worldneurosurgery. 103, 442-448 (2017).</li><li>Gore, S., Yeung, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+&amp;#34;inside+out&amp;#34;+transforaminal+technique+to+treat+lumbar+spinal+pain+in+an+awake+and+aware+patient+under+local+anesthesia:+results+and+a+review+of+the+literature.">The &amp;#34;inside out&amp;#34; transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: results and a review of the literature.</a> International journal of spine surgery. 8, (2014).</li><li>Choi, G., Pophale, C. S., Patel, B., Uniyal, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+Spine+Surgery.">Endoscopic Spine Surgery.</a> Journal of Korean Neurosurgical Society. 60 (5), 485 (2017).</li><li>Hoogland, T., Schubert, M., Miklitz, B., Ramirez, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transforaminal+posterolateral+endoscopic+discectomy+with+or+without+the+combination+of+a+low-dose+chymopapain:+a+prospective+randomized+study+in+280+consecutive+cases.">Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases.</a> Spine. 31 (24), E890-E897 (2006).</li><li>Ruetten, S., Komp, M., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+extreme+lateral+access+for+the+surgery+of+lumbar+disc+herniations+inside+the+spinal+canal+using+the+full-endoscopic+uniportal+transforaminal+approach-technique+and+prospective+results+of+463+patients.">An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients.</a> Spine. 30 (22), 2570-2578 (2005).</li><li>Johnson, E. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Visual analog scale (VAS). , (2001).</li><li>Fairbank, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Oswestry+disability+index.">Oswestry disability index.</a> Journal of neurosurgery Spine. 20 (2), 239 (2014).</li><li>Macnab, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Negative+Disc+Exploration:+an+analysis+of+the+causes+of+nerve-root+involvement+in+sixty-eight+patients.">Negative Disc Exploration: an analysis of the causes of nerve-root involvement in sixty-eight patients.</a> The Journal of bone and joint surgery. 53 (5), 891-903 (1971).</li><li>Hoogland, T., van den Brekel-Dijkstra, K., Schubert, M., Miklitz, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+transforaminal+discectomy+for+recurrent+lumbar+disc+herniation:+a+prospective,+cohort+evaluation+of+262+consecutive+cases.">Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases.</a> Spine. 33 (9), 973-978 (2008).</li><li>Yeung, A. T., Tsou, P. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Posterolateral+endoscopic+excision+for+lumbar+disc+herniation:+surgical+technique,+outcome,+and+complications+in+307+consecutive+cases.">Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases.</a> Spine. 27 (7), 722-731 (2002).</li><li>Kambin, P., Gellman, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+Lateral+Discectomy+of+the+Lumbar+Spine+A+Preliminary+Report.">Percutaneous Lateral Discectomy of the Lumbar Spine A Preliminary Report.</a> Clinical Orthopaedics and Related Research. 174, 127-132 (1983).</li><li>Hoogland, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+endoscopic+discectomy.">Percutaneous endoscopic discectomy.</a> Journal of neurosurgery. 79 (6), 967-968 (1993).</li><li>Knight, M., Goswami, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+isthmic+spondylolisthesis+with+posterolateral+endoscopic+foraminal+decompression.">Management of isthmic spondylolisthesis with posterolateral endoscopic foraminal decompression.</a> Spine. 28 (6), 573-581 (2003).</li><li>Pain, B., Telfeian, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+retrospective+evaluation+of+the+clinical+success+of+transforaminal+endoscopic+discectomy+with+foraminotomy+in+geriatric+patients.">A retrospective evaluation of the clinical success of transforaminal endoscopic discectomy with foraminotomy in geriatric patients.</a> Painphysician. 16, 225-229 (2013).</li><li>Kim, H. S., Ju, C. I., Kim, S. W., Kim, J. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+transforaminal+suprapedicular+approach+in+high+grade+inferior+migrated+lumbar+disc+herniation.">Endoscopic transforaminal suprapedicular approach in high grade inferior migrated lumbar disc herniation.</a> Journal of Korean Neurosurgical Society. 45 (2), 67 (2009).</li><li>Chae, K. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Strategies+for+noncontained+lumbar+disc+herniation+by+an+endoscopic+approach:+transforaminal+suprapedicular+approach,+semi-rigid+flexible+curved+probe,+and+3-dimensional+reconstruction+CT+with+discogram.">Strategies for noncontained lumbar disc herniation by an endoscopic approach: transforaminal suprapedicular approach, semi-rigid flexible curved probe, and 3-dimensional reconstruction CT with discogram.</a> Journal of Korean Neurosurgical Society. 46 (4), 312 (2009).</li><li>Anichini, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lumbar+endoscopic+microdiscectomy:+Where+are+we+now?+An+updated+literature+review+focused+on+clinical+outcome,+complications,+and+rate+of+recurrence.">Lumbar endoscopic microdiscectomy: Where are we now? An updated literature review focused on clinical outcome, complications, and rate of recurrence.</a> BioMed research international. , (2015).</li><li>Gotecha, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+transforaminal+percutaneous+endoscopic+discectomy+in+lumbar+disc+herniations.">The role of transforaminal percutaneous endoscopic discectomy in lumbar disc herniations.</a> Journal of craniovertebral junction &amp; spine. 7 (4), 217 (2016).</li><li>Ruetten, S., Komp, M., Merk, H., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recurrent+lumbar+disc+herniation+after+conventional+discectomy:+a+prospective,+randomized+study+comparing+full-endoscopic+interlaminar+and+transforaminal+versus+microsurgical+revision.">Recurrent lumbar disc herniation after conventional discectomy: a prospective, randomized study comparing full-endoscopic interlaminar and transforaminal versus microsurgical revision.</a> Clinical Spine Surgery. 22 (2), 122-129 (2009).</li><li>Weir, B., Jacobs, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reoperation+rate+following+lumbar+discectomy.+An+analysis+of+662+lumbar+discectomies.">Reoperation rate following lumbar discectomy. An analysis of 662 lumbar discectomies.</a> Spine. 5 (4), 366-370 (1980).</li><li>&#xD6;sterman, H., Sund, R., Seitsalo, S., Keskim&#228;ki, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+of+multiple+reoperations+after+lumbar+discectomy:+a+population-based+study.">Risk of multiple reoperations after lumbar discectomy: a population-based study.</a> Spine. 28 (6), 621-627 (2003).</li><li>Xin, G., Shi-Sheng, H., Hai-Long, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morphometric+analysis+of+the+YESS+and+TESSYS+techniques+of+percutaneous+transforaminal+endoscopic+lumbar+discectomy.">Morphometric analysis of the YESS and TESSYS techniques of percutaneous transforaminal endoscopic lumbar discectomy.</a> Clinical Anatomy. 26 (6), 728-734 (2013).</li><li>Pan, Z., Ha, Y., Yi, S., Cao, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+transforaminal+endoscopic+spine+system+(TESSYS)+technique+in+treating+lumbar+disc+herniation.">Efficacy of transforaminal endoscopic spine system (TESSYS) technique in treating lumbar disc herniation.</a> Medical science monitor: international medical journal of experimental and clinical research. 22, 530 (2016).</li></ol>

The study is based on the prospective analysis of 184 patients with lumbar disc disease that were managed at our institute. X-ray imaging, computed tomography (CT), and magnetic resonance imaging (MRI) were done in all cases to confirm the diagnosis and to rule out other pathologies. The findings demonstrated on the CT and MRI scans were correlated with a neurologic examination. After the proper diagnosis, patients were operated on with the mobile outside-in technique of PETLD. The exclusion criteria were the presence of...

Chronic low back pain and leg pain are common ailments in any society. The treatment modalities to combat degenerative lumbar disc diseases have been continuously evolving. The armamentarium has been wide, from open surgery and fixation to microlumbar discectomy, and now the endoscopic route1,2,3,4. The transforaminal pathway, initially suggested by Parvez Kambin, is now gradually becoming a standard of care5,6,7. The advantages of full-endoscopic spine surgeries are less soft-tissue dissection, less blood loss, reduced hospital admission days, an early functional recovery, and an enhancement in the quality of life8.
The traditional outside-in approach of PETLD, given by Schubert and Hoogland4, deals with the introduction of a working cannula in the foramen and then an enlargement of the foramen by using reamers. The rationale behind the novel technique of the outside-in approach mentioned here is that it does not solely depend on enlarging the foramen in all cases. The technique focuses on the precise placement of the working cannula within the foramen and then guiding the movement of the cannula toward the target fragment, under endoscopic vision9,10. Anatomically, there are three different routes into the transforaminal space, and if used effectively, percutaneous endoscopic spine surgery with the outside-in technique can be applied to a wider range of lumbar disc herniation. Central, paracentral, and high canal compromised Lumbar Disc Herniation (LDH) is approached by the intervertebral route; foraminal, superiorly migrated, and far lateral LDH is approached by the foraminal route, and inferiorly migrated LDH is approached by the suprapedicular route6. The advantage of this technique is that it preserves the normal anatomical structures with less discal injury, the epidural exposure is easy, and the manipulation of a working cannula in the foramen is not difficult. The technique described differs from the earlier one because it provides a precise vision of the structures within the foramen and focuses on the accurate placement of the cannula within the foramen, rather than on enlarging the foramen. The technique is equally safe as inside-out technique and provides an easy handling of structures, especially the extruded fragments. The goal of this study is to prove the versatility of this novel approach in managing different types of disc prolapse as central, paracentral, foraminal, far lateral, and up and down migration, and in high-canal compromise cases. The technique, however, demands a longer learning curve and so beginners need to be patient while learning.

<table border="0" cellpadding="0" cellspacing="0" width="651">
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			<td height="20" style="height:20px;width:176px;">Contrast dye injection</td>
			<td style="width:347px;">Iobrix injection, Taejoon pharm,Seoul, Korea</td>
			<td align="right" style="width:65px;">S.No. 1</td>
			<td style="width:64px;"></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">0.8% indigo carmine</td>
			<td>Carmine, Korea United Pharmaceutical, Yoenki, Korea</td>
			<td align="right">S.No. 2</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;width:176px;">30 degree endoscope</td>
			<td>Joimax GmbH, Germany</td>
			<td align="right">S.No. 3</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Radiofrequency coagulator</td>
			<td>Elliquence, New York, USA</td>
			<td align="right">S.No. 4</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Drill</td>
			<td>Primado 2 NSK, Tochigi, Japan</td>
			<td align="right">S.No. 5</td>
			<td></td>
		</tr>
	</tbody>
</table>

a mobile outside-in technique of transforaminal lumbar endoscopy for lumbar disc herniations

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are two techniques for the introduction of a working cannula with respect to disc&#8212;outside-in and inside-out. The aim of this prospective study is to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse. A total of 184 consecutive patients with unilateral lower limb radiculopathy due to lumbar disc prolapse were operated on with the mobile outside-in technique of PETLD. Their clinical outcomes were evaluated based on the type of disc prolapse they had, a visual analog scale (VAS) leg pain score, the Oswestry Disability Index (ODI), and the Macnab criteria. The completeness of the decompression was documented with a postoperative magnetic resonance imaging. The mean age of the patients was 50 &#177; 16 years and the male/female ratio was 2:1. The mean follow-up was 19 &#177; 6 months. A total of 190 lumbar levels were operated on (L1&#8211;L2: n = 4, L2&#8211;L3: n = 17, L3&#8211;L4: n = 27, L4&#8211;5: n = 123, and L5&#8211;S1: n = 19). Divided into types, the patient distribution was central: n = 14, paracentral: n = 74, foraminal: n = 28, far lateral: n = 13, superior-migrated: n = 8, inferior migrated: n = 38, and high canal compromise: n = 9. The mean operative time was 35 &#177; 12 (25 - 56) min and the mean hospital stay was 1.2 &#177; 0.5 (1&#8211;3) days. The VAS score for leg pain improved from 7.5 &#177; 1 to 1.7 &#177; 0.9. The ODI improved from 70 &#177; 8.3 to 23 &#177; 5. According to the Macnab criteria, 75 patients (40.8%) had excellent results, 104 patients (56.5%) had good results, and 5 patients (2.7%) had fair results. Recurrence (including early and late) was seen in 15 out of the 190 levels that were operated on (7.89%). This article presents a novel outside-in approach that relies on a precise landing within the foramen in a mobile manner and does not solely depend upon the enlargement of the foramen. It is more versatile in application and useful in the management of all types of disc prolapse, even in severe canal compromise and high migration.

Outcome Evaluation:
The outcome of the surgery was measured by the VAS leg pain score11, the ODI12, and the Macnab criteria13. These were measured in the preoperative period and during follow-up visits (1 week after the surgery, 3 months after the surgery, and at the last follow-up).
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Watch this Scientific Journal Video about A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations at JoVE.com

A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

Here we present a protocol of a novel outside-in technique of transforaminal endoscopic discectomy for lumbar disc herniations. The technical aspects of the technique, the wide indications of use, and the results of the treatment in 184 patients are described in detail.

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are ...

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