4.15. Learning endoscopic lumbar discectomy
@ProfFishchenkoLearning biportal endoscopic spine surgery should begin with lumbar discectomy for large sequestered disc herniations. A large sequestered fragment is easier to locate and identify in the operative field. Its removal helps demonstrate the relationship between fragment location, nerve root compression and the result of decompression.
Before surgery, sagittal and axial MRI series should be reviewed to establish the fragment's position relative to the dural sac and nerve root, as well as the direction and extent of migration. The surgeon should have a clear mental picture of where the fragment is expected and which structures must be exposed to visualize it.
During the first procedures, the main focus is on identifying the dural sac, nerve root and herniated disc tissue. Before mobilizing the sequestered fragment, its boundaries and relationship to the neural structures should be clearly visible. The working space must allow the instrument to reach the fragment and its tip to remain under control during grasping and removal. Inadequate visualization calls for adjustment of the endoscope position, hemostasis or enlargement of the approach [1].
The final inspection is correlated with the preoperative MRI. Particular attention is paid to the migration area, where individual fragments may remain. Removal of the largest sequestered fragment should be accompanied by inspection of the entire planned decompression zone.
Video review assesses the accuracy of reaching the sequestered fragment, maintenance of orientation, instrument control and manipulation near the nerve root. Once these stages have been mastered, training progresses to herniations with more complex migration, firm or calcified fragments, and subsequently to revision procedures with scar tissue.
References
- Kim S.K., Yi S., Park J.Y. Unilateral Biportal Endoscopy for Herniated Lumbar Disc. In: Unilateral Biportal Endoscopic Spine Surgery: Basic and Advanced Technique. Springer; 2022. P. 31–44; training and technical aspects: p. 43. Book chapter.
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