Technique Gold Papers 1

J Neurosurg (Spine 3) 99:320323, 2003
Posterolateral percutaneous endoscopic lumbar foraminotomy

for L5S1 foraminal or lateral exit zone stenosis
Technical note
YONG AHN, M.D., SANG-HO LEE, M.D., PH.D., WOO-MIN PARK, M.D.,
AND HO-YEON LEE, M.D., PH.D.
Division of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
The purpose of this study was to determine the efficacy and feasibility of posterolateral percutaneous endoscopic lumbar foraminotomy (PELF) for foraminal or lateral exit zone stenosis of the L5S1 level in the awake patient.
Twelve consecutive patients with L5S1 foraminal stenosis and associated leg pain underwent PELF between May
2001 and July 2002. Under fluoroscopic guidance, posterolateral endoscopic foraminal decompression was performed
using a bone reamer, endoscopic forceps, and a laser. Using this new technique, the authors removed part of the hypertrophied superior facet, thickened ligamentum flavum, and protruded disc compressing the exiting (L-5) nerve root. Clinical
outcome was measured using the Macnab criteria. The mean follow-up period was 12.9 months. All the patients were discharged within 24 hours. Satisfactory (excellent or good) results were demonstrated in 10 patients. There was no complication.
The PELF procedure provides a simple alternative for treating lumbar foraminal or lateral exit zone stenosis in selected cases. The authors found that the posterolateral endoscopic approach to the L5S1 foramen was usually possible and
that using a bone reamer to undercut the superior facet was effective.
KEY WORDS endoscopy foraminotomy foraminal stenosis disc protrusion
stenosis, which can anatomically be divided

into central and lateral canal stenosis, has many
causes. The anatomy of the lateral lumbar spinal
canal has been described in several studies.1,3,5,13,17 Compression of the exiting nerve root in the middle zone of the
foramen is referred to as foraminal stenosis.5 The extraforaminal zone lies outside the lateral border of the pedicle,12 and Maher and Henderson16 have referred to compression of the nerve root as it exits the foramen as lateral
exit zone stenosis. The dorsal root ganglion near the foramen is thought to be a pain generator because of its high
concentration of substance P and its sensitivity to external
pressure.2,6,18,19 Therefore, foraminal or lateral exit zone
stenosis could potentially result in significant radicular
and low-back pain due to compression of the structures
within the area.
Recently, some pioneers have developed the technique
known as percutaneous endoscopic lumbar discectomy or
foraminoplasty for various lumbar disc diseases.4,811,14,20,21
Although their clinical results were good, some technical
considerations for the endoscopic foraminal decompres-
PINAL
Abbreviations used in this paper: CT = computerized tomography; Ho:YAG = holmium yttrium-aluminum-garnet; MR = magnetic resonance; PELF = percutaneous endoscopic lumbar foraminotomy.
320
sion remain. First, the laser sculpturing of the hard osseous component might be demanding or ineffective.
Second, the procedure was performed mainly at or superior to the L45 level. In terms of the L5S1 level, the number of cases has been relatively small, because access at
this level is considered too difficult as the iliac crest and/or
L-5 transverse process act as obstacles. The most common
(75%) reported level of foraminal stenosis, however, has
been at L5S1.7 In the present study, a new technique to
solve these problems has been developed.
We describe the techniques for PELF in a series of 12
consecutive patients with L5S1 foraminal or lateral exit
zone stenosis.
Clinical Material and Methods
Patient Selection and Outcome Evaluation
Twelve consecutive patients with L5S1 foraminal or
lateral exit zone stenosis underwent PELF between May
2001 and July 2002. The inclusion criteria were as follows: 1) unilateral radicular leg pain rather than back pain;
2) L5S1 foraminal or lateral exit zone stenosis with or
without disc herniation, as demonstrated on CT and MR
imaging; 3) a documented transient effect of transforaminal selective L-5 nerve root block; and 4) failure of extensive conservative managements. The exclusion criteria
J. Neurosurg: Spine / Volume 99 / October, 2003
Percutaneous endoscopic lumbar foraminotomy
FIG. 1. Schematic diagrams depicting the surgical procedure. Left: Undercutting the hypertrophied superior facet.
Part of the superior facet can be safely punched out using a bone reamer. Center: After undercutting the superior facet,
sophisticated sculpturing was performed using a side-firing Ho:YAG laser and endoscopic forceps. The thickened ligamentum flavum, remnant bone fragment, shoulder osteophyte, and protruded disc material can be removed by rotating
the working cannula and the endoscope circumferentially. Right: After the procedure, the foramen was effectively
widened.
were definite segmental angular instability, spondylytic

spondylolisthesis, painless weakness, or cauda equina
syndrome. All patients underwent immediate postoperative CT or MR imaging, and were released to home within 24 hours. Clinical outcome was measured using the
Macnab criteria.15
Surgical Technique
The patient was placed prone, with the back mildly

flexed, on a radiolucent table. The patient was kept conscious during the procedure to enable the monitoring of any
changes in the symptoms and signs. Therefore, the treatment protocol allowed use of a local anesthetic agent.
The skin entry point was approximately 9 to 11 cm off
the midline. It was dictated by the size of the patient,
dimensions of the facet joints, and the desired location for
the tip of the needle in the triangular working zone. The
tip of the needle was positioned at the midpedicular line in
the anteroposterior projection and in alignment with the
posterior borders of the adjacent vertebral bodies in the
lateral projection. After insertion of the needle, discography was performed using a contrast mixture of 6 ml of
telebrix and 1 ml of indigo carmine.
A guidewire was inserted through the needle channel
into the anulus; a small stab incision was made at the entry
site of the needle. After withdrawing the needle, a tapered
cannulated obturator was slid over the guidewire and advanced into the foramen. A beveled working cannula was
introduced over the obturator, which was then removed,
and the endoscope (with an eccentrically placed 2.7-mm
working channel and two irrigation channels) was inserted. From the endoscopic intraforaminal view, the surgeon
was able to identify the hypertrophied superior facet and
other foraminal structures.
Using a bone reamer, the surgeon undercut the overhanging superior facet (Fig. 1 left). The bone reamer could
be advanced safely through the working cannula until the
medial pedicular line was met from the anteroposterior
projection. This step provided two effects. First, it directly decompressed the exiting nerve root by undercutting
the hypertrophied superior facet. Second, it made the
working space wide enough for additional decompression.
The remnant osseous fragments and thickened ligamenJ. Neurosurg: Spine / Volume 99 / October, 2003
tous material were removed using endoscopic forceps, as

well as a side-firing Ho:YAG laser until the epidural space
and dura were visualized (Fig. 1 center). Once the epidural space had been explored, the working cannula was
moved toward the pedicle of the upper vertebra to decompress the exiting nerve root directly. The exiting and traversing nerve roots were mobilized and decompressed
medially and laterally until the functional axilla of the
root at the apex of the triangular working zone was displayed. If the protruded disc or shoulder osteophytes compressed the exiting nerve root, they should be removed
(Fig. 1 center). Finally, an endoscopic foraminal and epidural examination completed the procedure (Fig. 1 right
and Fig. 2).
Results
Twelve patients who met the inclusion criteria underwent PELF. They ranged in age from 34 to 88 years (mean
56.8 years) and included five men and seven women. Three
patients suffered from severe osteoporosis and two had a
previously undergone open surgery at L5S1. The procedures were performed via a left-sided approach in four patients and a right-sided approach in eight, based on clinical
findings. Six patients underwent the foraminotomy without
discectomy and six with discectomy. Overall operative
time ranged from 45 to 110 minutes (mean 73 minutes).
The mean laser dose was 21.6 kJ (range 8.5241.47 kJ).
The mean follow-up period was 12.9 months (range 620
months). According to final follow-up Macnab criteria, an
excellent result was documented in four cases (33%), a
good result in six (50%), and a fair result in one. One
patient (Case 7), however, experienced a poor outcome,
with persistent leg pain, and subsequently underwent an
open paraspinal exploration. A missed foraminal disc fragment was found compressing the exiting nerve root, and
this was removed. There was no significant complication
(Table 1).
Discussion
In this study the symptoms in patients with foraminal or
lateral exit zone stenosis were characterized by severe
radicular pain, which worsened with back extension and
321
Y. Ahn, et al.
TABLE 1
Demographic and operative characteristics of the 12 patients
with L5S1 foraminal or lateral exit zone stenosis
Case
No.
Age (yrs),
Sex
1
2
3
4
5
6
7
8*
9
10
11
12
68, F
41, M
43, M
43, F
73, F
52, F
73, M
56, F
56, F
88, M
54, F
34, M
Associated
Problem
osteoporosis
osteoporosis
previous op
angina pectoris
osteoporosis
previous op
Laser
Strength (J)
Discectomy
Outcome
10,000
15,690
24,450
33,990
16,600
41,470
12,170
15,230
15,500
49,340
16,084
8,520
yes
yes
no
no
no
no
no
no
yes
yes
yes
yes
good
excellent
excellent
good
good
good
poor
good
good
fair
excellent
excellent
* The patient underwent simultaneous L45 and L5S1 surgery.
FIG. 2. Intraoperative endoscopic image (upper) and corresponding drawing (lower) demonstrating the anatomy after a successful decompression. Note the transforaminal endoscopic view
of the exiting nerve root, dural sac including the traversing root,
and the remaining ligamentum flavum.
walking, mild neurological deficits, and the absence of the

straight leg-raising sign. The MR imaging studies demonstrated a hypertrophied superior facet, thickened ligamentum flavum, and the loss of perineural fat in the foramen or
lateral exit zone. The main juxtaforaminal lesions that
might cause radicular pain are facet hypertrophy, thickened
ligamentum flavum, tough foraminal ligaments, shoulder
osteophytes, or foraminal disc herniation. The PELF technique allows the foramen to be explored, as well as ablation
of contributory osteophytes, disc protrusion, and epidural fibrosis. At the same time, ablative sculpturing of the
hypertrophied superior facet allows the foramen to be
enlarged under direct vision. There are several theoretical
mechanisms for foraminal decompression: 1) direct
mechanical widening of the foramen by undercutting the
hypertrophied superior facet; 2) removal of the foraminal
disc herniation and thickened ligaments; and 3) releasing
the nerve root from the inflamed or fibrotic adhesions.
The use of a bone reamer for undercutting the superior
facet is unique and has never been described in previous
studies.4,811,14,20,21 Authors of previous reports have only
used a laser beam in sculpturing the hypertrophied superior facet or other osseous structures.811,21 We found that the
combination of a bone reamer and a side-firing Ho:YAG
322
laser was more effective and time-saving than the use of a

laser alone. Moreover, widening of foramen can provide
enough working space for further sophisticated decompression. The undercutting can be performed safely under
fluoroscopic and endoscopic guidance.
Until now, an endoscopic approach to the L5S1 disc
level has been regarded as a difficult challenge; the iliac
crest and transverse process were the major obstacles.
There have been many reports on endoscopic discectomies, but in most the authors have described relatively
fewer cases at the L5S1.811,14 Our experience, however,
indicates that it was not so difficult to access the foraminal or lateral exit zone at L5S1. There are several keys to
accessing the L5S1 foramen easily. First, the skin entry
point is important. If it is too medial, the surgeon is not
able to explore the foramen entirely because of the limited angle of vision. If it is too lateral, the needle tip is subject to a blockage by the transverse process or iliac crest.
In our experience, the proper extent of skin entry point is
9 to 11 cm from the midline. Second, the working cannula should be introduced into the foramen as close to the
facet joint as possible to avoid injuring the exiting nerve
root. A beveled working cannula is safer than a standard
working cannula because it can easily slide into the foramen along the undersurface of the facet. Third, it is recommended that the initial endoscopic visualization should
mainly show the hypertrophied superior facet. The surgeon can then undercut the hypertrophied superior facet
safely and examine the epidural space more widely. It is
not necessary to insert the working cannula into the disc
space; intraforaminal placement is adequate in the initial
step. Decompression of the foramen should be initiated
from the caudal side of the facet and then moved toward
the cranial side to prevent neural injury.
In the present study, most patients experienced only unilateral radicular leg pain, with minor back pain. Many of
them were elderly individuals, medically compromised, or
suffered from severe osteoporosis, and this could not tolerate the general anesthesia required for a wide decompression and fusion surgery. Under these circumstances, the
PELF was useful as a minimally invasive spinal surgery.
Patients actually underwent this endoscopic surgery in an
awake state and returned to their normal activities of daily
Percutaneous endoscopic lumbar foraminotomy

References
FIG. 3. Preoperative (upper) and postoperative (lower) threedimensional CT reconstructions. The posterolateral view of the
right L5S1 foramen demonstrates the superior facet (SF), inferior
facet (IF), L-5 pedicle (P), sacral ala (A), and spinous process (SP).
Note that the foramen (arrowheads) was remarkably widened after
the operation.
living, with no significant postoperative pain or complication. Postoperative CT or MR imaging revealed the success
of the foraminal decompression (Fig. 3).
Finally, one of the most important factors is patient selection. Stenosis of the spinal canal, the lateral recess, and
the intervertebral foramen may be present at multiple levels. The accurate diagnosis of the pathological condition
in terms of its location, nature, and extent is important for
the preoperative planning of decompressive surgery. In
fact, in severe intracanalicular stenosis or segmental instability, PELF has little effect because of the limitation of
endoscopic decompression. Thus, thorough preoperative
evaluation is mandatory.
Conclusions
In this study, we have demonstrated the clinical efficacy of the posterolateral PELF for L5S1 foraminal or lateral exit zone stenosis. Our initial experience with PELF
indicates that the L5S1 foraminal portion can be accessed easily by using this technique and that the use of a
bone reamer and laser can offer effective mechanical
decompression and ablation of a pain source. The outcomes in our patients were comparable to those of conventional open surgical procedures. Moreover, this procedure can be useful in patients in whom general anesthesia
cannot be tolerated.
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Acknowledgments
We thank In-Sook Cho, Hye-Ran Lee, and James Lee for their
help in preparing the manuscript and figures.
Disclaimer
No funds were provided by any commercial source to support
this work.
Manuscript received February 29, 2003.

Accepted in final form June 16, 2003.
Address reprint requests to: Yong Ahn, M.D., Department
of Neurosurgery, Wooridul Spine Hospital, 47-4 Chungdam-dong
Kangnam-gu, Seoul 135-100, Korea. email: ns-ay@hanmail.net.
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Eur Spine J (2010) 19:181204

DOI 10.1007/s00586-009-1155-x
REVIEW ARTICLE
Transforaminal endoscopic surgery for symptomatic lumbar disc

herniations: a systematic review of the literature
Jorm Nellensteijn Raymond Ostelo Ronald Bartels
Wilco Peul Barend van Royen Maurits van Tulder
Received: 11 March 2009 / Revised: 29 June 2009 / Accepted: 19 August 2009 / Published online: 15 September 2009
The Author(s) 2009. This article is published with open access at Springerlink.com
Abstract The study design includes a systematic literature review. The objective of the study was to evaluate the
effectiveness of transforaminal endoscopic surgery and to
compare this with open microdiscectomy in patients with
symptomatic lumbar disc herniations. Transforaminal
endoscopic techniques for patients with symptomatic lumbar disc herniations have become increasingly popular. The
literature has not yet been systematically reviewed. A
comprehensive systematic literature search of the MEDLINE and EMBASE databases was performed up to May
2008. Two reviewers independently checked all retrieved
titles and abstracts and relevant full text articles for inclusion criteria. Included articles were assessed for quality and
outcomes were extracted by the two reviewers independently. One randomized controlled trial, 7 non-randomized
controlled trials and 31 observational studies were identified. Studies were heterogeneous regarding patient selection, indications, operation techniques, follow-up period
J. Nellensteijn
Department of Orthopaedics, EMGO Institute, VU University
Medical Center, Amsterdam, The Netherlands
R. Ostelo (&) M. van Tulder
Department of Health Sciences, EMGO Institute, VU University
Medical Center, VU University, De Boelelaan 1085,
room U-430, 1081 HV Amsterdam, The Netherlands
e-mail: r.ostelo@vumc.nl
W. Peul
Leiden University Medical Center, Leiden, The Netherlands
R. Bartels
Department of Neurosurgery, Radboud University Nijmegen
Medical Centre, Nijmegen, The Netherlands
B. van Royen
VU University Medical Center, Amsterdam, The Netherlands
and outcome measures and the methodological quality of

these studies was poor. The eight trials did not find any
statistically significant differences in leg pain reduction
between the transforaminal endoscopic surgery group
(89%) and the open microdiscectomy group (87%); overall
improvement (84 vs. 78%), re-operation rate (6.8 vs. 4.7%)
and complication rate (1.5 vs. 1%), respectively. In conclusion, current evidence on the effectiveness of transforaminal endoscopic surgery is poor and does not provide
valid information to either support or refute using this type
of surgery in patients with symptomatic lumbar disc herniations. High-quality randomized controlled trials with
sufficiently large sample sizes are direly needed to evaluate
if transforaminal endoscopic surgery is more effective than
open microdiscectomy.
Keywords Lumbar disc herniation Transforaminal
Endoscopic surgery Minimally invasive surgery
Systematic review
Introduction
Surgery for lumbar disc herniation can be classified into
two broad categories: open versus minimally invasive
surgery and posterior versus posterolateral approaches.
Mixter and Barr in 1934 were the first authors to treat
lumbar disc herniation surgically by performing an open
laminectomy and discectomy [41]. With the introduction of
the microscope, Caspar and Yasargil refined the original
laminectomy into open microdiscectomy [4, 63]. Laminectomy and microdiscectomy are open procedures using a
posterior approach. Currently, open microdiscectomy is the
most widespread procedure for surgical decompression of
radiculopathy caused by lumbar disc herniation, but
123
182
minimally invasive surgery has gained a growing interest.

The concept of minimally invasive surgery for lumbar disc
herniations is to provide surgical options that optimally
address the disc pathology without producing the iatrogenic morbidity associated with the open surgical procedures. In the last decades, endoscopic techniques have been
developed to perform discectomy under direct view and
local anaesthesia.
Kambin and Gellmann in 1973 [22] in the United States
and Hijikata in Japan in 1975 [12], independently performed a non-visualised, percutaneous central nucleotomy
for the resection and evacuation of nuclear tissue via a
posterolateral approach. In 1983, Forst and Housman
reported the direct visualization of the intervertebral disc
space with a modified arthroscope [9]. Kambin published
the first intraoperative discoscopic view of a herniated
nucleus pulposus in 1988 [21]. In 1989 and 1991 Schreiber
et al. described percutaneous discoscopy, a biportal
endoscopic posterolateral technique with modified instruments for direct view [52, 55]. In 1992, Mayer introduced
percutaneous endoscopic laser discectomy combining forceps and laser [40]. With the further improvement of
scopes (e.g. variable angled lenses and working channel for
different instruments), the procedure became more refined.
The removal of sequestered non-migrated fragments
became possible using a biportal approach [25]. The concept of posterolateral endoscopic lumbar nerve decompression changed from indirect central nucleotomy (inside
out, in which fragments are extracted through an annular
fenestration outside the spinal canal) to transforaminal
direct extraction of the non-contained and sequestered disc
fragments from inside the spinal canal. In this article, the
technique of direct nucleotomy is described as intradiscal
and the technique directly in the spinal canal is described
as intracanal technique; both are transforaminal approaches
(Fig. 1).
Eur Spine J (2010) 19:181204
The indications for transforaminal endoscopic treatment

are the same as classical discectomy procedures [6, 24, 38].
To reach the posterior part of the epidural space, the
superior articular process of the facet joint is usually the
obstacle. Yeung and Knight used a holmium-YAG
(yttrium-aluminium-garnet)laser for ablation of bony
and soft tissue for decompression, enhanced access and to
improve intracanal visualisation [30, 64]. Yeung developed
the commercially available Yeung Endoscopic Spine System (YESS) in 1997 [65] and Hoogland in 1994 developed
the Thomas Hoogland Endoscopic Spine System (THESSYS). With this latter system, it is possible to enlarge the
intervertebral foramen near the facet joint with special
reamers to reach intracanal extruded and sequestered disc
fragments and decompress foraminal stenosis [16].
Recently, also another minimally invasive technique,
microendoscopic discectomy (MED), has been developed.
In MED, a microscope is used and the spine is approached
from a posterior direction and not transforaminal. Therefore, this technique is not considered in the current systematic review.
Endoscopic surgery for lumbar disc herniations has been
available for more than 30 years, but at present a systematic review of all relevant studies on the effectiveness of
transforaminal endoscopic surgery in patients with symptomatic lumbar disc herniations is lacking.
Methods
Objective
The objective of this systematic review was to assess the
effectiveness of transforaminal endoscopic surgery in
patients with symptomatic lumbar disc herniations. The
main research questions were
1.
What is the effectiveness of transforaminal endoscopic

surgery?
a.
What is the effectiveness of the older intradiscal

transforaminal technique and the more recently
developed extracanal transforaminal technique?
b. What is the effectiveness of transforaminal endoscopic surgery for the different types of herniations (mere lateral herniations versus central
herniations versus all types of lumbar disc
herniations)?
2.
Fig. 1 Different posterolateral approaches to the lumbar disc. a The

intradiscal technique, b the intracanal technique
123

surgery when compared with open microdiscectomy?
For this systematic review, we used the method guidelines for systematic reviews as recommended by the
Cochrane Back Review Group [61]. Below the search
Eur Spine J (2010) 19:181204
183
strategy, selection of the studies, data extraction, methodological quality assessment and data analysis are described
in more detail. All these steps were performed by two
independent reviewers and during consensus meetings
potential disagreements between the two reviewers
regarding these issues were discussed. If they were not
resolved, a third reviewer was consulted.
Search strategy
An experienced librarian performed a comprehensive systematic literature search. The MEDLINE and EMBASE
databases were searched for relevant studies from 1973 to
May 2008. The search strategy consisted of a combination
of keywords concerning the technical procedure and keywords regarding the anatomical features and pathology
(Table 1). We conducted two reviews, one on lumbar disc
herniation and one on spinal stenosis, and combined the
search strategy for these two reviews for efficiency reasons.
These keywords were used as MESH headings and free text
words. The full search strategy is available upon request.
patient series). To be included, studies had to report on

more than 15 cases, with a follow-up period of more than
6 weeks.
Data extraction
Two review authors independently extracted relevant data
from the included studies regarding design, population (e.g.
age, gender, duration of complaints before surgery, etc),
type of surgery, type of control intervention, follow-up
period and outcomes. Primary outcomes that were considered relevant are pain intensity (e.g. visual analogue
scale or numerical rating scale), functional status (e.g.
Roland Morris Disability Scale, Oswestry Scale), global
perceived effect (e.g. McNab score, percentage patients
improved), vocational outcomes (e.g. percentage return to
work, number of days of sick leave), and other outcomes
(recurrences, complication, re-operation and patient satisfaction). We contacted primary authors where necessary
for clarification of overlap of data in different articles.
Methodological quality assessment
Selection of studies
The search was limited to English, German and Dutch
studies, because these are the languages that the review
authors are able to read and understand. Two review
authors independently examined all titles and abstracts that
met our search terms and reviewed full publications, when
necessary. In addition, the reference sections of all primary
studies were inspected for additional references. Studies
were included that describe transforaminal endoscopic
surgery for adult patients with symptomatic lumbar disc
herniations. As we expected only a limited number of
randomized controlled trials in this field, we also included
observational studies (non-randomized controlled clinical
trials, cohort studies, casecontrol studies and retrospective
Table 1 Selection of terms used in our search strategy
Technical procedure
Anatomical features/disorder
Endoscopy
Spine
Arthroscopy
Back
Video-assisted surgery
Back pain
Surgical procedures, minimally

invasive
Spinal diseases
Microsurgery
Disc displacement
Transforaminal
Intervertebral disc
displacement
Discectomy
Spinal cord compression
Percutaneous
Sciatica
Foraminotomy, foraminoplasty
discoscopy
Radiculopathy
Two review authors independently assessed the methodological quality of the included studies. Controlled trials
were assessed using a criteria list recommended by the
Cochrane Back review group as listed in Table 2 [61]. If
studies met at least 6 out of the 11 criteria, the study was
considered to have a low risk of bias (RoB). If only 5 or
less of the criteria were met, the study was labelled as high
RoB Non-controlled studies were assessed using a modified 5-point assessment score as listed in Table 3. Disagreements were resolved in a consensus meeting and a
third review author was consulted when necessary.
Data analysis
To assess the effectiveness of transforaminal endoscopic
surgery and to compare it to open microdiscectomy, the
results of outcome measures were extracted from the original studies. The outcome data of some studies were
recalculated, because the authors of the original papers did
not handle drop outs, lost to follow-up and/or failed operations adequately. If a study reported several follow-up
intervals, the outcome of the longest follow-up moment
was used.
Because only one randomized trial was identified and
the controlled trials were heterogeneous regarding study
populations, endoscopic techniques, outcome measures,
measurement instruments and follow-up moments, statistical pooling was not performed. The median and range
(minmax) of the results of the individual studies for each
outcome measure are presented.
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Eur Spine J (2010) 19:181204
Table 2 Criteria list for quality assessment of controlled studies

A
Was the method of randomization adequate?
Was the treatment allocation concealed?
Were the groups similar at baseline regarding the most important prognostic indicators?
Was the patient blinded to the intervention?
Was the care provider blinded to the intervention
Was the outcome assessor blinded to the intervention?
Were co-interventions avoided or similar?
Was the compliance acceptable in all groups?
Was the drop out rate described and acceptable?
Was the timing of the outcome assessment in all groups similar?
Did the analysis include an intention to treat analysis?
? score unclear
A: A random (unpredictable) assignment sequence. Examples of adequate methods are computer generated random number table and use of
sealed opaque envelopes. Methods of allocation using date of birth, date of admission, hospital numbers or alternation should not be regarded as
appropriate
B: Assignment generated by an independent person not responsible for determining the eligibility of the patients. This person has no information
about the persons included in the trial and has no influence on the assignment sequence or on the decision about eligibility of the patient
C: In order to receive a yes, groups have to be similar at baseline regarding demographic factors, duration and severity of complaints,
percentage of patients with neurological symptoms and value of main outcome measure(s)
D: The reviewer determines if enough information about the blinding is given in order to score a yes
E: The reviewer determines if enough information about the blinding is given in order to score a yes
F: The reviewer determines if enough information about the blinding is given in order to score a yes
G: Co-interventions should either be avoided in the trial design or similar between the index and control groups
H: The reviewer determines if the compliance to the interventions is acceptable, based on the reported intensity, duration, number and frequency
of sessions for both the index intervention and control intervention(s)
I: The number of participants who were included in the study but did not complete the observation period or were not included in the analysis
must be described and reasons given. If the percentage of withdrawals and drop outs does not exceed 20% for short-term follow-up and 30% for
long-term follow-up and does not lead to substantial bias a yes is scored. (N.B. these percentages are arbitrary, not supported by literature)
J: The timing of outcome assessment should be identical for all intervention groups and for all important outcome assessments
K: All randomized patients are reported/analysed in the group they were allocated to by randomization for the most important moments of effect
measurement (minus missing values) irrespective of non-compliance and co-interventions
Table 3 Criteria list for quality assessment of non-controlled studies
A
Patient selection/inclusion adequately described?
Drop out rate described?
Independent assessor?
Co-interventions described?
Was the timing of the outcome assessment similar?
? score unclear
A: All the basic elements of the study population are adequately described; i.e. demography, type and level of disorder, physical and radiological
inclusion and exclusion criteria, pre-operative treatment and duration of disorder
B: Are the patients of whom no outcome was obtained, described in quantity and reason for drop out
C: The data were assessed by an independent assessor
D: All co-interventions in the population during and after the operation are described
E: The timing of outcome assessment should be more or less identical for all intervention groups and for all important outcome assessments
Results
Search and selection
Two thousand five hundred and thirteen references were
identified in MEDLINE and EMBASE that were
123
potentially relevant for the reviews on lumbar disc herniation and spinal stenosis. After checking the titles and
abstracts, a total of 123 full text articles were retrieved that
were potentially eligible for this review on lumbar disc
herniation. Reviewing the reference lists of these articles
resulted in an additional 17 studies. Some patient cohorts
Eur Spine J (2010) 19:181204
were described in more than one article. In these cases, all

articles were used for the quality assessment of the study,
but outcome data reporting the longest follow-up was used.
After scrutinising all full text papers, 39 studies reported in
45 articles were included in this review. Sixteen studies
(41%) had a mean follow-up of more than 2 years. The
characteristics and outcomes of the included studies are
presented in Tables 4, 5, 6 and 7.
Type of studies and methodological quality
A total of six prospective controlled studies and two retrospective controlled studies were included. Of the six
prospective controlled studies, only the study by Hermantin
et al. [11] was considered to have a low RoB. The other
five prospective controlled studies and two retrospective
controlled were labelled as a high RoB (the full RoB
assessment is available upon request).
Furthermore, 12 studies were designed as prospective
cohort (without control group) and there were 19 retrospective studies (also without control group). When it was
unclear whether the study was prospective or retrospective,
the study was considered retrospective.
Of the six prospective controlled studies, four compared
transforaminal endoscopic surgery with open discectomy
or microdiscectomy. All four were reported as randomized
trials, but in three of them the method of randomization
was inadequate. Mayer and Brock [39] did not describe the
randomization method at all, and Krappel et al. [31] and
Ruetten et al. [47] did not randomize, but allocated patients
alternately to transforaminal endoscopic surgery or
microdiscectomy. Only in the low RoB study by Hermantin
et al. [11] randomization was adequately performed in 60
patients with non-sequestered lumbar disc herniations.
However, the generalizability of this study is poor because
patients with a specific type of herniated disc were selected
and results are consequently not directly transferable to all
patients with lumbar disc herniations.
Outcomes
1.

surgery?
No randomized controlled trials were identified. Outcomes

of 31 observational, non-controlled studies are presented in
Table 8. The median overall improvement of leg pain
(VAS) was 88 (range 6589%), global perceived effect
(MacNab) 85 (7294%), return to work of 90%, recurrence
rate 1.7%, complications 2.8% and re-operations 7%.
1a.
What is the effectiveness of the older intradiscal

technique and the more recently developed intracanal technique?
185
No randomized controlled trials were identified. In Table 9

the results of 14 non-controlled studies describing the
intradiscal technique and 16 non-controlled studies
describing the intracanal technique are presented. The
median leg pain improvement (VAS) was 83% (7888%)
for the intradiscal versus 88% (6589%) for the intracanal
technique and the results for global perceived effect were
(MacNab) 85% (7889%) versus 86% (7293%), respectively; and other outcomes are listed in Table 9.
1b.
What is the effectiveness of transforaminal endoscopic surgery for the different types of herniations (mere lateral herniations versus central
herniations versus all types of lumbar disc
herniations)?
No randomized controlled trials were identified. Six noncontrolled studies described surgery for far-lateral herniations, one for central herniations and in 15 studies all types
of herniations were included. The median GPE (MacNab)
was 86% (8586%) for lateral herniations, 91% for central
herniations and 83% (7994%) for all types of herniations.
Other outcomes are listed in Table 10.
2.

surgery compared to open microdiscectomy?
Six controlled studies (n = 720) were identified that
compared transforaminal endoscopic to open microdiscectomy. Four of them were prospective and two retrospective
studies.
Only one randomized controlled trial (n = 60) with a
low RoB was identified that compared pure intradiscal
technique with open laminotomy [11]. There were no statistically significant differences between the two groups.
The pain reduction in the transforaminal endoscopic surgery group was 71 versus 82% in the open laminotomy
group after on average 32 months follow-up. The overall
improvement was 97 versus 93%, re-operation rate 6.7
versus 3.3% and complication rate 6.7 versus 0%, respectively. Overall, the controlled studies found no differences
in outcomes: leg pain reduction in the transforaminal
endoscopic surgery group was 89 versus 87% in the open
microdiscectomy group, overall improvement (GPE) was
84 versus 78%, re-operation rate 6.8 versus 4.7% and
complication rate 1.5 versus 1.0%, respectively (Table 11).
In none of the studies, there were any statistically significant differences between the intervention groups on pain
improvement and global perceived effect. Ruetten et al.
[47] (n = 200) reported statistically significant differences
on return to work, but this was a secondary outcome and it
was unclear how many subjects in each group had work
and if groups were comparable regarding work status and
history of work absenteeism at baseline.
In one study, transforaminal endoscopic surgery was
compared with the same operation combined with
123
123
Hoogland et al. [16], not

adequately randomized
(birth date) n = 280
Inclusion criteria
Hermantin et al. [11],

randomized n = 60
Previous surgery (same

level)
Obesity
Exclusion criteria
Neurological deficit
Post-tension sign
Radiculopathy
Inclusion criteria

level)
Central or lateral stenosis
Exclusion criteria
Sequestration
Post-tension sign
Radiculopathy
Main inclusion criteria,

main exclusion criteria
Study/author, methodology
Table 4 Prospective controlled studies
Level: single level,

L2S1
Type: all LDH

L2S1
Type: intracanal LDH
Type/level LDH
Index: transforaminal endoscopic

discectomy
Intradiscal and intracanal technique,
Thessys instrumentation, n = 142 $50
#92, mean 41 years, range 1860
Control: transforaminal endoscopic
discectomy combined with injection of
low-dose (1,000 U) chymopapain.
n = 138 $44 #94, mean 40.3 years,
range 1860
Pure intradiscal technique Kambin

technique biportal: n = 2
n = 30 $8 #22, mean 39 years, range
1566
Control: open Laminotomie, n = 30 $13
Index: arthroscopic microdiscectomy
Interventions/technique/instrumentation
Pain leg (VAS) I: pre-op. 8.0, follow-up

2.0, difference 6.0 = 75%
C: pre-op. 8.2, follow-up 1.9, difference
6.3 = 77%
Pain back (VAS) I: pre-op. 8.2, followup 2.6, difference 5.6 = 68%
5.4 = 66%
GPE (MacNab) I: 16% excellent, 33.8%
good, 0.9% poor
C: 63% excellent, 27% good, 0.9% poor
NS
PS I: 85%, C: 93% S
Recurrence I: 7.4%, C: 4.0%
Complications I: 2.1%, C: 2.2% NS
Re-operations I: 6.1%, C: 1.6%
Complications I: 6.7%, C: 0%
Re-operations I: 6.7%, C: 3.3%
Follow-up I: 24 months, 16% lost to
follow-up
C: 24 months, 16% lost to follow-up
Follow-up I: mean 31 months (range 19

42), 0% lost to follow-up
C: mean 32 months (range 2142), 0%
lost to follow-up
Pain (VAS) I: pre-op. 6.6, follow-up 1.9,
difference 4.7 = 71%
5.6 = 82%
Return to work (mean): I: 27, C: 49 days
GPE (unclear instrument) I: 97%, C:
93% excellent ? good
PS (very satisfied) I: 73%, C: 67%
Follow-up: duration and outcome
Comment
186
Eur Spine J (2010) 19:181204
Mayer and Brock [39],

randomization not specified
n = 40
Lee et al. [34], not adequately

randomized, (preference of
surgeon) n = 300

L4S1
Radiculopathy

L3S1
Radiculopathy

L2L5
Radiculopathy
Exclusion criteria
Sequestration
level)
Cauda syndrome
Segmental instability
Post-tension sign
Type: not specified
Inclusion criteria
Sequestration
Exclusion criteria
Type: not specified
Inclusion criteria
Exclusion criteria
Sequestration
High iliac crest
Post-tension sign
Type: not specified
Inclusion criteria
Krappel et al. [31], not

(alternating) n = 40
Type/level LDH

Table 4 continued
Index: percutaneous endoscopic

discectomy
Pure intradiscal technique, modified
Hjikata instrumentation, n = 20 $8
Control: open microdiscectomy, n = 20
$6 #14, mean 42 years, range 1963
Index: percutaneous endoscopic laser

discectomy (PELD), n = 100 $35 #65
Pure intradiscal technique, Kambin
technique
Control 1: chemonucleolysis, n = 100
$24 #76
Control 2: automated percutaneous
discectomy, n = 100 $28 #72
Index: endoscopic transforaminal

nucleotomy
Pure intradiscal technique, Mathews
technique, Sofamor-Danek
endoscope, n = 20 $? #?, mean
41 years, range 3654
Control: Open nucleotomy, n = 20 $?
#?, mean 39 years, range 2543
Patient satisfaction I: 55%, C: 55%

Recurrence I: 5%, C: 0%
Complications I: 0%, C: 5%
Re-operations I: 15%, C: 5%
C: 65% satisfactory, 15% poor
Return to work (6 weeks) I: 81%, C1:

67%, C2: 66%
Complications I: 4%, C1: 10%, C2: 3%
Re-operations I: 9%, C1: 18%, C2: 20%
Follow-up 24 months, 0% lost to followup
GPE (S/S-score) I: 70% satisfactory, 0%
poor
I: 9%, C1: 18%, C2: 20% poor
GPE (MacNab) I: 16% excellent, 68%

good, 0% poor
C: 15% excellent, 60% good, 0% poor
NS
Return to work I: 100%, C 100%
Recurrence I: 5%, C 0%
Complications I: 0%, C 0%
Re-operations I: 5%, C 0%
Follow-up 12 months, 0% lost to followup
GPE (modified MacNab) I: 29%, C1:
20%, C2: 18% excellent
I: 39%,C1: 35%, C2: 30% good
Follow-up I: range 2436 months, 5%

lost to follow-up
C: range 2436 months, 0% lost to
follow-up
Authors included
n = 3 patients in
satisfactory group
after re-operation.
These were labelled
as adverse effects
and re-operations
in this review
Comment
Eur Spine J (2010) 19:181204

187
123
123
Inclusion criteria
Ruetten et al. [47], not

(alternating by independent
person) n = 200
L1S1
Type: all LDH
Type/level LDH
Index: endoscopic transforaminal and

interlaminar lumbar discectomy
Intracanal technique, YESS, Richard
Wolf instrumentation, n = 100
Control: open microdiscectomy,
n = 100, mean 43 years, range 2068
Overall, n = 200 $116 #84, mean
43 years, range 20-68
Pain leg (VAS) I: pre-op.75, follow-up 8,

difference 67 = 89%
C: pre-op. 71, follow-up 9, difference
62 = 87%
Pain back (VAS) I: pre-op. 19, follow-up
11, difference 8 = 42%
-3 = -8.3%
Functional status: (ODI) I: pre-op. 75,
follow-up 20, difference 55 = 73%
49 = 67%
Patient satisfaction I: 97%, C: 88%
Return to work (mean) I: 25 days
C: 49 days S
Recurrence I: 6.6% C: 5.7% NS
Complications I: 3%, C: 12% S
Re-operations I: 6.8% C: 11.5
Follow-up I: 24 months, 8% lost to

follow-up
C: 24 months, 8% lost to follow-up
Authors excluded
n = 6 from analyses
due to revision
surgery. These were
taken into account
in this review,
n = 41 were
operated via a
transforaminal
endoscopic
technique, n = 59
patients were
operative via an
interlaminar
endoscopic
technique
Comment
Intervention as quoted in original article. Post-tension signs denotes positive tension signs (straight leg raising test or contralateral straight leg raising test)
Outcomes: S statistically significant, NS not statistically significant, PS patient satisfaction, MacNab MacNab score as described by MacNab [39]. The sum of excellent and good outcomes are labelled
satisfactory, GPE global perceived effect, S/S-score Suezawa and Schreiber score [40], ODI Oswestry disability index [38]
Not specified
Exclusion criteria
Radiculopathy

Table 4 continued
188
Eur Spine J (2010) 19:181204

Spondylolisthesis
Re-operations I: 3.3%, C: 0%
Complications I: 0%, C: 0%

good, 3.3% poor
C: 3542 (36) months, 0% nonresponders
Follow-up I: mean 38 months (range

3245), 0% lost to follow-up
C: 78% excellent, 17% good, 0% poor
Control: open microdiscectomy, n = 30

Pure intradiscal technique,

instrumentation not specified, n = 30
Index: percutaneous endoscopic lumbar

discectomy (PELD)
Complications I: 3.1% C: 2.0% NS

Re-operations I: 9.5% C: 6.3% NS
Level: single level, L4S1
Type: not specified
C: 48% excellent, 37% good, 6.6%

poor NS

good, 5.4% poor
Stenosis
Exclusion criteria
Radiculopathy
Inclusion criteria

YESS, Richard Wolf instrumentation,
n = 295 $107 #188, mean 35 years,
range 1383
Follow-up: mean 23.6 months (range

1836), I: 2.5%, C: 3.5% nonresponders
Control: open microdiscectomy, n = 607 Recurrence I: 6.4% C: 6.8% NS

$215 #392, mean 44 years, range
1780
Index: percutaneous transforaminal

endoscopic discectomy (PTED)
Type: central, paramedian

and foraminal LDH
Type/level LDH
Lee et al. [32], randomly

selected patients with
follow-up [ 3 years in
both groups
Spinal stenosis
Previous surgery
(same level)
Extraforaminal LDH
Exclusion criteria
Post-tension sign
Kim et al. [26], all patients Inclusion criteria

that underwent the
procedures in a certain
period
Radiculopathy
Study, methodology
Table 5 Retrospective controlled studies
Primary outcome of
the study was a
radiologic
evaluation
Comment
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189
123
123
Kafadar et al. [20]
Hoogland and
Schenkenbach [15]
Schenkenbach and
Hoogland [51]
Recurrent disc herniation
Post-tension sign
Exclusion criteria
Previous surgery(same level)
Spinal stenosis
Calcified LDH
Radiculopathy
Inclusion criteria
Exclusion criteria
Not specified
Radiculopathy
Post-tension sign
Exclusion criteria
Not specified
Inclusion criteria
Post-tension sign
Level: single level, L4L5
Type: all LDH
n = 42 $2 #40, range 18
74 years
n = 130 $43 #87, mean

39 years
Type: all LDH
Previous surgery (same level)
Radiculopathy
Endoscopic transforaminal
Follow-up: 24 months, 9% lost to follow-up Authors included only
discectomy (ETD)
patients with recurrent
LDH, more than
Intradiscal and intracanal technique Pain leg (VAS): pre-op. 8.5, follow-up 2.6,
6 months after open
differences 5.9 = 69%
microdiscectomy or
Thessys instrumentation
Pain back (VAS): pre-op. 8.6, follow-up 2.9,
endoscopic surgery
GPE (MacNab): 31% excellent, 50% good,
2.5% poor
Patient satisfaction: 51% excellent, 35%
good, 5% poor
Recurrence: 6.3%
Complications: 1.1%
Re-operations: 7%
Endoscopic transforaminal
Follow-up: 12 months, 5.1% lost to followdiscectomy (ETD)
up
Intradiscal and intracanal technique Pain leg (VAS): difference 5.9
Thessys instrumentation
Pain back (VAS): difference 5.4
6% poor
Return to work (6 weeks): 70%
Complications: 1.5%
Re-operations: 4.6%
Percutaneous endoscopic
Follow-up: mean 15 months (range 624)
Authors excluded n = 8
transforaminal discectomy
(SD 4), 0% lost to follow-up
from analyses due to
(PETD)
stopped procedures.
These were taken into
Pure intradiscal technique
GPE (S/S-score): 14% excellent, 36% good
account in this review
36% poor
Karl Storz instrumentation
Recurrence: 0%
Complications: 45%
Re-operations: 17%
Comment
n = 262 $76 #186, mean

Type: all LDH
Inclusion criteria
Hoogland et al. [17]
Interventions/technique/
instrumentation
Number of participants type/

level LDH

Study
Table 6 Prospective cohort studies
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Lee et al. [33]
Knight et al. [27];

Knight et al. [29]
Non-contained or sequestered
LDH
Exclusion criteria
Radiculopathy
Leg pain
Radiculopathy
Exclusion criteria
Cauda syndrome
Painless motor deficit
Inclusion criteria
Prior disc surgery n = 75

Back pain
Post-tension sign
Exclusion criteria
Large extraligamental LDH
Cauda syndrome
Degenerative disc
Inclusion criteria
Radiculopathy
Kambin [23]; Kambin Inclusion criteria
Study
Table 6 continued
Percutaneous endoscopic lumbar

Follow-up: mean 14.5 months (range 920),
discectomy (PELD)
0% lost to follow-up
Intradiscal and intracanal technique Pain leg (VAS): pre-op. 7.5, follow-up 2.6,
YESS, Richard Wolf
GPE (Modified MacNab): 45% excellent,
instrumentation
47% good, 6.0% poor
Return to work: average 14 days, range
148 days
Recurrence: 0%
Complications: 0%
Re-operations: 0%
n = 116 $43 #73, mean

Type: not specified
Endoscopic laser foraminoplasty

Follow-up: mean 30 months (range 2448)
(ELF)
(SD 5.87), 3.2% lost to follow-up
Intradiscal and intracanal technique Pain (VAS [ 50% improvement): 56%
Richard Wolf instrumentation
Functional status (ODI): 60%
improved C 50%
Complications: 0.8%
Re-operations: 5.2%
n = 250 $? #?, mean

Type: All LDH
Level: single and multiple
level, L2S1
Level: single level, L2-S1
Type: all LDH
Arthroscopic microdiscectomy and Follow-up: mean 48 months (range 2478),

selective fragmentectomy
3.4% lost to follow-up
GPE (Modified Presby, St Luke score): 77%
excellent, 11% good, 12% failed
Kambin technique
Return to work (3 weeks): 95%
Biportal n = 59
Complications: 5.3%
Re-operations: 7.7%
n = 175 $76 #99
instrumentation

level LDH
Authors included also

degenerative and lateral
stenosis in this study
Comment
Eur Spine J (2010) 19:181204

191
123
123
Ruetten et al. [46]
Ramsbacher et al.
[45]
Inclusion criteria
Morgenstern et al.
[42]
Far cranial/caudal migrated

sequester
Spinal stenosis
Exclusion criteria
Radiculopathy
Exclusion criteria
Far migrated sequesters
High iliac crest
Inclusion criteria
Radiculopathy
Exclusion criteria
Sequestration
Inclusion criteria
Radiculopathy

Study
Table 6 continued
Endoscopic spine surgery
n = 144 $48 #96, mean

Type: all LDH
SofamorDanek endoscope
Transforaminal endoscopic
sequestrectomy (TES)
Intracanal technique
Pain leg (VAS): pre-op. 6.7, follow-up 0.8,

PS: 77% (very satisfied ? satisfied)
Complications: 5.1%
Re-operations: 10%
Follow-up: 6 weeks, 0% lost to follow-up
Complications: 0%
Re-operations: 6.9%
Extreme-lateral transforaminal
Follow-up: 12 months, 10% lost to followapproach
up
Intracanal technique, Richard Wolf Pain leg (VAS): pre-op. 7.1, follow-up 0.8,
instrumentation, n = 27 bilateral
Level: multiple level n = 46,
L1L5
Functional status (ODI): pre-op. 78, followup 20, difference 58 = 74%
Recurrence: 6.9%
n = 517 $277 #240, mean

Type: all LDH
n = 39 $21 #18, mean

50 years
Type: all LDH
Follow-up: mean 24 months (range 348),

0% lost to follow-up
Intradiscal and intracanal technique GPE (MacNab): 83% excellent and good,
3% poor
Level: multiple level n = 60, YESS, Richard Wolf
Complications: 9%
L1S1
instrumentation
Re-operations: 5.6%
instrumentation

level LDH
Primary outcome of this

study was to compare
normal versus intensive
physical therapy post
operative revalidation
Comment
192
Eur Spine J (2010) 19:181204
Exclusion criteria
Cauda syndrome
Spinal stenosis
Radiculopathy
Sequestration
Exclusion criteria
Inclusion criteria
Post-tension sign
Radiculopathy
Exclusion criteria
Inclusion criteria
Post-tension sign
instrumentation
Transforaminal nucleotomy with

foraminoplasty
Intracanal technique, Thessys
instrumentation
Percutaneous transforaminal
endoscopic sequestrectomy
(PTFES)
Type:
foraminal ? extraforaminal
instrumentation not specified
LDH
n = 25 $11 #14, mean

n = 558 $179 #379, mean

Type: all LDH
n = 66 $36 #30, median

Percutaneous endoscopic
discectomy (PED)
Type:
Pure intradiscal technique Karl
foraminal ? extraforaminal
Storz instrumentation
LDH

level LDH
Comment

Complications: 4%
Re-operations: 8%
Follow-up: 12 months, 8.7% lost to followup

0.3% poor
Recurrence: 3.6%
Complications: 0.7%
Re-operations: 3.6%
Follow-up: 6 weeks, 0% lost to follow-up
All patients operated
under general
anaesthesia and EMG
monitoring
Functional status (ODI): pre-op. 78, followup 8, difference 70 = 90%

Complications: 6.1%
Re-operations: 7.6%
Pain (VAS): pre-op. 8.2, follow-up 1.2,

Follow-up: 12 months, 0% lost to follow-up
satisfactory, GPE global perceived effect, S/S-score Suezawa and Schreiber score [40], Presby. St Luke score Rush-Presbyterian-St Luke score [23], ODI Oswestry disability index [38]
Suess et al. [57]
Schubert and
Hoogland [54]
Inclusion criteria
Sasani et al. [48]
Radiculopathy

Study
Table 6 continued
Eur Spine J (2010) 19:181204

193
123
123
Choi et al. [6]
Chiu [5]
Exclusion criteria
Calcified disc
Post-tension sign
Radiculopathy
Radiculopathy
Exclusion criteria
Cauda syndrome
Painless motor deficit
Inclusion criteria
Pain in back
Virgin and prior disc surgery
n = 41, $23 #18, mean

Type: extraforaminal LDH
Level: single and multiple

level
Re-operations: not specified
GPE (unclear instrument): 94% excellent or

good, 3% poor
Complications: 1%
Follow-up: mean 42 months (range 672), 0%

non-responders
Follow-up: range 2439 months, 0% nonresponders

4.7% poor
Complications: 4.6%
Re-operations: 2.3%
Extraforaminal targeted fragmentectomy Follow-up: mean 34 months (range 2058),

4.9% non-responders
Pure intradiscal technique, YESS,
Richard Wolf instrumentation
Return to work: mean 6 weeks (range 424)
Functional status (ODI): pre-op. 66.3, follow-up
11.5, difference 54.8 = 83%
PS: 92%
Recurrence: 5.1%
Complications: 5.1%
Re-operations: 7.7%
Karl Storz instrumentation
Transforaminal microdecompressive
endoscopic assisted discectomy (TFMEAD)
Intradiscal and intracanal technique
Radiculopathy
n = 2,000 $990 #1010,

mean 44 years, range 24
92
Type: not specified
Prior disc surgery
Post-tension sign
Exclusion criteria
Spondylolisthesis
Calcified fragments
Inclusion criteria

discectomy (PELD)
n = 43 $11 #32, mean

Type: all LDH
Inclusion criteria
Ahn et al. [3]
instrumentation
Type /level LDH

Study
Table 7 Retrospective cohort studies

patients with stenosis
and degenerative disc
disease
Authors included only

patients with recurrent
LDH, more than
6 months after open
microdiscectomy
Comment
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Eur Spine J (2010) 19:181204
Hochschuler
[13]
Haag [10]
Eustacchio [8]
Radiculopathy
Exclusion criteria
Previous operation (same
level)
Sequestration
High iliac crest
Type: all LDH

Radiculopathy
Exclusion criteria
Discus narrowing
Calcified disc
Inclusion criteria
n = 18 $5 #13, mean
Type: not specified
Level: L3-S1
n = 101
Inclusion criteria
Exclusion criteria
Cauda syndrome
Post-tension sign
Radiculopathy

Kambin technique
Arthroscopic microdiscectomy (AMD)
microdiscectomy
SofamorDanek instrumentation
Endoscopic percutaneous transforaminal

treatment
n = 122 $36 #86, median

Type: all LDH
L2S1
Flexible endoscope
Level: single level
Post-tension sign
Exclusion criteria
Spinal stenosis
Inclusion criteria
Radiculopathy
Endoscopic transforaminal lumbar

discectomy
n = 110 $40 #70, median

55 years, range 20 to [ 60
Type: all LDH
Inclusion criteria
Ditsworth [7]
instrumentation
Type /level LDH

Study
Table 7 continued
Comment

non-responders
Re-operations: 11%
Follow-up: mean 35 months (range 1553), 0% Authors excluded n = 10

non-responders
stopped procedures.
GPE (MacNab): 45% excellent, 27% good, 27%
poor
Functional status (PROLO): 71.9% excellent or
good
Return to work: 94%
Recurrence: 12%
Complications: 9%
Re-operations: 27%
Follow-up: mean 28 months (range 1526), 9% Authors excluded n = 3
non-responders
technical problems
PS: good: 66%, satisfied: 9%, poor: 25%
during procedures.
Complications: 7.6%
Re-operations: 17%

GPE (MacNab): 91% excellent or good, 4.5%
poor
Recurrence: 0%
Complications: 0.9%
Re-operations: 4.5%
Eur Spine J (2010) 19:181204

195
123
123
n = 35 $20 #15, mean
Type: foraminal and
extraforaminal LDH
Jang et al. [19] Inclusion criteria

segmental instability
Spinal stenosis
Listhesis
Lew et al. [35] Inclusion criteria
n = 47 $12 #35, mean
Radiculopathy
Type: foraminal and
extraforaminal LDH
Post-tension sign
Level: L1L5
Exclusion criteria
Exclusion criteria
Radiculopathy
Not specified
n = 149 $62 #87, mean

Type: all LDH
Exclusion criteria
Central stenosis
Iprenburg [18]
Level: not specified
Exclusion criteria
Not specified
Inclusion criteria
n = 246
Type: not specified
Inclusion criteria
Hoogland [14]
Type /level LDH
Not specified

Study
Table 7 continued
Pain (VAS): not specified

poor
Complications: 1.2%
Re-operations (1st year): 3.5%
Follow-up: not specified, 29% non-responders
Follow-up: 24 months, 0% non-responders
Complications: 17%
Re-operations: 8.6%
Transforaminal percutaneous endoscopic Follow-up: mean 18 months (range 451), 0%
discectomy
non-responders
GPE (MacNab): 85% excellent or good, 11%
poor
Surgical dynamics instrumentation
Return to work: 89%
Complications: 0%
Re-operations: 11%
Functional status (ODI): not specified

Recurrence: 6%
Complications: not specified
discectomy (TPED)
non-responders
poor
Recurrence: 0%

instrumentation
Transforaminal endoscopic surgery
Transforaminal endoscopic discectomy

with foraminoplasty
instrumentation
instrumentation

patients with foraminal
stenosis
Comment
196
Eur Spine J (2010) 19:181204
Exclusion criteria
Not specified
[58]; Leu
Sequestration
and
Schreiber
[36];
Schreiber
and Leu [52]
Shim et al.
Inclusion criteria
[56]
Radiculopathy
Level: single level, T12S1
n = 71 $39 #32, mean

Type: not specified
YESS, Richard Wolf instrumentation
Transforaminal endoscopic surgery
Percutaneous nucleotomy with

discoscopy
Modified Hijikata instrumentation
biportal
Return to work (6 months): 67%
Pure intradiscal technique, Kambin

technique

non-responders
6.5% poor
Complications: 2.8%
Re-operations: 7.0%
Re-operations: 21%
Follow-up: mean 28 months, 0% nonresponders

GPE (S/S-score): 85% excellent or good
Complications: 10%
Re-operations: 1.3%
Complications: 5.3%
Follow-up: 6 months, 0% non-responders
Percutaneous lumbar discectomy with

endoscope
Exclusion criteria
Sequestration
Cauda syndrome
Spinal stenosis
Listhesis
Savitz [49, 50] Inclusion criteria
n = 300 $132 #168, range
1681 years
Radiculopathy
Post tension sign
Type: not specified
Exclusion criteria
L2S1
Sequestration
Obesity
Schreiber and Inclusion criteria
n = 174 $68 #106, mean
Suezawa
[53];
Radiculopathy
Type: not specified
Suezawa and
Exclusion criteria
Level: multiple level n = 25
Schreiber

L2L5
Post-tension sign

GPE (S/S-score): 67% excellent or good, 33%
moderate or poor
Return to work: 7.1 4.2 weeks, 90%
(6 months)
Complications: 3.3%
Re-operations: 3.3%

discectomy (PELD)
n = 30 $11 #19
Type: not specified
Inclusion criteria
Mayer and
Brock [39]
instrumentation
Type /level LDH
Radiculopathy

Study
Table 7 continued
n = 14 patients with L5S1 level LDH are

operated via a
interlaminar approach

patients with
degenerative disc
disease, only the scores
from LDH are quoted in
this review
Twenty of the patients

were described in a
prospective study [41].
In this review
reoperations were
labelled as moderate or
poor outcome on GPE
Comment
Eur Spine J (2010) 19:181204

197
123
123
Radiculopathy
Exclusion criteria
Sequestration
Central and lateral stenosis
Prior disc surgery n = 31
Exclusion criteria
Sequestration
Chronic back pain
Inclusion criteria
Radiculopathy
Exclusion criteria
Sequestration
Spinal stenosis
Calcified disc
Cauda syndrome
Inclusion criteria
Pain in leg and back
Posterolateral endoscopic excision for

lumbar disc herniation
n = 307 $102 #205, mean

Type: all LDH
Modified Hijikata instrumentation
Endoscopically assisted percutaneous

lumbar discectomy
Level: not specified
n = 43 $25 #18, mean

30 years
Type: not specified
Possible patient overlap

with other study [65]
Comment
Follow-up: mean 19 months (range 12?), 8.8% Possible patient overlap

non-responders
with other study [65]
poor
Recurrence: 0.7%
Complications: 3.9%
Re-operations: 4.6%
GPE (unclear instrument): 64% good, 36%

satisfied, 0% poor
Complications: not specified
Follow-up: 18 months, 16.3% non-responders

lumbar discectomy (TPELD)
non-responders
GPE (modified MacNab): 28% excellent, 61%
good, 3.7% poor
Level: multiple level n = 20, Instrumentation not specified
Recurrence: 0.7%
L2S1
Complications: 6.0%
Re-operations: 4.5%
n = 134 $56 #78, mean

Type: all LDH
Follow-up: mean 20 months (range 12108),

11.9% non-responders
poor
Recurrence: 2.7%
Complications: 2.7%
Re-operations: 4.6%
? unknown, is not described in the study

Intervention as quoted in original article, Post-tension signs denotes positive tension signs (straight leg raising test or contralateral straight leg raising test)
satisfactory, GPE global perceived effect, S/S-score Suezawa and Schreiber score [40], ODI Oswestry disability index [38], PROLO prolo functional-economic outcome rating scale [44]
Yeung and
Tsou [65]
Wojcik [62]
Tzaan [60]
Exclusion criteria
Sequestration
Previous operation (same
level)
Inclusion criteria
Radiculopathy
decompression
n = 219 $83 #136, mean

42 years range 1771
Type: central LDH
Inclusion criteria
Tsou and
Yeung [59]
instrumentation
Type /level LDH

Study
Table 7 continued
198
Eur Spine J (2010) 19:181204
Eur Spine J (2010) 19:181204

Table 8 Overall outcome, noncontrolled studies
199
Outcome measure (instrument)
Studies (patients)
Outcome median (minmax)
Pain leg (VAS)
7 (n = 1,558)
88% (6589%) improvement
Pain back (VAS)
5 (n = 1,401)
Pain (region not specified) (VAS)
3 (n = 144)
GPE (MacNab)
15 (n = 2,544)
85% (7294%) satisfactory

6% (0.327%) poor
Outcomes: MacNab MacNab

score as described by MacNab
[39]. The sum of excellent and
good outcomes are labelled
satisfactory, GPE global
perceived effect, ODI Oswestry
disability index [38]
Table 9 Intradiscal and

intracanal techniques, outcomes
non-controlled studies
Functional status (ODI)
3 (n = 624)
Patient satisfaction
3 (n = 181)
Return to work
5 (n = 757)
90% (6795%)
Recurrence
13 (n = 2,612)
1.7% (012%)
Complication
28 (n = 6,336)
2.8% (040%)
Re-operation
28 (n = 4,135)
7% (027%)
Studies
Pure intradiscal technique 14 studies (n = 1,267) intradiscal technique

Pain leg (VAS)
2 (n = 66)
Pain back (VAS)
1 (n = 25)
75% improvement
1 (n = 66)
85% improvement
GPE (MacNab)
3 (n = 279)
Recurrence
3 (n = 217)
0.7% (05.1%)
Complication
12 (n = 1,206)
5.3 % (040%)
Re-operation
14 (n = 1,267)
7.5% (1.330%)
6.5% (3.711%) poor
Intracanal technique 16 studies (n = 4,985)
Outcomes: MacNab MacNab

score as described by MacNab
[39]. The sum of excellent and
good outcomes are labelled
satisfactory, GPE global
perceived effect
Pain leg (VAS)
5 (n = 1,524)
Pain back (VAS)
4 (n = 1,408)
2 (n = 78)
GPE (MacNab)
12 (n = 2,292)
Recurrence
10 (n = 2,395)
3.2% (012%)
6% (0.39.3%) poor
Complication
17 (n = 5,362)
2.1% (017%)
Re-operation
15 (n = 3,098)
4.6% (027%)
chymopapain, and one study compared endoscopic surgery

with chemonucleolysis and automated discectomy
(Table 4).
Discussion
In the current review, all available evidence regarding the
effectiveness of transforaminal endoscopic surgery was
identified and systematically summarized. We identified 1
randomized controlled trial, 7 non-randomized controlled
trials and 31 observational studies. The methodological
quality of these studies was poor. The eight trials did not
find any statistically significant differences in leg pain
reduction between the transforaminal endoscopic surgery
group (89%) and the open microdiscectomy group (87%);

overall improvement (84 vs. 78%), re-operation rate (6.8
vs. 4.7%) and complication rate (1.5 vs. 1%), respectively.
We conclude that current evidence on the effectiveness of
transforaminal endoscopic surgery is poor and does not
provide valid information to either support or refute using
this type of surgery in patients with symptomatic lumbar
disc herniations. High-quality randomized controlled trials
with sufficiently large sample sizes are direly needed.
This study has a number of limitations that should be
considered when drawing conclusions regarding the
effectiveness of transforaminal endoscopic surgery for
lumbar disc herniations. The included studies in this review
were heterogeneous with regard to the selection of patients,
the indications for surgery, the surgical techniques used
123
200
Table 10 Outcomes of
improvement in lateral
herniations, central herniations
and all types of herniations
Eur Spine J (2010) 19:181204
Studies
Type: far-lateral LDH 6 studies (n = 214)

4 (n = 167)
GPE (MacNab)
2 (n = 52)

9.8% (8.611%) poor
Functional status (ODI)

Recurrence
2 (n = 76)
2.6% (05.1%)
Complication
5 (n = 214)
5.1% (017%)
Reoperation
5 (n = 214)
8.0% (7.611%)
GPE (MacNab)
1 (n = 71)
91% satisfactory
Complication
1 (n = 71)
2.7%
Re-operation
1 (n = 71)
4.6%
Type: central LDH 1 study (n = 71)

12% poor
Type: all LDH 15 studies (n = 3,067)
LDH lumbar disc herniation,

Type in transversal section,
subdivided in central,
paramedian, foraminal and
extraforaminal herniations
Table 11 Outcomes of
improvement of transforaminal
endoscopic versus open
microdiscectomy
Pain leg (VAS)
4 (n = 1,374)
Pain back (VAS)
4 (n = 1,374)
1 (n = 43)
70% improvement
GPE (MacNab)
9 (n = 1,810)
Recurrence
9 (n = 2,201)
3.6% (012%)
Complication
15 (n = 2,934)
4.9% (045%)
Re-operation
15 (n = 2,934)
5.6% (2.327%)
4.6% (0.39.3%) poor
Studies
Endoscopic (index) versus open microdiscectomy (control)

Pain leg (VAS)
1 (n = 200)
Index 89% improvement

Control 87% improvement
Pain back (VAS)
1 (n = 200)

Control -8.3% improvement
1 (n = 60)
GPE (MacNab/other)
5 (n = 1,102)
Index 84% (7097%) satisfactory
Control 82% improvement

1.7% (05.4%) poor
Control 78% (6593%) satisfactory
3.3% (015%) poor
Recurrences
4 (n = 1,182)
Index 5.7% (56.6%)

Control 2.9% (06.8%)
Complications
Re-operations
6 (n = 1,302)
Index 1.5% (06.7%)
6 (n = 1,302)
Control 1.0% (012%)

Index 6.8% (3.315%)
I index intervention, C control

intervention
and the duration of follow-up. Furthermore, different outcome measures were used in the studies and different
instruments used for the same outcomes. Below we will
elaborate on the most important sources of heterogeneity in
more detail.
123
Control 4.7 % (011.5%)
Selection of patients
Patient selection and in/exclusion criteria were often not
clearly described. Amongst others, this includes physical
examinations, radiological findings, the period and type
Eur Spine J (2010) 19:181204
of pre-operative therapies and duration of symptoms. In

most studies, patients received some type of preoperative
conservative treatment for a few months, but the exact
content of the conservative treatment was not specified.
Also, duration of symptoms before surgery differed
amongst studies and in some studies patients with acute
onset (\2 weeks) of complaints were also included. In
some studies only virgin discs were included, whilst in
others a previous disc operation was not an exclusion
criterion or it was not mentioned if patients with a previous disc operation were excluded or not. In two studies
only recurrent herniations after open microdiscectomy
were treated with transforaminal endoscopic surgery [3,
17]. Some studies included only lateral or central herniations, whereas others included all herniations. Given
this, there is much heterogeneity in patient selection
between the studies which hinders comparability between
studies.
Techniques
Indications for endoscopic surgery have changed over
time with the introduction of new techniques, scopes and
instruments. Initially non-contained, sequestered and
central herniations were exclusion criteria for endoscopic
surgery and L5S1 level herniations were not always
possible to reach as the diameter of the foramen intervertebral decreases in the lumbar area from cranial to
caudal [46]. In the earlier studies of transforaminal
endoscopic surgery, discectomy was performed through a
fenestration in the lateral annulus and the focus was
limited on central debulking and reduction in intradiscal
pressure. Later studies described that the hernia was
extracted from the spinal canal with or without an intradiscal debulking. We found comparable outcomes for
these intradiscal and intracanal techniques. However, one
could debate whether these procedures are really two
different techniques. The main distinction is a 10 difference in direction and may be within the limits of
measurement error and anatomical variation. Far-lateral
herniations occur in 311% of lumbar disc herniations
and usually cause severe sciatic pain [1, 2, 43, 44]. Some
reports mentioned more difficulty to assess an extraforaminal herniated lumbar disc through an open procedure
and it is often associated with the substantial bone
removal [35]. Because transforaminal endoscopic surgery
is a posterolateral approach to the spine, lateral herniations might be more easily reached [60]. With lateral
herniations, the angle of the instruments should be steeper
and, thus, the insertion closer to the midline [6, 19]. We
compared the effect of transforaminal endoscopic surgery
for lateral herniations with central and all herniations. All
outcomes were comparable.
201
Methodological quality
Most studies had major design weaknesses and the quality
of the identified studies was poor, indicating that studies
had a high RoB. Only one adequately randomized controlled trial was identified. In most studies, randomization
was not performed at all, not performed adequately or not
described adequately. Obviously, patients and surgeons
cannot be blinded for the surgical intervention. However,
many other important quality items were also not met by
the majority of studies. Although transforaminal endoscopic surgery for lumbar disc herniation was introduced
about 30 years ago and many patients have undergone this
intervention since its introduction, only one randomized
controlled trial with a low RoB has been published. Only
high-quality, randomized controlled trials with sufficiently
large sample sizes comparing transforaminal endoscopic
surgery to other surgical techniques for lumbar disc herniations can provide strong evidence regarding its effectiveness. Preferably, these trials should be conducted by
independent research institutes.
Outcome measures
The most frequently used outcome measures in the included studies are the VAS score for pain and the MacNab
score for global perceived effect. To compare the VAS
scores across studies, we calculated the percentage of
improvement between the postoperative and preoperative
scores. The MacNab score is a 4-point scale ranging from 1
(excellent); 2 (good), 3 (fair) to 4 (poor). In most studies
excellent and good were combined and labelled satisfactory. Although a close inspection of the score good on
the MacNab, reveals that patients still have occasionally
ongoing symptoms, sufficient to interfere with normal
work or capacity to enjoy leisure activities [37]. We considered labelling this as a satisfactory outcome was
somewhat too positive. Therefore, whenever possible, we
presented the original MacNab scores. Although some
studies used validated outcomes (e.g. the Oswestry Disability Questionnaire for low back pain-specific functional
disability) others used non-validated outcomes, or did not
describe at all how disability and improvement were
measured. Future trials should use valid and reliable
instruments to measure the primary outcomes.
Adverse effects
Recurrences
Eighteen studies reported recurrence rates of lumbar disc
herniations, but the definition of recurrence varied. In
123
202
this review, we defined a recurrence as a re-appearance

of a symptomatic lumbar disc herniation at the same
level after a pain-free interval of longer than a month.
When in a study the symptomatic hernia appeared within
a month, we considered it a recurrence. The median
recurrence rate of included studies was 1.7% (range 0
12%). The reported recurrence rate in the literature of
open microdiscectomy is similar with reported ranges
from 5 to 11% [60]. The controlled studies found no
significant difference in recurrences between the two
techniques.
Re-operation
In the observational studies, the median re-operation rate
was 7% (027%). The controlled studies found no significant differences in re-operation percentages between
endoscopic transforaminal surgery and open microdiscectomy (6.8 vs. 4.7%). As in most surgical interventions,
adequate patient selection and accurate diagnosis seem
very important. Most common cause for re-operations was
persistent complaints due to missed lateral bony stenosis
and remnant fragments [23].
Complications
One of the suggested advantages of transforaminal endoscopic surgery compared with open microdiscectomy is a
lower complication rate [28]. Because of the small incision
and minimal internal tissue damage, the revalidation period
is supposed to be shorter and scar tissue minimised [29]. In
the current review, we found no severe neurological injury
and a mean percentage of complications after transforaminal endoscopic surgery of 2.8%. There were no substantial differences in serious complications between
endoscopic surgery and open microdiscectomy. Most
reported complications were transient dysaesthesia or
hypaesthesia. However, it has to be noted that none of the
included studies was specifically designed for the assessment of adverse effects, and, therefore, these results have
to be interpreted cautiously; also, disadvantages have been
reported. Transforaminal endoscopic surgery has a steep
learning curve that requires patience and experience,
especially for those unfamiliar with percutaneous techniques. In some studies, the patients operated at the
beginning of the learning curve had worse outcome [10, 20,
26, 56, 60]. Some patients may experience local anaesthesia as a disadvantage. In three studies, the operations
were performed under general anaesthesia [47, 48, 57].
Comprehensive preoperative information about the intervention and permanent communication and constant
observation during the operation is of major importance.
123
Eur Spine J (2010) 19:181204
Future research
Only randomized controlled trials that are adequately
designed, conducted and reported and that have a low RoB
will provide sufficient evidence regarding the effectiveness
of transforaminal endoscopic surgery for lumbar disk herniation. High-quality, randomized controlled trials with
sufficiently large sample sizes that compare the effectiveness of transforaminal endoscopic surgery with open
microdiscectomy for lumbar disc herniations are needed.
The short hospital stay, shorter revalidation period and
earlier return to work may result in an economic advantage,
although this has never been evaluated. Economic evaluations should be performed alongside these trials to assess
the cost-effectiveness and cost utility of transforaminal
endoscopic surgery.
Conclusion
This systematic review assessed the effectiveness of
transforaminal endoscopic surgery. Of the 39 studies
included in this review, most studies had major design
weaknesses and were considered having a high RoB. Only
one randomized controlled trial was identified, but this trial
had poor generalizability. No significant differences in
pain, overall improvement, patient satisfaction, recurrence
rate, complications and re-operations were found between
transforaminal endoscopic surgery and open microdiscectomy. Current evidence on the effectiveness of transforaminal endoscopic surgery is poor and does not provide
valid information to either support or refute using this type
of surgery in patients with symptomatic lumbar disc
herniations.
Conflict of interest statement For this review the authors received
a grant from The Health Care Insurance Board (CVZ), Diemen, The
Netherlands.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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Neuroradiology
Jon K. Kostelic, BA
Victor M. Haughton, MD
Lowell A. Sether, PhD
Lumbar Spinal Nerves in the Neural

Foramen: MR Appearance'
The appearance of the proximal
lumbar spinal nerves at magnetic
resonance (MR) imaging has not, to
the authors' knowledge, been de
scribed. MR images and exactly cor
responding sections obtained from
four cadavers by means of a freezing
microtome were correlated to char
acterize the MR appearance of the
proximal spinal nerves. The junc
tion of the dorsal and ventral rami
with the dorsal and ventral roots
consists of a group of six to 15 fasci
des measuring 2-6 mm in length.
These fascicles appear in MR images
obtained with short repetition times
as small foci of lower signal intensi
ty than that of surrounding fat. The
proximal spinal nerve and its rela
tionship to the intervertebral disk
and osseous margins of the neural
foramen can be demonstrated effec
tively with MR imaging.
Index terms:
Nerves,
Nerves, MR studies, 33.1214
spinal,
Radiology
ECTIONAL
anatomic
studies
of the
lumbar neural fonamina (1) dem

onstrated that the junction between
the lumbar spinal nerve roots and

the dorsal and ventral nami is a group
of fascicles separated by areolar con
nective tissue containing
fat and nu
merous small blood vessels. The exis
tence of the fascicles just distal to the
dorsal moot ganglion
MR imaging and anatomic study, we

illustrate the MR appearance
of the
plexus of fascicles that constitutes
the
proximal 2-6 mm of the lumbar spi
nal nerves.
MATERIALS
AND METHODS
Four cadavers aged 45-76 years were

selected from the Body Donation Pro
gram at the Medical College of Wiscon
sin. The cadavers were frozen at 20C
for 3 days, and the lumbar spines and ad
jacent soft tissues were harvested
with a
high-speed band saw. The spine speci

mens were vacuum-sealed in plastic,
thawed for 6-12 hours, and then imaged
by means
of a 1.5-T Signa
imager
Medical Systems, Milwaukee).
(GE
Images of
sections i mm thick were obtained

in a
sagittal plane. An experimental
program
IFrom
theDepartments
ofRadiology
part by grant AR33667-04 from the National

stitutes of Health. Address reprint requests
V.M.H.
C RSNA,
1991
In
to
relationships
of the
to 15 fascicles that connect those

structures
were well demonstrated
on the parasagittal
MR images. The
dorsal and ventral roots, located in
the superior portion of the neural fo
namen (Figs la, 2), appear on MR im
ages as a region of intermediate
sig
nal intensity surrounded
by the high
signal intensity of fat (Fig le). They
are easily differentiated
from trans
vertebral veins, which are located in
the inferior portion of the neural fo
mamma and are characterized
by a
low signal intensity at MR. The don
sal moot ganglion is identified
as the
bulbous structure in the superior
portion of the neural fomamen (Fig
ib). In the MR images obtained,
the
dorsal moot ganglion has an intenme
diate signal intensity
(Fig if). The
considerably
smaller solitary, oval
ventral moot adjacent to the dorsal
moot ganglion has low signal intensi
ty. Anterior and inferior to the gan
glion is the intervertebral
disk, and
posterior to it is the ligamentum
sections was used. With this program (MP

222; Andrzej
Jesmanowicz,
PhD, Milwau
500 msec, an echo time of 38 msec, a 256
Ave.
The anatomic
dorsal and ventral nerve roots, the

dorsal and ventral nami, and the five
vum, which also can be identified

at
MR imaging.
The ventral and dorsal roots con
nect with a plexus of fascicles at the
lateral margin of the dorsal moot gan
glion. Over the anterior surface of
the dorsal moot ganglion,
the ventral
root bifuncates into superior and in
femiom divisions, which then further
divide into two to five fascicles (Fig
ic). The dorsal moot ganglion con
Lutheran
9200 W Wisconsin
RESULTS
that provides spin-echo images with a
kee) and a solenoid local coil, images

were obtained with a repetition time of
Hospital,
blade of the freezing microtome in 33-@zm

sections. Photographs of the cut surface
were obtained as each anatomic landmark
was exposed and after each millimeter of
tissue was removed (i3).
small field of view and 4-inch-diameter
(V.M.H.) and Anatomy (LAS.), Medical Col

lege of Wisconsin (J.K.K.), Froedtert Memorial
Milwaukee, WI 53226. Received August 3, 1990;
revision requested September 13; revision re
ceived and accepted October 22. Supported in
that slices could be obtained

in the exact
parasagittal
planes that were used for MR
imaging. Tissue was removed with the
explains the ab
sence of a distinct spinal nerve on

conventional
panasagittal
magnetic
resonance
(MR) images of the neural
fomamen. To our knowledge,
the MR
appearance
of the fascicles that form
the proximal spinal nerve has not
been described. To describe the MR
appearance
of the proximal spinal
nerves in the lumbar neural foramina
on the basis of correlations
between
33.92
1991; 178:837-839
(PMV 2250; PMV, Brmma,Sweden) so
x 256matrix,twosignalsaveraged,asec
tion thickness of i mm, and a field of
view of 4 cm2.
The lumbar spine specimens were then
refrozen at 20C
for 3 days and mount
ed on the stage of a freezing microtome
fla
837
Figure 1. Parasagittal
freezing microtome
sections (a-d) and corresponding
MR im
ages (e-h) through the L-4 vertebral body
(L4 in a and e) of a 68-year-old woman.
(a, e) The nerve rootslie in the superiorpor

tion of the foramen (arrowheads).
The supe
nor (S) and inferior (I) articular processes
posterior to the nerve roots and the inter
vertebral veins (open arrow) inferior to
them are identified.
The intervertebral
disk
(d) lies anteroinfeniorly. Two millimeters
lateral to a and e (b, f), the ventral root fasci
des (curved arrows) are anterior to the don
sal root ganglion (g) and ligamentum
fla
vum (f). In sections immediately
lateral to
the ganglion, a plexus of root fascic!es (black
arrows in c and g) is identified. One level
above, the ventral ramus of L-3 (white an
rows) can be seen above the L-4 pedicle. In
sections 1 mm further lateral (d, h), the fas
cicles merge to form the ventral ramus
(black arrows).
nects with five to 10 fascicles. The

seven to 15 fascicles communicating
with the dorsal and ventral moot
make up the proximal spinal nerve

(Fig 2). On a pamasagittal MR image 2
mm lateral to the dorsal root gangli
on (Fig ig), a group of low-intensity
structures
seven to 15 in number and
1 mm on less in diameter is identified
in the location at which the freezing

micmotome sections show the fasci
des (Fig ic). The fascicles are lower
(more caudal) in the neural fomamen
and closer to the intervertebral
disk
than are the roots. One millimeter
anterior
to the fascicles lies the later
al edge of the vertebral
body and in
terventebral disk and posteriorly lies

the ligamentum flavum.
Two to five millimeters lateral to
the dorsal
converge
moot ganglion,
the fascicles
into the ventral and dorsal
rami (Fig id). Fascicles originating

from both the dorsal moot ganglion
and the ventral moot converge

form the ventral
ramus,
which
to
is evi
dent in the pamasagittal MR image

(Fig ih) and freezing microtome sec
tions (Fig id). The ventral mamus lies
in the inferior portion of the neural
fomamen close to the lateral edge of

the vertebra and ventral to the psoas
muscle. The dorsal mamus is also
formed from fascicles originating

from both the dorsal and ventral
roots.
DISCUSSION
The resolution
achieved at MR im
aging in this study is not obtainable
in clinical examinations
at present.
coils are scaled
for specimens,
not for
The acquisition program that pro

vides 1-mm-thick sections and small
clinical studies. Furthermore, physio

logic and voluntary motion that may
be factors in clinical imaging were
not present in our experiment. The
fields of view is currently

mental. The small-diameter
use of previously
frozen tissue does
not affect the results significantly
be
838
Radiology
experi
solenoid
cause little distortion

tomic relationships
of normal ana
is produced
freezing (4). The appearance

culam structures
by
of vas
in the specimens
dif
fers from their appearance in vivo.

The anatomy of the lumbar neural
foramina has been described in detail
March 1991
and ventral root occupy the superior

portion of the neural fomamina; the
fascicles lie centrally in the lateral
portion of neural foramen approxi
mately 1 mm posterior and superior
to the intervertebral disk. The fasci
des have a closer relationship ana
tomically to the ligamentum flavum
and intervertebral
FASCICLE
VENTRAL RAMUS
Figure 2. Anatomic relationships of the

nerve roots, fascicles, and rami. Fascicles
emerge from the lateral border of the spinal
(dorsal root) ganglion
(DRG) and from the
ventral roots (VR) laterally and converge to

form the ventral and smaller dorsal rami of
the spinal
nerve proper.
nerve roots.
The MR appearance of the lumbar
spine has been reported (9), but to
our knowledge the MR appearance of
the lumbar spinal nerves has not
been systematically described. In
pamasagittal images, the dorsal moot
ganglion and the smaller ventral root
are landmarks. Two millimeters lat
enal to the dorsal root ganglion in
parasagittal images, the nerve is not a
unitary structure but a collection of
small fascicles. At this level, the mela
tionship
(3,58),but the appearance of the

proximal lumbar spinal nerve be
tween
the mami and the roots has
only recently been described (1). The

proximal common spinal nerve com
prises seven to 15 small fascicles 26
mm in length. The majority of the
fascicles are continuous with the dom
sal root; the remainder, with the yen
tral moot. The dorsal moot ganglion
Volume 178
Number 3
disk than do the
of the nerve
to the disk mar
gin is not evident at MR imaging un

less the fascicles are recognized. The
ventral mamus is located 6 mm lateral
to the dorsal root ganglion. Although
computed tomography and MR imag
ing can effectively demonstrate disk
hemniations and nerve root compres
sion, they may fail to demonstrate
lution MR techniques, the fascicles

and the proximal portions of the yen
tral mamus can be distinguished.
U
References
1. Kostelic J, Haughton VM, Sether L. Anato
my of the proximal lumbar spinal nerves in
the neural foramen. Clin Anat (in press).
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Pech P, Daniels
DL, Williams
AL, Haughton
VM. The cervical neural foramina: correla

lions of microtomy and CT anatomy. Radio!ogy 1985;155:143-146.
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Rauschning
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anatomy of the lumbar root canals. Spine

1987;12:1008-1019.
Pech P. Bergstrom K, Rauschning W,
W.
Normal
and pathologic
Haughton VM. Attenuation values, vol

ume changes, and artifacts in tissue due to
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5.
Crock HV.
Normal
and pathological
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omy of the lumbar spinal nerve root canals.
J Bone Joint Sung [Br] 1981;63:487-490.

6.
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Bosse K, Balasubramanian P. Nerve root

canals of the lumbar spine. Spine 1984;
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fifth lumbar spinal nerve root. South Afr
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B, Silverman
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Sung [Am] 1969; 51:947956.
Reicher MA, Gold RH, Halbach VD,
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the anatomic relationship between

the disk and the proximal 2-6-mm
segment of the spinal nerve that is
not a solid structure. With high-reso
Radiology
839
Available online at www.sciencedirect.com
Surgical Neurology 68 (2007) 623 631

www.surgicalneurology-online.com
Spine
Targeted percutaneous transforaminal endoscopic diskectomy in

295 patients: comparison with results of microscopic diskectomy
Myung-Jin Kim, MDa, Sun-Ho Lee, MDb,4, Eul-Soo Jung, MDa, Byong-Gil Son, MDa,
Eun-Seok Choi, MDa, Jong-Hyun Shin, MDa, Joo-Kyung Sung, MDb, Yong-Chul Chi, MDa
b
a
Department of Neurosurgery, Bogang Spine Hospital, Daegu, Republic of Korea
Department of Neurosurgery, Kyungpook National University, School of Medicine, Daegu, Republic of Korea
Received 5 July 2006; accepted 13 December 2006
Abstract
Background: The aim of this study is to compare the clinical outcomes and complications after
targeted PTED and conventional microscopic diskectomy for removing 1-level unilateral LDH and
to evaluate the efficacy of PTED for the treatment of LDH.
Methods: The authors retrospectively examined 915 consecutive patients who underwent PTED
(group A, 301 patients) and microscopic diskectomy (group B, 614 patients) for 1-level unilateral
LDH. Patients who were treated with a diskectomy in the period from July 2003 to December 2004
were evaluated by telephone interview and institute visit. This assessment was performed at least 18
months (range, 18-36 months) after their operation. The follow-up rate in groups A and B was 97.5%
(295 patients) and 96.5% (607 patients), respectively.
Results: Good or excellent results were obtained in 84.7% and 85.0% of groups A and B ( P = .92).
The rates of recurrence were 6.44% and 6.75% in groups A and B ( P N .05). Twenty-eight patients
(14 cases of recurrence, 5 cases of incomplete removal, 5 cases of stenosis, 2 cases of diskogenic
back pain, and 2 cases of diskitis) in group A and 38 patients (26 cases of recurrence, 6 cases of
incomplete removal, 2 cases of stenosis, 2 cases of diskogenic back pain, 1 case of hematoma, and
1 case of diskitis) in group B underwent reoperation.
Conclusions: Based on our results, the PTED can be a reasonable alternative to a conventional
microscopic diskectomy for the treatment of patients with LDH, except for those in downward
far-migrating cases beneath the pedicle of the lower vertebra or in cases involving L5-S1 with a
high pelvis.
D 2007 Elsevier Inc. All rights reserved.
Keywords:
Transforaminal; Endoscopic; Microscopic diskectomy; Comparison
1. Introduction
The surgical treatment of LDH has evolved considerably
since Dandy reported the first cases in 1929 [5]. In 1978,
Williams [28] described the concept of microscopic diskectomy, which became the criterion standard of surgical
treatment of LDH so far [1]. Minimal invasive surgical
techniques for various spinal pathologies are under develop-
Abbreviations: AP, anteroposterior; CT, computed tomography; LDH,

lumbar disk herniation; MR, magnetic resonance; PTED, percutaneous
transforaminal endoscopic diskectomy; YAG, Yttrium aluminum garnet.
4 Corresponding author. Tel.: +82 53 420 5649; fax: +82 53 423 0504.
E-mail address: sobotta@dreamwiz.com (S.-H. Lee).
0090-3019/$ see front matter D 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.surneu.2006.12.051
ment, and many spinal surgeons have been interested in

the percutaneous approach for management of LDH
[7,9,10,12,14-17,21,22,24]. Since the introduction of the
arthroscope for herniated disk removal, various procedures
for percutaneous endoscopic diskectomy have been described in cases of mild herniation (contained and small
subligamentous disk herniation) [11,15]. Noncontained and
migrating LDHs have been considered contraindications
for this procedure because of the restricted surgical field
[7,8,20-23], although a few reports have suggested that
PTED may be a valuable method for these as well [15,25-27].
Recently, as endoscopic instruments and techniques have
developed, it has become possible to perform selective and
targeted fragmentectomy with direct visualization of the
624
M.-J. Kim et al. / Surgical Neurology 68 (2007) 623631
pathological lesion and neural structures [20,25-27]. Some

reports suggested that PTED could be widely used for most
LDHs, with comparable clinical outcomes to those of
conventional open surgery [16,27].
Here we presented the surgical outcomes and complications of 902 patients with LDH who underwent targeted
PTED or conventional microscopic diskectomy for LDH
and compared the efficacy of targeted PTED as a standard
treatment of LDH with that of microscopic diskectomy.
with contained, noncontained, or migrating L1 to S1 LDHs.

The other authors performed a microscopic diskectomy only
on 614 patients during the same period. The inclusion
criteria of PTED met the objective indications for the
conventional open microdiskectomy procedure. In contrast,
we limited the exclusion criteria of PTED to downward
high-grade migrating disk cases and some cases involving
L5-S1 with a high pelvis because we could not access the
affected region with PTED. The average period from
symptom initiation to index surgery was 10.8 weeks.
2. Materials and methods
2.2. Surgical techniques in targeted PTED
2.1. Patient population
Percutaneous transforaminal endoscopic diskectomy was

performed with the patient under local anesthesia; the
patient was placed in the knee-chest prone position on a
radiolucent table with mild flexion of the back. We used the
Yeung Endoscopic spine system (Richard Wolf Surgical
Instrument Co, Vernon Hills, Ill), which was reported by
Yeung [26]. The procedure was performed after the patients
had received local anesthesia and intravenous sedation to
minimize anxiety or discomfort and to allow continual
feedback during the procedure. The entry site on the
trajectory line was determined according to the location of
the disk herniation. The entry point was also estimated from
abdominal CT, which provides precise planning and safety,
and is generally 10 to 14 cm from midline (Fig. 1). In the
case of a contained and paracentral LDH, a long 18-gauge
spinal needle was inserted from the entry point toward the
medial pedicular line in the AP view under fluoroscopic
guidance. Otherwise, in cases of noncontained or migrated
herniation, the entry site was further lateral than that of the
contained case (Fig. 1). The needle tip was positioned at
the medial pedicular line in the AP projection and on the
posterior vertebral line in the lateral projection (Fig. 2A and
B). After inserting the needle, an epidurogram was
performed with 3 mL of contrast media (Fig. 2C). At this
time, a transforaminal epidural infiltration with 1% lidocaine is recommended to prevent approach-related pain and
discomfort. After confirming the exiting and traversing root,
a needle was advanced to the center of the disk and
intraoperative diskography was performed using a mixture
containing 9 mL of contrast media and 1 mL of indigo
carmine. The pathologically degenerated nucleus and
annular fissure can then be stained for easy discrimination
through both the fluoroscope and endoscope.
After performing a diskography, a guide wire was
advanced through the needle channel until the tip had
reached the center of the disk space on the AP projection;
and then the spinal needle was removed. After making a 6to 7-mmlong skin incision, an obturator was passed over
the guidewire to near the medial margin of the pedicular line
on the AP view, at which time the posterior annular surface
was reached and further advanced to the center of the disk
by gentle hammering (Fig. 2D). A 6-mmdiameter working
cannula with an oblique window was advanced over the
obturator (Fig. 2E).
The general inclusion criteria for surgical intervention

required clinical evidence of disk herniation at 1 disk level
from L1 to S1 and 3 to 6 weeks of conservative treatment
that failed to improve major motor weakness, intractable leg
pain, and functional impairments. All patients included in
this study had intractable radicular symptoms such as
sciatica, a positive straight-leg raising test, and sensory
and/or motor disturbances. This study included unilateral
intracanal and foraminal soft herniations of 1 level. The
cases with recurrent herniation and far lateral herniation and
those with incomplete fragment removal after previous
surgical intervention at the index level, spinal stenosis, and
segmental instability including spondylolisthesis were excluded from the study group.
According to these criteria, a retrospective review
was performed on 301 consecutive patients who underwent
PTED (group A) and 614 patients who underwent conventional open microscopic diskectomy (group B) for
1-level unilateral LDH in the period from July 2003 to
December 2004. Two authors (MJK, BGS) performed
PTED as the treatment method in 301 consecutive patients
Fig. 1. The disk level on the L4-5 segment in the axial of abdominal CT.
The entry point and angle were calculated from the abdominal CT. The
entry site and angle on the trajectory line are dependent on the location of
the herniation and the level of obesity in the patients. It is generally 10 to 14
cm from the midline in cases of paracentral herniation. The approaching
angle of the spinal needle is 258 to 358.
625
Fig. 2. The surgical procedure of noncontained LDH from the fluoroscopic view. A: This image shows the AP view when the guide needle is positioned at the
medial pedicular line. B: Lateral view when the guide needle is positioned at the posterior vertebral line on the lateral view. C: AP view after an epidurogram
(white arrow, exiting nerve; arrowhead, traversing nerve). D: The needle was replaced by a guide wire followed by an obturator and a final working cannula in
that sequence (E).
An endoscope was introduced through the working

cannula after removing the obturator. Diskectomy was
performed as a standard approach to LDH after insertion
of endoscope. In the endoscopic view of most cases, the
degenerated disk materials, which were stained bluish by

indigo carmine, could be observed and removed under
direct visualization (Fig. 3A). Sometimes, it was also useful
to release annular tissue around the herniated disk to
626
generate enough working space to move the endoscopic

instrument. Sometimes, to gain access to the herniated
fragment, the sidewalls of the annular fissure were widened
using a side-firing holmium-YAG laser and a bipolar
radiofrequency coagulator (Ellman; Ellman International,
Hewlett, NY). After a sufficient annulectomy, blue-stained
herniated fragments could be observed. After decompress-
ing the lesioned disk space, the epidural fat tissue and
traversing root could be well visualized; and the deeper
portion of intraspinal canal was examined by advancing the
endoscope under the traversing root and dura (Fig. 3B).
Finally, the intradiskal decompression was performed
around the lesion site.
Using this approach and technique, we could access the
ventral dura and remove the extruding disk easily in the
epidural space. In cases of disk migration, we could move
the working cannula to the cephalic or caudal portion of the
epidural space under direct visualization and obtain enough
space to reach the migrating portion by angulation of the
cannula in that direction. A large migrated disk material and
a small fragment were found between the ventral dura and
dorsal vertebral body. These were removed successfully
using an endoscopic forceps and a dissector (Fig. 3C).
After removing the endoscope, a 1-point stitch was
performed and a sterile dressing was applied. During the
whole procedure, the amount of blood loss was minimal (less
than 1-5 mL). The patients were generally discharged the next
day after surgery if there were no postoperative problems.
2.3. Assessment of clinical outcome
The evaluation was performed in a surgeon-independent
manner at least 18 months after the index operation. The
clinical material available for evaluation included all information submitted according to the predetermined surgical
protocol. The clinical material included preoperative history
and physical examination, operating notes, image studies,
intraoperative videotapes, and laboratory reports. The postoperative data included follow-up, telephone interviews, and
any revisions as the clinical situation required. Results were
determined to be excellent, good, fair, or poor according to
the MacNab criteria [19]; and a successful outcome was
defined as excellent or good based on our criteria (Table 1).
Follow-up examinations were carried out on postoperative
day 1, then after 1, 3, and 6 months and every 12 months.
Statistical analysis was performed using Student t test, v 2 test,
and Fisher exact test, with 2-tailed P values less than 0.05
considered significant.
3. Results
Among 301 patients who underwent PTED, 295 patients
were evaluated through follow-up (group A). There were 188
(63.7%) male and 107 (36.3%) female patients with a mean
Fig. 3. Intraoperative endoscopic view. A: The degenerated disk materials,
which were stained bluish by indigo carmine, could be observed and
removed under direct visualization B: After the adequate removal of the
disk, the anatomical details are well demonstrated, including the traversing
root (R), posterior longitudinal ligament (P), and the remaining nucleus
pulposus (N). C: In the case of an upward migrating disk, enough space was
obtained to reach the migrating portion by the angulation of the cannula in
that direction. A migrated disk material and fragment were found between
the ventral dura (D) and dorsal vertebral body (B). Exiting root (R)
surrounding epidural fat tissue was visualized.

Table 1
MacNab criteria
Table 3
Clinical outcome and surgical-related complication of 902 follow-up patients
Classification
Criteria
Excellent
Good
No pain; no restriction of activity occasional

Back or leg pain of sufficient severity to interfere
with the patients ability to do normal work or
capacity to enjoy leisure hours
Improved functional capacity, but handicapped by
intermittent pain of sufficient severity to curtail or
modify work or leisure activity
No improvement or insufficient improvement to
enable increase in activities; further operative
intervention required
Fair
Poor
age of 34.9 years (range, 13-83 years). The levels of disk herniation were L1-2 (3 cases), L2-3 (3 cases), L3-4 (17 cases),
L4-5 (191 cases), and L5-S1 (81 cases). In group B, 607 of the
initial 614 patients (392 men, 64.6%; 215 women, 35.4%)
with a mean age of 44.4 years (range, 17-80 years) were
evaluated through follow-up. The levels of disk herniation
were L1-2 (4 cases), L2-3 (16 cases), L3-4 (32 cases), L4-5
(362 cases), and L5-S1 (240 cases). The follow-up rate was
97.5% in group A and 96.5% in group B. The average followup period was 23.6 months (range, 18-36 months). The
demographic characteristics are summarized in Table 2.
3.1. Comparisons of clinical outcome
The results for these 2 groups are shown in Table 3.
Based on the MacNab criteria, the surgical outcomes were
rated as follows: (1) Group AOut of 295 patients, 140 had
excellent results, 110 had good results, 29 had fair results,
and 16 had poor results. Of the 29 fair results, 5 patients had
stenosis, 12 had recurrence, and 2 had diskogenic back pain.
In the 16 poor cases, 7 recurrences, 7 with incomplete
extirpation of disk, and 2 with diskitis were included. (2)
Group BOut of 607 patients, 290 had excellent results,
226 had good results, 51 had fair results, and 40 had poor
Table 2
Demographic summary in 295 patients of PTED and 607 patients of
microscopic diskectomy for treatment of LDH
Parameter
No. of cases
Sex (M: F)
Age (y)
b 20
20-29
30-39
40-49
50-59
N 60
Level of surgery (%)
L1-2
L2-3
L3-4
L4-5
L5-S1
627
PTED
(n = 295)
Microdiskectomy P
(n = 607)
Clinical outcome
Excellent (cases)
140
290
Good
110
226
Fair
29
51
Poor
16
40
Success rate
84.7
85.0
No. of poor outcome (%)
45 (15.3)
91 (15.0)
Operation time (min)
53.0 F 13.0 64.6 F 28.7
No. of surgical complication (%) 9 (3.05)
10 (1.98)
Dural tear
3
6
Dysesthesia
4
2
Diskitis
2
2
Wound infection
1
Hematoma
1
No. of reop (%)
28 (9.5)
38 (6.3)
NSa
NSa
b .001b
NSc
NSc
The data are expressed as the mean F standard deviation. Reop indicates
reoperation; NS, not significant.
a
Statistical significance test was done by the v 2 test.
b
Statistical significance test was done by the t test.
c
Statistical significance test was done by the Fisher exact test.
results. Of the 51 fair results, 8 patients had stenosis, 19

patients had recurrence, and 19 patients had lumbar back
pain of unknown origin. In the 40 poor cases, 22
recurrences, 1 severe diskogenic back pain, 1 stenosis, and
3 diskitis were included. The rates of recurrence were 6.44%
in group A and 6.75% in group B; there was no significant
difference between these rates ( P N .05). In total, the
percentages of successful outcomes, with excellent or good
results, were 84.7% for group A and 85.0% for group B
( P N .05). The percentages of unsuccessful results (defined
as failed back surgery syndrome), which included fair and
poor results, were 15.3% for group A and 15.0% for group
B. The causes of failed back surgery syndrome are described
in Table 4. Both groups had negligible blood loss that had
no significant clinical influence. Mean operative time (F
standard deviation) was 53.7 F 11.3 minutes in group A and
65.2 F 19.5 minutes in group B ( P N .0 1).
Procedure
Group A (PTED)
Group B (microdiskectomy)
295
188:107
34.9 (13-83)
22
70
71
65
36
31
607
392:215
44.4 (17-80)
19
108
150
121
107
101
3
3
17
191
81
4
17
32
325
229
(1.0)
(1.0)
(5.8)
(64.7)
(27.5)
(0.7)
(2.2)
(5.4)
(57.2)
(34.4)
Table 4
Cause of the unsuccessful outcome in both groups
Cause
PTED (%) n = 295
MD (%) n = 607
Recurrence
Residual disk
Lateral stenosis
Diskogenic LBP
Neuropathic pain
Unknown LBP
Diskitis and infection
Hematoma
Total
19
7
5
2
4
6
2
45
41
6
9
2
2
27
3
1
91
NSa
.102a
NSb
NSb
.093b
.07a
NSb
NSa
(42.2)
(15.6)
(11.1)
(4.4)
(8.9)
(13.3)
(4.4)
(45.1)
(6.6)
(9.9)
(2.2)
(2.2)
(29.7)
(3.3)
(1.1)
MD indicates microscopic diskectomy; NS, not significant; LBP, lumbar

back pain.
a
Statistical significance test was done by the v 2 test.
b
Statistical significance test was done by the Fisher exact test.
628
Table 5
Cause of and procedure for the reoperation
No. of cases (type of revision)
Recurrence
Residual disk
Stenosis
Diskogenic LBP
Diskitis
Hematoma
Total
PTED
Microscopic diskectomy
14
5
5
2
2
28
26
6
2
2
1
1
38
(P:3, M:7, F:4)

(M:5)
(F:5)
(F:5)
(P:1, E:1)
(P:2, M:9, F:15)

(M:6)
(F:2)
(F:2)
(E:1)
(E:1)
P indicates percutaneous transforaminal endoscopic diskectomy; M,

microscopic diskectomy; F, fusion surgery; E, exploration only.
3.2. Surgical complications and reoperation

Nine patients in group A and 12 patients in group B had
surgical complications related to the operation. The rate of
surgical complication was 3.05% in group A and 1.98% in
group B. There was postoperative dysesthesia in 4 and
2 patients in groups A and B, respectively. There were no
deaths and no intraoperative vascular injuries (Table 3).
In all, 28 patients in group A (14 cases of recurrence,

5 cases of incomplete removal, 5 cases of stenosis, 2 cases
of diskogenic pain, and 2 cases of diskitis) and 38 patients
in group B (26 cases of recurrence, 6 cases of incomplete
removal, 2 cases of stenosis, 2 cases of diskogenic pain,
1 case of hematoma, and 1 case of diskitis) underwent
reoperation (Table 5). The rate of reoperation was 9.5%
in group A and 6.3% in group B. There were no
significant differences in the rates of surgical complications and reoperation between the 2 groups.
4. Discussion
Although the concept of posterolateral percutaneous
lumbar disk decompression was first introduced by Kambin
in 1973 [14], more than a quarter of a century later,
endoscopic lumbar spine surgery is still limited to a small
number of surgeons because of several technical challenges
presented by the posterolateral endoscopic procedure. First,
safe and effective access is limited to a narrow channel.
Second, there is little or no working space, as compared
Fig. 4. Case illustrations. A and B: A 36-year-old man with severe right leg pain and weakness of dorsiflexion on ankle and great toe, caused by severe,
noncontained, LDH on L4-5, was treated with PTED. C: Postoperative MR images show complete removal of extruded material. D: A 50-year-old man
with right buttock pain and weakness of knee extension, caused by downward migrating lumbar disk on L3-4, was also treated with PTED. E: Postoperative
T2-weighted sagittal MR images show removal of migrating disk. White arrowheads indicate herniated disk.
with conventional open surgery. Third, creation of an

intradiskal work space is needed before intracanal disk
fragment extraction. Fourth, a herniated fragment is
accessible only when the operating instrument is placed in
the optimal trajectory [27].
Since Yeung introduced a rigid rod lens, integrated,
multichannel, wide-angle operating spinal endoscope
[25-27], the available data indicate that the PTED technique
is versatile and safe. A bevel-ended tubular-access cannula
allows same-field viewing of the epidural space, annular
wall, and intradiskal space. The various tissuesdisk, bone,
ligament, fat, vessel, nerve, and duraare readily identifiable under the endoscope. Although it was widely accepted
that the L5-S1 disk space and large herniations were
generally inaccessible before the advent of endoscopic
visualization [4,12-15], recent adaptations allow surgeons
a wide-angle view of the surgical field and decompression
of nerve roots under direct vision through a single portal in
most cases. In 295 of the consecutive cases of LDH using
targeted PTED, the authors evaluated surgical technique,
outcome, and complications retrospectively. The series
included both noncontained and foraminal herniations.
There were no exclusions for technique-related reasons.
The authors experience with the lumbar posterolateral
transforaminal endoscopic technique indicates that most
lumbar disk spaces and their adjacent epidural spaces are
accessible, with the exception of some cases involving the
L5-S1 disk.
4.1. Approaches for extruded and migrating disk herniation
In dealing with migrated herniations, some potential
problems cause surgeons to consider the percutaneous
endoscopic technique demanding. First, access through a
narrow channel might be ineffective and might cause an
injury to the neural structure during extraction of the
migrated fragments with endoscopic forceps. Second, the
mechanical ability to reach and grasp the herniated fragments lags behind the endoscopes optical capabilities [27].
Placement of the endoscope in the optimal trajectory
improves the mechanical instruments effective reach. Noncontained herniations in the epidural space require an access
trajectory of 158 to 208 so that the endoscopic instrument
can reach posteriorly into the epidural space (Fig. 4A-C).
The surgical techniques to gain access to fragments located
in the epidural space, including widening of the intradiskal
working canal and a sufficient extension of the annular tear,
are always necessary, too. When adequate widening of
the intradiskal working cavity is achieved, the angle of the
endoscope becomes more horizontal and pivots on the
foramen. Thus, a surgeon can examine the full undersurface
of the annulus and identify the blue-stained, epidurallocated disk fragments [2].
In the anatomical aspect of the intervertebral foramen, the
available angle to reach around the superior boundary of the
foramen is much larger than that around the inferior boundary
of the foramen. Intraoperatively, these anatomical character-
629
istics allowed the endoscopic instruments enough angles to

go through the foramen into the upper portion of the spinal
canal and to successfully and easily remove cephaladmigrated disk materials. On the other hand, in the case of
caudal-migrated disk herniations, the inferior boundary of the
foramen was a serious obstacle to reaching the spinal canal
below the disk level; and complete removal of sequestrated
disk material was sometimes impossible [3]. If the fragments
were not too far away from the disk space beneath the lower
pedicle, however, the results of this study show that the
migrated fragments were accessible with current instrument
and technique in most cases (Fig. 4D and E).
4.2. Comparison of clinical outcomes
In our series, the minimal follow-up period of 18 months
seems to be satisfactory for evaluating the endoscopic
excision in a herniated lumbar disk. The satisfactory
result rate of 84.4% in this series is comparable to the
successful outcome of 85.0% in our conventional diskectomy group and the 88.2% in a restricted endoscopic series
by Kambin et al [15]. The satisfactory result rate of 87.3%
for microscopic diskectomy reported by Abernathey and
Yasargil is also statistically comparable [1]. In 1993,
Mayer and Brock showed that the clinical results of PTED
are comparable, and in some respects superior to those of
conventional microscopic diskectomy [21,22]. They noted
that the PTED required local anesthesia and shorter
hospitalization and resulted in less tissue trauma and
less epidural scarring. A study by Lew et al has shown
considerably more promise, as in our series; early
results obtained from their series, in which transforaminal endoscopic lumbar diskectomy was performed, are
similarly encouraging [18]. They reported an overall success
rate of 85% (42 of 47 cases) and revision rate of 11%
(5 cases).
Delamarter and McCulloch [6] reported a recurrence rate
of 5% F 2% after microscopic diskectomy for LDH. The
recurrence rate of 6.44% in our PTED group was
comparable to that of our conventional group (6.75%) and
the previous outcome data.
4.3. Surgical complications of PTED
This study had a minimal combined major and minor
complications rate. There were 9 complications after
percutaneous endoscopic diskectomy (3.05%) and 10
complications after conventional diskectomy (1.98%) in
the present series. The published complication rate for
endoscopic excision of LDH was also low. As a technique,
many clinicians have developed a variation of the freehand,
biplane, c-arm guidance method to gain posterolateral entry
into the intradiskal and epidural spaces with the patient
under local anesthesia. The patient, in a continuous
awakened state, is instructed to alert the surgeon if there
should be any inadvertent physical trauma to the nervous
structures. Pain relief from adequate nerve root decompression in a conscious patient is quickly apparent in the
630
operating room. Should the radicular pain persist because of

a missed fragment, the problem is readily identified within
the immediate postoperative period.
In terms of surgical complications, our series included
4 patients in group A and 2 patients in group B who
experienced transient extremity dysesthesia; the condition
improved within 6 months. Besides complications due to the
approach such as dysesthesia or nerve root injury, there were
no significant differences in complications between the
2 groups. Choi et al proposed that heat transmission to the
neural structures from a radiofrequency coagulator was
the main cause of painful postoperative dysesthesia [3]. On
the other hand, the mechanical compression of dorsal root
ganglia by the cannula in the epidural space could be
another cause of dysesthesia [4]. The patients with these
complications fully recovered from their condition after
conservative management including physical therapy and
repeated epidural injection therapy, so these results were not
subject to the mandatory poor rating rule. To decrease the
risk of complications, detailed evaluation of preoperative
abdominal CT images for possible variations as well as
correct probe placement will provide more safety.
surgical method chosen was according to the surgeons own

preference. The lack of standardization of the study groups
is another limitation of a retrospective study. Because of the
possible patient selection biases of these groups, the relevant
clinical significance of the surgical outcome and revision
could not be investigated properly. Therefore, a further
examination and future clinical study will be needed to
determine the clinical effectiveness and safety of PTED.
4.4. Reoperation of PTED and its cause
References
Despite the younger age of the PTED group, there was a

higher revision rate (9.5%) than that of the microscopic
diskectomy group (6.3%). First, PTED has its own learning
curve like every new technique. When the results were
evaluated every sixth month, in the first 6 months, 15
reoperations (18.1%) were performed in 83 patients, and 4 of
the 5 residual disks were developed in this period. However,
there were only 5 (4.8%) reoperations in the 105 operated
patients during the last 6 months, and there were no revisions
of the residual disk. Second, we tended to underestimate the
concurrent pathology of LDH in the younger patients (eg,
5 cases of stenosis). Schaffer and Kambin analyzed 11 patients
who underwent reoperation out of 100 patients treated with
PTED in 1991 [23]. In their analysis, the most common causes
for subsequent surgery for the 11 patients were a lateral recess
stenosis, sequestered herniation, and improper placement of
the working instruments. With the exception of recurring or
residual disk, the presence of concurrent lateral recess stenosis
was the major factor predicting a poor outcome. If the hernia
mass is overtly calcified or combined with severe spinal
stenosis, the effect of an endoscopic removal could be limited.
If there are severe neurological deficits such as cauda equina
syndrome or foot drop, an open reexploration is mandatory.
These results showed that PTED is safe and effective after a
sufficient learning curve if the patient selection criteria are
followed strictly.
4.5. Limitation of the study
Despite these outstanding results, this study had some
limitations. One is the lack of surgeon standardization. This
report of our PTED experience was from the data collected
from 6 surgeons at a single institution. In addition, the
5. Conclusions
In this study, we have demonstrated the safety and
efficacy of PTED in the treatment of patients with LDH of
various sites. Our success rate is comparable with that of
conventional open surgical procedures. The complication
and revision rates were also comparable to conventional
treatment. Based on these results, PTED can be a
reasonable alternative to conventional microscopic diskectomy for the treatment of patients with LDH, except in
downward far-migrating cases or in cases involving L5-S1
with a high pelvis.
[1] Abernathey CD, Yasargil MG. Results in microsurgery. In: Watkins

RG, editor. Microsurgery of the lumbar spine. Rockville7 Aspen
Publishers; 1999. p. 223 - 6.
[2] Ahn Y, Lee SH, Park WM, et al. Percutaneous endoscopic lumbar
discectomy for recurrent disc herniation: surgical technique, outcome,
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[3] Choi SJ, Ji C, Ahn JG, et al. Efficacy of percutaneous transforaminal
endoscopic discectomy in noncontained and extruded lumbar disc
herniation. Kor J Spine 2004;1:107 - 12.
[4] Choi G, Lee SH, Raiturker PP, et al. Percutaneous endoscopic
interlaminar discectomy for intracanalicular disc herniations at L5-S1
using a rigid working channel endoscope. Neurosurgery 2006;
58(1 Suppl):59 - 68.
[5] Dandy WE. Loose cartilage from intervertebral disc simulating tumor
of the spinal cord. Arch Surg 1929;19:660.
[6] Delamarter RB, McCulloch JA. Microdiscectomy and microsurgical
spinal laminotomies. In: Frymoyer JW, editor. The adult spine:
principles and practice, 2nd ed Philadelphia7 Lippincott-Raven; 1997.
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[7] Ditsworth DA. Endoscopic transforaminal discectomy and reconfiguration: a posterolateral approach into the spinal canal. Surg Neurol
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[8] Hermantin FU, Peters T, Quartararo L. A prospective, randomized
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[9] Hijakata S, Yamgishi M, Nakayama T, et al. Percutaneous discectomy:
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[10] Hijakata S. Percutaneous nucleotomy. A new concept technique and
12 years experience. Clin Orthop 1989;238:9 - 23.
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JW, editor. The adult spine: principles and practice, 2nd ed
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[13] Kambin P. Arthroscopic microdiscectomy. Arthroscopy 1992;8:287 - 95.

[14] Kambin P, Brager MD. Percutaneous posterolateral discectomy:
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[15] Kambin P, OBrien E, Zhou L, et al. Arthroscopic microdiscectomy
and selective fragmentectomy. Clin Orthop 1998;347:150 - 67.
[16] Kambin P, Savitz MH. Arthroscopic microdiscectomy: an alternative
to open disc surgery. Mt Sinai J Med 2000;67:283 - 7.
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100 patients and current practice. Clin Orthop 1989;238:24 - 34.
[18] Lew SM, Mehalic TF, Fagone KL. Transforaminal percutaneous
endoscopic discectomy in the treatment of far-lateral and foraminal
lumbar disc herniation. J Neurosurg (spine 2) 2001;94:216 - 20.
[19] MacNab I. Negative disc exploration: an analysis of the causes of
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(PELD). Neurosurg Rev 1993;16:115 - 20.
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[26] Yeung AT. The evolution of percutaneous spinal endoscopy and
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t h e s u r g e o n x x x ( 2 0 1 2 ) 1 e7
Available online at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges

of Surgeons of Edinburgh and Ireland
www.thesurgeon.net
Review
Transforaminal endoscopic spinal surgery: The future gold

standard for discectomy? e A review
J.N. Alastair Gibson a,*, Jonathan G. Cowie a, Menno Iprenburg b
a
b
Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SU, United Kingdom
Spine Clinic Iprenburg, Veenhuizen, Hospitaallaan 10, 9341 AH Veenhuizen, Netherlands
article info
abstract
Article history:
Background: Lumbar disc prolapse is common and the primary method of care in most
Received 27 October 2011
centres is still open discectomy facilitated by microscope or loupe magnification and
Received in revised form
illumination. Hospitalisation may be less than 24 h, but post-operative pain usually
5 March 2012
requires an overnight stay. This review describes transforaminal endoscopic spinal surgery
Accepted 9 May 2012
(TESS) using HD-video technology, that is generally performed as a day case procedure
Available online xxx
under sedation or light general anaesthesia, and collates the evidence comparing the
technique to microdiscectomy.
Keywords:
Methods: The method of TESS is described and an electronic literature search performed to
Discectomy
identify papers reporting clinical outcomes. International data were translated where
Endoscopic
necessary and proceedings abstracts included. In addition, papers held by the authors and
Microdiscectomy
colleagues in personal libraries were carefully cross-referenced to the obtained database.
Trans-foraminal
Results: Analysis of the data supports the use of a transforaminal endoscopic approach to
Surgery
the lumbar intervertebral disc and suggests that outcomes following surgery are at least
equivalent to those following microdiscectomy. Significant cost-savings in terms of inpatient stay may be generated. In addition, there is also some evidence supporting endoscopic surgery for relief of foraminal stenosis.
Conclusion: Based on current evidence there are good arguments supporting a more widespread adoption of transforaminal endoscopic surgery for the treatment of lumbar disc
prolapse with or without foraminal stenosis.
Crown Copyright 2012 Published by Elsevier Ltd. All rights reserved.
Introduction
Lumbar disc herniation, with a reported prevalence of 1e3%1
is the commonest pathological process leading to spinal
surgery. However, despite dramatic advancements in minimally invasive surgery in other fields, the treatment of disc
prolapse in many centres has made only small advances since

the initial description of the pathology in the early 1930s.2,3
This is a recognition of the fact that laminotomy and discectomy produce good to excellent results in up to 90% of
patients, even without use of an operating microscope.4
However, whether a ten percent failure rate from an
* Corresponding author. Tel.: 44 (0) 131 2423471; fax: 44 (0) 131 4455586.
E-mail address: j.n.a.gibson@blueyonder.co.uk (J.N.A. Gibson).
1479-666X/$ e see front matter Crown Copyright 2012 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.surge.2012.05.001
Please cite this article in press as: Gibson JNA, et al., Transforaminal endoscopic spinal surgery: The future gold standard for
discectomy? e A review, The Surgeon (2012), doi:10.1016/j.surge.2012.05.001
t h e s u r g e o n x x x ( 2 0 1 2 ) 1 e7
invasive procedure, producing significant epidural scarring, is

acceptable in the 21st Century is a matter for debate. This is
especially the case if newer methods are associated with
a shorter hospital stay and lower cost base.
The first attempt to improve matters was in the 1960s,
when chymopapain injection was introduced as an alternative to lumbar discectomy. There was evidence of a satisfactory outcome in approximately 75% of treated patients but
strong evidence from randomized controlled trials suggested
that although more effective than placebo, chemonucleolysis
was less effective than discectomy.5 These facts, combined
with concerns regarding an allergic response to chymopapain
limited sales from the pharmaceutical companies leading
eventually to cessation of compound production.
In the 1970s, similar 75% rates of success were reported
following percutaneous dorso-lateral nucleotomy,6 leading to
the availability of a plethora of mechanical devices in the
1980s that would core out the centre of the disc relieving
pressure on the exiting root. Outcomes never unfortunately
reach those of standard discectomy.1e9 and even advanced
techniques using laser to vaporize the nucleus and lay open
the foramen (endoscopic laser foraminoplasty) have not been
widely adopted.10e12 These methods did however lay a base
for the current revolution in care that results from access
through the safe extraforaminal working zone,6 improved
arthroscopic equipment and high definition video.13e15
Surgical approach and technique for

transforaminal endoscopic spinal surgery
Operating technique
The operation is possible with the patient lying laterally or
prone. Optimal positioning of the patient is essential. The
authors prefer the lateral position for the following reasons.
Firstly, a pillow under the waist will open up the foramen and
allow the dura to fall down to the contra-lateral side avoiding
damage on introduction of the cannula. Secondly, the reduced
intra-abdominal pressure will decrease bleeding. This is
especially important in larger patients. Thirdly, and perhaps
of greatest importance, it is easier for the surgeon to maintain
verbal contact with the patient (Fig. 1).
We generally advise that the procedure is performed under
sedation and local anaesthesia rather than general anaesthesia. The patient is then able to warn the surgeon if
instrumentation impinges on a nerve root. It is essential to
have orthogonal bi-planar imaging (AP and Lateral) with an
image intensifier and confirmation of the position of any
annular tear, protrusion and/or sequestrated disc material
may be obtained by intra-operative discography.
The position of the iliac crest is marked and a line is
drawn along the spinous processes. With X-ray guidance,
a line is then drawn on the skin in line with the isthmus of
the lamina to the upper backside of the lower vertebral
body. Local anaesthesia is administered and an 18 guage
needle then introduced between 10 and 15 cm from the
midline of the spine, to the disc herniation, passing over the
anterior side of the isthmus. One should aim at a position
a few millimetres medial of the medial interpedicular line
through the caudal part of the foramen (as low through the
foramen as possible). The position of the needle is checked
in two planes during its introduction with the image intensifier. After the tip of the needle has reached the correct
position, a discogram may be performed, if required, to
further delineate the pathology and a guide wire introduced
(Figs. 2,3).
A small skin incision of 8 mm is then made and the
needle removed leaving the guide-wire in situ. A 2 mm
conical rod is introduced over the guiding wire, and then
sequentially the first, second and third sleeves (guiding
tubes) dilating the soft tissues to 6.5 mm. At the levels L4/L5
and L5/S1 the procedure is usually carried out close to the
iliac crest. Passing the iliac crest may be painful and it is
recommended that extra anaesthetic is placed down to the
iliac crest at this stage.
The second and third sleeves are then removed and over
the first sleeve, the first of sequentially larger reamers
introduced anti clockwise, to avoid damage to the spinal
muscles as shown in Fig. 4. The patient is told to alert the
surgeon if he or she experiences pain. In the case of L4/5 and
L5/S1 herniations this is usually localised under the knee.
Occasionally, pain is felt in the trochanteric region during
reaming or in the proximal upper lateral leg, although more
commonly the patient is comfortable and can talk to
a member of the team.
Continuously checking with the image intensifier the
lamina may then be reamed (cutting clockwise) and the
reamer advanced safely to 1 or 2 mm inside the medial pedicular line. The procedure is repeated with each of the
sequentially larger rods, tubes and reamers. The working
cannula can be introduced over the third conical rod. Its tip
should be located on the herniated disc (Fig. 5).
The endoscope may now be introduced and the hernia
removed (Fig. 6). Sometimes a large sequestered disc can be
removed immediately, but in most cases the disc fragments
have to be taken out with small forceps. The patient should be
asked to confirm that no pain is being experienced on leg
movements. After removing the hernia the working cannula is
also removed and the skin is closed with a subcutaneous
suture and a steristrip. Two hours following surgery the
patient can mobilise and be discharged home.
Figure 1 e Theatre set-up.
t h e s u r g e o n x x x ( 2 0 1 2 ) 1 e7
Figure 4 e Spine radiograph showing placement of conical

rod, sleeve and reamer.
Figure 2 e Guide wire placement.
Current literature
with the following search terms: endoscopic discectomy,

microdiscectomy, transforaminal discectomy, lumbar discectomy, percutaneous discectomy; combinations of the
preceding interventions. Proceedings abstracts were
Methods of review
A systematic literature review of Pubmed, Google scholar,
Cinahl and Cochrane library databases was performed for
articles, including randomized trials (RCTs), controlled clinical
trials (CCTs) and reviews, up to and including December 2011
Figure 3 e Discogram showing lateral disc prolapse.
Figure 5 e Placement of working cannula.
t h e s u r g e o n x x x ( 2 0 1 2 ) 1 e7
Figure 6 e Endoscopic view.
included. Reference lists from the sourced articles were

scanned for other relevant publications. The authors
personal papers and communications were also reviewed and
cross-referenced against the main database.
Results
We identified three review articles that covered transforaminal endoscopic spinal surgery as part of their remit.
Gotfryd and Avanzi16 looked at the safety and effectiveness of
different discectomy techniques for the treatment of herniated lumbar discs. Karnezis17 looked at all minimally invasive
interventions in the spine, touching on transforaminal endoscopic discectomy as part of a larger review. Nellensteijn and
colleagues18 were the first group to specifically review the
literature regarding transforaminal endoscopic discectomy
for symptomatic lumbar disc herniations.
We identified seven publications directly comparing the
outcomes of traditional microdiscectomy and TESS. Mayer,19
Hermantin,20 Krappel21 and Ruetten22 carried out randomized or quasi-randomized controlled trials (allocation by
a method that was not strictly random: alternation of participants21,22) comparing endoscopic and microdiscectomy.
These trials had small numbers and only Hermantins study
had a low risk of bias as per the criteria of the Cochrane Back
Review group (Table 1).23 All the trials found benefits in
endoscopic surgery over micro discectomy but no statistically
significant changes in satisfaction outcomes. Mayer used
a direct approach to the disc and showed that patients
following percutaneous endoscopic discectomy were more
likely to return to work (95% vs 72.2%). After TESS, Hermantin
showed a shorter duration of post-operative disability with
less need for analgesia and Ruetten showed shorter operating
times, more rapid rehabilitation (25 days vs 49 days), lower
costs of care and reduced trauma. Krappel suggested that
there was less scarring after endoscopic surgery.
A small matched cohort series by Lee et al.24 showed very
successful clinical outcomes in both groups (96.7% in the
percutaneous endoscopic discectomy group vs 93.3% in the
Table 1 e Risk of bias of Randomised Studies.23
Patient number
Random sequence generation (selection bias)
Allocation concealment (selection bias)
Outcome assessment e functional outcomes,
pain, clinical outcomes, complications
(perfomance bias and detection bias):
Outcome assessment e death, re-operation
(perfomance bias and detection bias)
Incomplete outcome data (attrition bias): death,
re-operation
Selective reporting (reporting bias)
Balance in baseline characteristics
Mayer 1993
Hermantin 1999
Krappel 2001
Ruetten 2008
40
U
U
L
60
L
L
L
40
H
H
L
200
H
H
L
L
L
L
L
L
L
L
U
Risk of Bias: L Low, H High and U Unclear.
t h e s u r g e o n x x x ( 2 0 1 2 ) 1 e7
open microdiscectomy group, n 60) but statistically significant differences in only the radiological parameters. Retrospective comparative studies were published by Kim25 who
compared 295 TESS patients with 607 patients that had
a micro discectomy at one institution, and by Iprenburg26 who
compared 255 TESS patients with microdiscectomy patients
from the Swedish national spine register. Kim showed similar
clinical outcomes from the two techniques. Iprenburg showed
the VAS scores for back and leg pain, walking distance and
patient satisfaction in the TESS group were significantly better
than in the micro discectomy group.
Forty-nine case series which included over 6000 patients
who have had TESS were reviewed. These reported a multitude of outcomes including visual analogue scores, Oswestry
disability index (ODI), global perceived effects (McNab score),
patient satisfaction and quality of life scores. Complications
such as recurrence, dural tears and nerve root injuries were
monitored. Duration before return to work, rehabilitation
required and overall costs were also studied.
Chiu27 reviewed 2000 patients who underwent transforaminal endoscopic surgery for herniated discs. 94% of the
patients had good or excellent results and the morbidity rate
was less than 1%. It is not clear what percentage of these
patients had percutaneous surgery or open endoscopic
surgery.
A number of studies have shown that there is a learning
curve with TESS. Wang28 and Lee29 have both shown that the
complication rate and the requirement for conversion to open
techniques vastly decreases after the first twenty cases.
The recurrence rate following TESS at approximately 8%
is comparable with the 5% recurrence rate quoted for
microdiscectomy.30 However, recent publications are also now
showing improved outcomes in revision surgery in patients
that have had recurrence after endoscopic surgery in comparison to those that have recurrence after microdiscectomy.18e20
This is thought to be due to reduced scarring present after
TESS. The risk of dural tear or nerve root injury at 1.1%31 and 2%16
respectively also compare favourably to traditionally quoted
values for microdiscectomy.
Peng et al.32,33 have shown that there are significant
improvements in quality of life scores (SF-36) and that these
improvements correlated with improvements in The North
American Spine Society (NASS) score. Allen and Garfin34
reviewed the literature with regard to the cost effectiveness
of minimally invasive spinal surgery in general. They
concluded that minimally invasive surgery has the potential
to be cost effective provided that the improved clinical
outcomes noted in the short term are maintained.
Entry to the spine by the transforaminal approach allows
widening of the foramen to relieve foraminal exit stenosis,
access to the lateral recess with decompression and soft tissue
ablation in patients with spondylolytic defects. Seven observational studies of patients with stenosis were reported by
Nellensteijn35 showing satisfactory outcomes in 69e83% of
patients, although no randomised controlled trials were found.
Preliminary results from the Edinburgh RCT

In 2006, a RCT was set up to compare the outcomes of TESS
and microdiscectomy at the Royal Infirmary of Edinburgh. The
trial was approved by the Regional Ethics Committee and

patients randomized to treatment by computer. Patients aged
25e55 years with single level disease, clinical and radiological
evidence of nerve root compression and failure of conservative management (including physiotherapy) for six weeks
were included. Excluded were those patients of excess weight
(>100 kg), with a disc prolapsed above the level of L3/4 or with
sequestered fragments >2 cm length, and those with previous
disc surgery.
Results from the initial 48 patients have been reported.36
Three months following surgery leg pain scores had
decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both
groups by 1 year and this improvement was maintained to 2
years (final scores: 7 3 TESS versus 14 13 Microdiscectomy:
means SD; difference at p < 0.05: Students t-test). In-patient
stay was lower in the TESS patients with the majority of the
later cases being treated as day cases (0.8 0.5 days TESS
versus 1.8 1.4 days Micro: means SD). One revision was
reported at 12 months (TESS) and one at 18 months (Micro).
Two patients presented with a disc prolapse at a different
level and side (both TESS).
In the 101 currently recruited patients (Gibson et al.
unpublished results: 52 TESS, 49 Micro; 62% L5/S1 level)
complications have been rare. Two endoscopy patients complained of excessive pain thought probably due to failure to
anaesthetize the iliac wing periosteum that is richly innervated. Greater care was subsequently taken to observe the
prescribed anaesthetic protocol37 and there have been no
further complaints in 40 trial and non-trial consecutive
surgeries. Five patients (3 TESS, 2 Micro) suffered dysaesthesia
persisting for greater than one week after surgery, but in each
instance resolving within four weeks. There have been no
infections and no patient has had a CSF leak. Four further
patients have required revision surgery (1 micro 3 TESS), three
of whom chose secondary endoscopy.
Discussion
Our data and other reviews of the medical literature reveal
that TESS has short to medium term follow up benefits in
comparison to microdiscectomy. This is borne out in good
clinical outcomes, high patient satisfaction rate and
improvements in quality of life. Patients have less surgical
scarring, shorter hospital stay and generally are able to return
to work sooner.
Early results from the Edinburgh RCT are very much in line
with those reported elsewhere. Improvements in ODI and
Physical Function are marked. A higher rate of revision
following TESS may be a reflection of the learning curve related
to the procedure. Reported rates of revision in the Dutch
series26 have been 5% lower in the second hundred patients
treated. In a commentary in the Spine Journal, Benzel and Orr38
noted that in reference to endoscopic interlaminar discectomy,
that the learning curve for the procedure was shallow (the
graphical representation showing that the rate of improvement in performing a task as a function of time) rather than
steep as suggested by Wang.28 This is clearly also the case in
TESS. The transforaminal approach does pass adjacent to the
t h e s u r g e o n x x x ( 2 0 1 2 ) 1 e7
exiting spinal nerve root and it would be expected that a nerve

root injury could occur. However, the rate of recorded
complications including dysaesthesias (5e10%), persistent
sensory deficits (1%) and dural tears (0.3%)39e41 are certainly no
greater than those after open surgery.3
In the last five years the quality of the equipment available
has dramatically improved, particularly in respect to the
arthroscopic instrumentation systems that are now coupled
to high definition TV monitors. The development of angled
instruments, arthroscopic osteotomes and reamers have all
facilitated surgical access. This improves the ability to teach
the technique and reduces the exposure of multiple patients
to surgeons learning these skills. Access through the transforaminal approach also allows widening of the foramen to
ensure that the exiting and traversing nerve roots are free.
Although evidence supporting decompression for stenosis in
isolation is currently sparse,35,42 quality endoscopic burrs and
shavers will undoubtedly increase the spectrum of conditions
routinely treated.
Conclusion
There are now a substantial number of reports supporting the
use of the transforaminal endoscopic discectomy. Although
still relatively scarce, RCT evidence including our own,
suggests that outcomes at least equate and are probably better
than those from microdiscectomy in selected patients. The
majority of patients are treated in day care facilities leading to
cost savings. Minimization of scarring makes secondary
surgery easier and is thought to lead to less long term low back
pain. We would recommend that surgeons start performing
the procedure under experienced guidance, after attending
cadaveric workshops.
In East Asia up to 30% of all spinal surgery is now performed by endoscopic techniques. We believe that it is only
a matter of time before there is a similar radical shift in the
United Kingdom and Ireland.
Funding
No financial support was received for this work.
Conflict of interest
JNAG and MI have received payments for teaching from Joimax, GmbH, Germany.
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SPINE Volume 31, Number 24, pp E890 E897

2006, Lippincott Williams & Wilkins, Inc.
Transforaminal Posterolateral Endoscopic Discectomy

With or Without the Combination of a Low-Dose
Chymopapain: A Prospective Randomized Study in 280
Consecutive Cases
Thomas Hoogland, MD, PhD, Michael Schubert, MD, Boris Miklitz, BSc, and Agnes Ramirez, ASS
Study Design. A prospective randomized study involving 280 consecutive cases of lumbar disc herniation managed either by an endoscopic discectomy alone or an
endoscopic discectomy combined with an intradiscal injection of a low dose (1000 U) of chymopapain.
Objective. To compare outcome, complications, and
reherniations of both techniques.
Summary of Background Data. Despite a low complication rate, posterolateral endoscopic nucleotomy has
made a lengthy evolution because of an assumed limited
indication. Chemonucleolysis, however, proven to be safe
and effective, has not continued to be accepted by the
majority in the spinal community as microdiscectomy is
considered to be more reliable.
Method. A total of 280 consecutive patients with a
primary herniated, including sequestrated, lumbar disc
with predominant leg pain, was randomized. A clinical
follow-up was performed at 3 months, and at 1 and 2
years after the index operation with an extensive questionnaire, including the visual analog scale for pain and
the MacNab criteria. The cohort integrity at 3 months was
100%, at 1 year 96%, and at 2 years 92%.
Results. At the 3-month evaluation, only minor complications were registered. At 1-year postoperatively,
group 1 (endoscopy alone) had a recurrence rate of 6.9%
compared to group 2 (the combination therapy), with a
recurrence rate of 1.6%, which was a statistically significant difference in favor of the combination therapy (P
0045). At the 2-year follow-up, group 1 reported that
85.4% had an excellent or good result, 6.9% a fair result,
and 7.7% were not satisfied. At the 2-year follow-up,
group 2 reported that 93.3% had an excellent or good
result, 2.5% a fair result, and 4.2% were not satisfied. This
outcome was statistically significant in favor of the group
including chymopapain. There were no infections or patients with any form of permanent iatrogenic nerve damage, and no patients had a major complication.
Conclusions. A high percentage of patient satisfaction
could be obtained with a posterior lateral endoscopic
discectomy for lumbar disc herniation, and a statistically
significant improvement of the results was obtained
From the Department of Spine Surgery, Alpha Klinik Munich, Munich,

Germany.
Acknowledgment date: January 12, 2006. First revision date: June 7,
2006. Acceptance date: July 10, 2006.
The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Thomas Hoogland,
MD, PhD, Department of Spine Surgery, Alpha Klinik Effnerstr. 38
81925 Munich, Germany; E-mail: hoogland@alphaklinik.de
E890
when an intradiscal injection of 1000 U of chymopapain

was added. There was a low recurrence rate with no
major complications. The method can be applied in any
type of lumbar disc herniation, including the L5S1 level.
Key words: endoscopic discectomy, chymopapain, Chymodiactin, chemonucleolysis, HNP, disc herniation, percutaneous nucleotomy. Spine 2006;31:E890 E897
It can be assumed that worldwide, dorsal mini-open and

microdiscectomy is the most widespread procedure for
the decompression of a radicular syndrome caused by
disc herniation. A breakthrough of less invasive decompressive procedures was made by the introduction of
chymopapain by Smith.1,2 After the Food and Drug Administration approval of chymopapain in 1982, the intradiscal injection of chymopapain received worldwide
popularity, but after several years, the enthusiasm regressed because of a few serious complications, like
transfers myelitis (most likely due to false intrathecal
injections) and anaphylactic reactions. In addition, transient postoperative back spasms in up to 35% of the
cases occurred, and a failure rate of about 20% occurred3,4 requiring subsequent surgery. This has faded
the enthusiasm cipher of the enzyme in favor of microdiscectomy. As more recently published,5 the application
of chymopapain should still be considered an effective
and safe treatment for the herniated discs. A number of
other transforaminal percutaneous treatments emerged6,7
as transforaminal decompression appeared to cause less
instability compared to posterior decompression.8 In
1975, Hijikata et al9 published their first experiences
with the closed percutaneous nucleotomy with a 2.6-mm
cannula, where as Kambin et al10 19 used a 4-mm
Craig20 cannula. Onik et al21 introduced a suction probe
having an outer diameter of 2.5 mm for removal of nuclear tissue. This procedure was extensively studied and
reported with limited results.2224 Choy25 introduced
percutaneous laser nucleolysis of the lumbar disc herniation, and many authors26,27 reported the results. Additional percutaneous techniques were developed.28,29
Comparative studies, however, did demonstrate that
chemonucleolysis appeared to be more effective than percutaneous nucleotomy or percutaneous laser decompression.30 Disappointment with the outcome of central nuclear evacuation evolved the technology that permitted
transforaminal access to the herniation site and the compressive elements, resulting in cannulas of a 6.5 and
Transforaminal Posterolateral Endoscopic Discectomy Hoogland et al E891
8.5-mm outer diameter.10 19 In addition, arthroscopes31

and endoscopes32,33 were introduced to visualize the intraforaminal nerve root, thereby avoiding postoperative
radiculitis. With the until recently available instruments,
the main disadvantages of the percutaneous transforaminal procedures have been: (1) its limited indication for
patients with a contained and small-sized subligamentous lumbar disc herniation34 36 and (2) a 10% reoperation rate.37 Access to the L5S1 level can be difficult,
particularly in males because of interference of the iliac
crest. In 1994, new instrumentation was introduced in
our institution,38 41 enabling the enlargement of the foramen with special reamers so that the anterior spinal
canal could be made accessible for endoscope and instruments also for the L5S1 level, and avoiding injury to
the exiting nerve root, a problem that has been reported
after the regular transforaminal approach. At that point,
all types of disc herniations became accessible with the
lateral percutaneous approach.42 A total of 137 patients
with a 1-year follow-up was reported with this technique
in 1998, with a 88.3% success rate.43 In September
1995, the indication was extended to all types of disc
herniations, and the present study was initiated to evaluate the effect of an additional injection of a low-dose
chymopapain. As in 1 study44 in open lumbar discectomy, the adjunct did reduce the recurrence rate. Both
the endoscopic discectomy and the treatment with chymopapain are established treatments in Germany for
herniated discs, and, besides specific informed consent
regarding the potential complications, including an anaphylactic reaction with chymopapain, no specific approval of the ethical committee was required.
Materials
From January 9, 1996, until January 7, 1998, 280 patients
were randomized in 2 groups. Inclusion criteria were: (1) primarily radicular pain; (2) magnetic resonance imaging (MRI)
or computed tomography proven disc herniation corresponding to the neurologic findings; (3) a clear nerve-root tension
sign with a straight leg raising sign of less than 45, or a positive
neurologic finding in terms of an absent knee or ankle reflex,
corresponding dermatomal numbness or weakness of quadriceps, foot-toe-dorsiflexors or triceps-weakness; and (4) in all
patients, conservative treatment had failed. Exclusion criteria
were: (1) obesity (patients that had an excess weight of 30 kg
over: body weight minus body length minus 100 cm 1 kg);
(2) previous disc surgery; (3) symptomatic herniations at more
than 1 level; (4) patients younger than 18 years; and (5) patients
older than 60 years. A total of 280 consecutive patients that
met the inclusion criteria were randomized into 2 groups according to their birthday. Patients with an even birthday (group
1: 142 patients) underwent the endoscopic discectomy alone,
and patients with an uneven birthday (group 2: 138 patients)
had the combination with 1000 U of intradiscal chymopapain.
Methods
All patients were treated as a day case or with one overnight
stay and the first outpatient follow-up on the next day. The
procedure was performed with local anesthesia, intravenous
sedation with opioid anesthesia, and 210 mL midazolam se-
dation. The procedure was performed with the patient lying on

his opposite site on a radiolucent table in the operating suite.
The back of the patient was disinfected, and a sterile screen
drape was applied. A biplane fluoroscopy was used for radiograph imaging. Then the entrance point was determined with a
metal rod that was projected with imaging guiding toward the
isthmus of the upper lamina of the involved level. Depending
on the size of the patient, gender, and level, the entrance point
was located at the L5S1 level at 1216 cm from the midline,
at the L4L5 level at 1114 cm from the midline, at the
L3L4 level 810 cm from the midline, and at L2L3 level
79 cm from the midline. Then the skin was infiltrated with
local anesthesia, and an 18-gauge needle was aimed at the isthmus of the upper lamina for the L4L5 and L5S1 levels, and
it was aimed at the facet joints of the affected levels in herniations at the L3L4 level or above. Once the isthmus was
reached, a second, longer 22 curved needle was introduced and
guided into the extruding or sequestrated fragment. Then the
first needle was advanced over the second needle up to disc
height. The second needle was then withdrawn and again introduced with the curve pointed laterally entering the disc
space. With the second needle, the disc space was usually entered into the center of the disc. Subsequently, up to 3 cc of
iohexol (240 mg/mL) contrast was injected, and pain reaction,
dye leakage, and resistance were recorded. In patients in group
2, it was determined whether a low-resistant massive dye leakage was present. In group 2, out of the 138 patients, 8 did
demonstrate a massive leakage of low dose, meaning that a
intradiscal injection of chymopapain was fruitless and possibly
dangerous, and these patients were excluded from the study
and only had an endoscopic decompression and fragment removal without chymopapain injection. If no massive lowpressure leakage was present, in group 2, all patients first received an intradiscal injection of 1000 U of chymopapain. At
that point, the second needle was withdrawn and replaced by a
guidewire. Over the guidewire, a stab incision of about 8 mm
was made, and stepwise guiding and dilatation rods were introduced. The first guiding rod was a straight rod that was
introduced up to the isthmus of the lamina. Subsequently dilating cannulas of 3.5, 5, and 6 mm were advanced up to the
facet joint, then the faced joint capsule was infiltrated with 5 cc
of lidocaine 2% with adrenaline. Following this, the rod and
cannulas were removed except for the guiding wire, and, under
imaging, a curved guiding rod of 2 mm then was advanced into
the extruding or sequestrated fragment. Subsequently, a
3.5-mm tube was pushed over the curved rod up to the facet
joint area (Figures 13).
At that point, the first cannula was docked at the facet capsule or bone. Over this rod, a 4.5-mm hand reamer was then
introduced over the cannula and the resisting capsule, and bone
was reamed away until resistance faded, meaning that the spinal canal was about to be entered. This was checked with an
anteroposterior image view. At this point, except the guiding
wire, all instruments were removed, and a second, thicker,
guiding rod was reintroduced over the guiding wire. At the level
of the isthmus, the guiding wire was then removed, and the
guiding rod was introduced deeper and advanced with the aid
of a mallet advancing the tip of the guiding rod into the direction of the herniated fragment. The position of the tip of the
guiding rod was inspected in 2 directions with the image intensifier, and it was ensured that the guiding rod came in the
vicinity of the extruding or protruding fragment. In case this
could not be achieved, the first step of the operation was re-
E892 Spine Volume 31 Number 24 2006
Figure 1. Endoscopic approach.

peated. After that, guiding rod No. 2 was again introduced and
advanced toward the aimed fragment of the disc herniation. At
that point, a corresponding 4.5-mm cannula was introduced
over the guiding rod. This again was blocked at the facet level,
and a larger 5.5-mm reamer was then used to, subsequently,
open and enlarge the foramen. After the second reaming, all
instruments were again removed except for the guiding wire,
and a third guiding rod 5.5 mm in diameter was introduced
again up until the isthmus. The guiding rod was then advanced
with a mallet under imaging in 2 directions toward the fragment to be removed. Subsequently, a 6.5-mm cannula and
7.5-mm reamer were introduced, yielding in a foraminal opening of 7.5 mm. In difficult cases with difficult access to the
fragment, particularly in the presence of foraminal stenosis, a
fourth step was performed with a reamer of an outer diameter
of 8.5 mm. As a rule, after the third reaming step, a working
cannula of 7.5 mm was then advanced. Image intensifying controlled all steps, and the working cannula with a 1-sided opening was directed exactly up to the area of the extruding or
sequestrated fragment. As a rule, it takes 10 15 minutes between the intradiscal chymopapain injection and the final
placement of the working cannula. In group 1, all steps were
Figure 2. Radiographic view.
Figure 3. Radiographic view.

identical, except for the enzyme injection. At this point, a special spine scope was introduced and the reached area inspected.
As a rule, an extruding or sequestrated disc fragment could be
observed. Occasionally, a small part of the affected nerve root
was visible. In cases where the nerve root was also visible, a
working forceps was introduced through the endoscope that
has a lumen of 2.8 mm, and under endoscopic view, the fragments underneath the nerve root were removed. The cannula
was then rotated so that the closed part of the cannula was
protecting the nerve root. Subsequently, the endoscope is removed, and the large forceps is introduced, grabbing the remaining disc fragments and sequester. When at the introduction of the endoscope, no nerve root could be seen, at that
point, the endoscope was removed, and a large grasping forceps was introduced, and the position of the instrument was
controlled and checked with the image intensifier in 2 directions. If the isthmus was exactly at the site of the extruding
fragment, according to the MRI or computed tomography
scan, then a firm bite was taken, usually resulting in the extraction of the most important compressing disc fragment. Once a
considerable disc fragment could be extracted, the endoscope
again was introduced, and the nerve root was inspected. Remaining fragments were then removed under endoscopic vision. When the localization of the instruments was uncertain,
the position of the instruments was checked with the image
intensifier in 2 directions. At all times at the end of the procedure, the freed nerve root could be identified, and it always
could be visualized that the nerve root was mobile with the
heart rate (not with the breathing rate) (Figures 4 and 5).
After the extruded or sequestrated fragment had been removed, the working cannula was then directed at disc level
with the opening away from the spinal canal, and with small
forceps, the hole in the disc was entered. All attainable loose
disc material in the posterolateral segment of the ruptured disc
was then removed. During this maneuver, usually the center of
the disc was not bothered. An intradiscal irrigation was performed with a mixture of saline and nebacetin. Steroids were
not used. Then the cannula was removed, and the skin was
Figure 4. Removal of disc material in endoscopic view.

closed with one stitch. Patients were then observed for 2 hours
in the recovery room and discharged with a flexible back brace.
A postoperative checkup was performed the next day, and at
that point, the patient did receive extensive instructions about
postoperative restrictions and rehabilitation according to a
standardized program.
Follow-up. The day after surgery, all patients received a follow-up booklet, including 3-month, 1-year, 2-year, and 5-year
questionnaires and preaddressed envelopes. Three months after surgery, all patients returned for a clinical follow-up, except
for 2 patients with an early recurrence and treatment elsewhere. At the 3-month follow-up, the patients returned a questionnaire to evaluate possible complications, including infection, wound healing, thrombosis, recurrent or persistent
radicular pain, numbness, or weakness. Also, a checkup MRI
was made to exclude re-prolapse or re-herniation. The clinical
evaluation included a straight leg raising test and check of the

strength of the quadriceps, foot and toe extensors, as well as
triceps strength in order to detect possible persistent or reherniation. The 1-year follow-up questionnaire first of all included a subjective rating about the result of the operation,
being excellent, good, fair (somewhat improved), or not satisfied. On a 10-point visual analog scale (VAS), the amount of
preoperative and postoperative back pain was plotted, the
same as for leg pain. Numbness was rated as: (1) vanished, (2)
improved, (3) unaltered, or (4) worse. Weakness was rated as:
(1) vanished, (2) improved, (3) unaltered, or (4) worse. An
identical questionnaire was completed 2 years postoperatively
with additional questions pertaining to the MacNab45 score.
Patients indicated the amount and frequency of pain medication, their work ability, and activities of daily life. Furthermore,
at 2 years, a sport activity evaluation was performed, including
intensity and type of sport before the symptomatic herniation,
the interval to sport resumption, intensity of sport activities at
2 years, and comparison to pre-herniation level. All patients
were asked to whether they would undergo the same procedure
again for the same problem. All patient data were implemented
into Microsoft Access (Microsoft, Corp., Redmond, WA) and
evaluated with SPSS software (version 8.0; SPSS, Inc., Chicago,
IL). Monthly, a computer check was performed as to whether
the patients had returned their 1 and 2-year questionnaires in a
timely manner. If not, a reminder was sent out. If no response
occurred in 4 weeks, the patient was called, and the questionnaire was completed by telephone. Since 1995, all German and
Dutch-speaking patients operated on at the spine department
of the Alpha Klinik are included in follow-up systems, as described above. The statistical evaluation of the results and of
the recurrence rates was performed with SPSS (version 8.0;
evaluating the 2 test).
Complications. At 3 months, all patients returned for the

clinical follow-up, and the perioperative and postoperative
complications were evaluated.
Group 1 (endoscopic discectomy alone). In group 1, there
were 2 patients with a superficial skin infection, both healed in
34 weeks with prolonged dressing care. One patient had a
2-month nerve root irritation that cleared with diclofenac and
codeine medication. There were 5 early recurrences after 3, 4,
6, 8, and 9 weeks. All 5 were reoperated on with microdiscectomy. One patient had a postoperative allergic reaction to
cephalosporin antibiotic, with a skin reaction that cleared with
antihistamines.
Figure 5. Endoscopic view of the freed nerve.
Group 2 (endoscopic discectomy enzyme). Two patients

reported significant postoperative nerve root pain without
nerve root tension signs and no evidence of recurrence. Both
patients were treated with tramadol and diclofenac for 4 and 5
weeks. The radicular pain subsided after 6 and 10 weeks, and
both patients were pain free at the 3-month follow-up. One
patient had a superficial wound infection that cleared with
prolonged dressing care in 3 weeks. There was 1 patient who
had an early recurrent herniation 3 weeks postoperatively,
which was successfully treated with microdiscectomy. One patient had a recurrence at 11 weeks and was successfully reoperated one with a second endoscopic discectomy.
Neither patients in group1 nor in group 2 had signs of deep
vein thrombosis, discitis, increased weakness of quadriceps,
foot/toe extensors, or triceps strength.
Results
Demographics
Table 1. Subjective Satisfaction of the Patients in Group

1 Two Years Postoperative
Group 1Endoscopy Group (n 142). Of the 280 patients

that entered the study, 142 were randomized into group1
(even birthday). Of these 142 patients, 130 (92%) returned their 1-year questionnaire, and 119 patients
(83.8%) returned their 2-year questionnaire. The average age of these patients was 41 years, and 35% were
female, and 65% were male. Of patients, 62% were operated on at level L5S1, 31% at level L4L5, 4% at
level L5L6, 2% at level L3L4, and 1% at level
L2L3.
Group 2Endoscopy in Combination With Chymopapain Group
(n 138). A total of 138 patients were randomized in
group 2 (uneven birthday). Of these 138 patients, 8 patients appeared to have massive dye leakage during diskography and were, therefore, excluded from the study.
Of the remaining 130 patients, all returned for the
3-month follow-up, and 125 (96.2%) returned the
1-year and 116 (89.2%) returned the 2-year questionnaires. In group 2, 32% were female and 68% were
male, with an average age of 40.3 years. Of patients in
this group, 60% were operated on at level L5S1, 36%
at level L4L5, and 4% at level L3L4.
A questionnaire was used to evaluate all patients at 1
year for the following criteria: (1) subjective patient satisfaction, classified as excellent, good, fair, or not satisfied; (2) leg pain level according to the 10-point VAS; (3)
back pain according to the 10-point VAS; and (4) subjective grading of sensibility disturbances.
On the 2-year follow-up questionnaire, the same criteria were inquired with additional questions regarding
MacNab criteria and sporting activities.
Subjective Satisfaction of the Patients
In group 1, 63.1% of the patients rated the operation
result as excellent after 1 year, 23.1% as good (top 2
86.2%), 6.1% as fair, and 7.7% as not satisfied. Questioned after 2 years, 59.2% of the patients in group1
rated the result of the operation as excellent, 26.2% as
good, 6.9% as fair, and 7.7% were not satisfied.
Questioned after 1 year, 68% of the patients in group
2 rated the operation result as excellent, 25.6% as good
(top 2 93.6%), 1.6% as fair, and 4.8% as not satisfied.
Questioned after 2 years, 70.6% of the patients in group
2 rated the result of the operation as excellent, 22.7% as
good, 2.5% as fair, and 4.2% as poor (Tables 1, 2).
Leg Pain (VAS)
The average 10-point VAS improvement of back pain 1
year postoperatively in group1 amounted to 6.3 points.
Three patients in group1 complained about a slight increase of 13 points. Two years postoperatively, patients
in group 1 noticed an improvement in leg pain, averaging
6.03 points according to the VAS (preoperative 8.05 and
postoperative 2.02 points).
One year after the operation, the average improvement of leg pain according to the 10-point VAS
amounted to 6.4 points in group 2. There were no patients that had a worsening of leg pain. Two years postoperatively, the average improvement of leg pain in
group 2 amounted to 6.37 points (preoperative 8.22
points, postoperative 1.85 points).
Back Pain (VAS)
The average improvement of back pain according to the
10-point VAS amounted to 5.7 points. Four patients in
group1 complained about a slight increase of 23
points. Two years postoperatively, patients in group1
noticed an improvement in back pain, averaging 5.6
points (preoperative 8.2 and postoperative 2.6 points).
In group 2, the average improvement of back pain
according to the 10-point VAS amounted to 5.7 points
1-year postoperatively. One patient complained about a
slight increase of back pain of 2 points, 1 patient complained about an increase of 4 points, and 1 of 7 points.
Two years postoperatively, group 2 reported an improvement in back pain, averaging 5.35 points (preoperative 8.19 points; postoperative 2.84 points) according
to the 10-point VAS.
Subjective Grading of Sensibility Disturbances
Of the 130 patients in group 1, 94 had complained about
a preoperative sensibility disturbance. One year after the
treatment, 68% quoted having no sensibility disorder,
28% felt that the disorder improved, 3% felt that the
sensibility disorder was unaltered, and 1% felt that it had
worsened.
Table 2. Subjective Satisfaction of the Patients in Group

2 Two Years Post Operative
A total of 112 patients in group 2 had complained

about a preoperative sensibility disturbance. Of these
patients, 70% were quoted as having no sensibility disorder 1 year after the percutaneous endoscopic discectomy, 21% felt that the disorder improved, 7% felt that
the sensibility disorder was unaltered, and 2% felt that it
was somewhat worse.
MacNab Score at 2 Years
Excellent: No pain, no restriction of activity.
Good: Occasional back or leg pain of sufficient severity to interfere with the patients ability to do normal work or capacity to enjoy him/herself in leisure
hours.
Fair: Improved functional capacity but handicapped by intermittent pain of sufficient severity to
curtail or modify work or leisure activities.
Poor: No improvement or insufficient improvement
to enable increase in activities; further operative intervention required.36
According to this classification, 50.8% of patients in

group 1 had an excellent result, 33.8% a good result,
14.4% had a fair result, and 0.9% (1 patient) had a poor
result. According to this classification 62.7% of group 2
had an excellent result, 27.2% a good result, 9.2% had a
fair result, and 0.9% (1 patient) had a poor result.
Sporting Activities
Of patients in group 1, 73 engaged in sporting activities
before their slipped disc. At the 2-year follow-up, 7 of
these patients no longer engaged in sporting activities
after the endoscopic discectomy.
Of patients in group 1, 85 engaged in sporting activities after surgery, of whom 18 (21.2%) had not engaged
in sporting activities before their slipped disc. This increase means that after the postoperative rehabilitation
endeavors, additional patients could be motivated for
sporting activities; 71.2% were able to perform at the
same or higher level, 20.2% at a lower level, and 8.3%
did quit sport activities. The activities began after an
average of 10.6 weeks.
A total of 69 patients in group 2 engaged in sporting
activities before their slipped disc. At the 2-year followup, 3 of these patients no longer engaged in sporting
activities after the endoscopic discectomy, and 84 patients were engaged in sporting activities (an increase of
18 patients 12.9%). A total of 71.2% of patients were
able to perform at the same or higher level, 24.5% at a
lower level, and 4.3% did quit their sporting activities.
The activities began after an average of 11.9 weeks.
Statistical Significance
A statistical evaluation with the Microsoft Access and
the SPSS 8.0 system was performed comparing the results of both groups pertaining to: (1) recurrence rate in
the first year, (2) recurrence rate in the second year, (3)
subjective satisfaction of the patient at 2 years, and (4)
MacNab criteria at 2 years.
Recurrence Rate in the First Year

In the first postoperative year, a clear re-herniation (recurrent significant leg pain and an MRI proven reherniation) occurred in 9 patients (6,9%) in group 1, 8 of
them requiring reoperation. Two patients (1.6%) in
group 2 developed a re-herniation, both of them requiring reoperation. Statistical evaluation (SPSS 8.0/2)
shows a significant (P 0.045) reduction of recurrences
in the group receiving additional enzyme.
Comparison Results of Endoscopy With Enzyme Versus
Endoscopy Alone (Table 3)
Recurrence Rate in the Second Year. In the second postoperative year, there were 2 recurrences (1.5%) in group
1 and 3 recurrences in group 2 (2.4%). The comparison
did not show statistical significance.
Subjective Satisfaction of the Patients at 2 Years

When comparing the subjective satisfaction of patients in
groups 1 and 2, a statistically significant result (P
0.025% according to 2) in favor of the enzyme group
could be reported. Of the patients in group 2, 93.3% had
a top 2 result, rating the outcome of their operation as
excellent or good. Only 85.4% of the patients in group 1
(no enzyme) had a top 2 result, a discrepancy of 7.9%.
MacNab Criteria at 2 Years
A comparison of the 2-year outcome of both groups according to MacNab did not show statistical significance.
Discussion
In 2002, Yeung and Tsou32 reported the outcome and
complications in 307 cases of posterolateral endoscopic
discectomies with a minimal follow-up of 1 year (average
follow-up was 19 months). They reported an 83.6% excellent or good result and a 9.3% rate of poor results.
Their reoperation rate was 5%, with an average follow-up of 19 months. These results are comparable to
the results in our group of endoscopic discectomy alone.
The additional intradiscal injection of 1000 U of chymopapain in the second group of our study yielded a significant improvement of patient satisfaction and decreased
recurrence rate. Although there were no complications
related to the use of 1000 U chymopapain, there is a
basic complication risk with the use of intradiscal chymopapain, primarily in the form of potential anaphylactic reaction. The standard dose of intradiscal chymopa-
Table 3. Comparison Results of Endoscopy With Enzyme

Versus Endoscopy Alone
pain as a single treatment for herniated disc is 4000 U.

Incidents of anaphylaxis with this dose have been documented to be 0.4%.5 In our institution, we have injected
a low dose (1000 U) of chymopapain in 3645 cases,46
and we have seen 2 cases of anaphylactic relations that
were appropriately treated, including intubation. Both
female patients could be extubated the next morning and
discharged in a stabile condition, with no sequela. We
believe that when a careful, slow intradiscal injection of
chymopapain is preceded by a 2-direction image intensifier documentation of central intradiscal needle placement, diskography with 2 cc of contrast dye to exclude
intravenous, or intravascular dye leakage or massive epidural dye leakage, will avoid the additional (rarely reported) complications of transverse myelitis and subdural
hemorrhage. The overall safety of the use of chymopapain,
when properly applied, has been documented in many studies.5,47 49 The majority in the spine surgeon community
does consider microdiscectomy to be the gold standard
operative treatment for lumbar disc herniation that is not
adequately responding to conservative treatment.50 52
The main objections against percutaneous procedures
include the inferior efficacy, higher recurrence rate, and
limited indication of percutaneous procedures.53 This
study as well as the previously reported series32 do, however, demonstrate that posterolateral endoscopic discectomy has an equal efficacy as microdiscectomy, and in
combination with chymopapain, it might even exceed
the results of microdiscectomy. In terms of efficacy, a
multicenter randomized study can only prove the superiority of one procedure over the other. From a practical
standpoint, however, such a comparative study does not
appear to be feasible, as proven by the effort trial by
Haines et al.54 The advantages of a transforaminal endoscopic discectomy over a microdiscectomy are, however, obvious: (1) no need for general anesthesia; (2)
less/no cases of iatrogenic neurologic damage; (3) significantly less infections; (4) a direct approach to the extruded disc fragment; (5) no sacrifice of ligamentum flavum or intracanal capsule structures, therefore less scar
formation; and (6) no disturbing scar tissue in case of
re-intervention. As a matter of fact, in case of recurrence
after a dorsal procedure, the posterolateral endoscopic
operation is preferred over a repeated dorsal approach.
Since the introduction of the arthroscopic microdiscectomy in 1992,10 19 many authors have reported the results
of the transforaminal endoscopic discectomy. There is extensive literature regarding the results of microdiscectomy
after its introduction.54 59 In terms of complications, there
is a large variety in the incidence of dural tears, infection,
reoperation rate, vascular injury, neural injury, and the
complication rate may well be surgeon dependent.60 Nevertheless, the complication rate of percutaneous procedures
is, in all aspects, significantly smaller than any type of discectomy through the dorsal approach. It is obvious that a
nonsuccessful minimal invasive percutaneous procedure
does not exclude or compromise a second dorsal, more
extensive procedure.
A study36 in 1993 reported the superiority of percutaneous, endoscopic discectomy over microsurgical discectomy
in a small group of patients and limited indication. An
equally good efficacy of open versus arthroscopic transforaminal discectomy was reported in 1999.61
The applied technique is an extended version of techniques described by Kambin et al,17 and Yeung and
Tsou,32 being a uniportal outside-in technique, whereas
Kambin et al, and Yeung Tsou use the inside-out uniportal or biportal technique. Modern instrumentation, as
developed by the senior author, allows a stepwise enlargement of the intervertebral lateral foramen, allowing
a working cannula to be introduced up to the spinal
canal and creating access to the anterior epidural space in
order to remove sequestrated fragments.
This study has demonstrated the efficacy of this procedure, and showed that the addition of a low-dose chymopapain yields a statistical improvement of outcome and a
statistically significant reduction of the early recurrence
rate.
Conclusions
Transforaminal endoscopic discectomy performed by an
experienced spine surgeon can be as effective as dorsal
microdiscectomy with less potential complications. Significant improvement of the outcome and recurrence rate
can be obtained with the addition of an intradiscal injection of a low-dose of chymopapain enzyme.
Key Points
A prospective randomized study involving 280
consecutive cases of lumbar disc herniation compared the outcome managed either by an endoscopic discectomy alone or an endoscopic discectomy combined with an intradiscal injection of a
low dose (1000 U) of chymopapain.
A high percentage of patient satisfaction could
be obtained with a posterior lateral endoscopic
discectomy for lumbar disc herniation, and a statistically significant improvement of the results was
obtained when an intradiscal injection of 1000 U of
chymopapain was added.
There was a low recurrence rate with no major
complications. The method can be applied in any
type of lumbar disc herniation, including the
L5S1 level.
This study has demonstrated the efficacy of this
procedure, and showed that the addition of a lowdose chymopapain yields a statistical improvement
of outcome and a statistically significant reduction
of the early recurrence rate.
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to the virgin herniated lumbar disc. Spine 1978;3:175 82.
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surgeons experience: Comparative studies. Spine J 2004;4:550 6.
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comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg 1999;81:958 65.
Satishchandra Gore
www.drgore.in
PUNE, India.
Large proportion of patients with acute severe sciatica have positive imaging or EMG tests.
Masui, T., Y. Yukawa, et al. (2005). "Natural history of patients with lumbar disc herniation
observed by magnetic resonance imaging for minimum 7 years." J Spinal Disord Tech 18(2): 121126.
Perceived pain and disability measures do not correlate with clinical findings or imaging results in acute
patients with severe pain.
severity of pain and functional disability are not explained by structural derangements or by disturbed
nerve function alone, as detected with the current techniques of investigation.
*
*
The basic function of axons is nerve conduction.
precipitating cause of neuropathic pain is generation of abnormal impulses in the somatosensory

system.
Axons that were initially only conductors of impulses become, due to hyper excitability, generators.
For the system to be reliable, conduction must be accomplished both without loss and without gain.
Loss is seen as sensory deficit.
Chen, C., J. M. Cavanaugh, et al. (2004). "Effects of nucleus pulposus on nerve root neural
activity, mechanosensitivity, axonal morphology, and sodium channel expression." Spine (Phila Pa
1976) 29(1): 17-25.
HOW TO DETECT THIS HYPEREXCITABILITY? IS BASIC QUESTION.
* Definition of degenerative disc disease is degenerate disc
that is also painful.(Adams and Roughley 2006)

* Adams, M. A. and P. J. Roughley (2006). "What is
intervertebral disc degeneration, and what causes it?" Spine
(Phila Pa 1976) 31(18): 2151-2161.
* Backache and sciatica is mainly caused by structural and
functional alteration in posterior annulus and nucleus and
response of nervous system to it.
* Outcome of sciatica and backache are decided by amount of
cytokines, size of nuclear fragment and degree and
resolution of inflammation.
* Takahashi, H., T. Suguro, et al. (1996). "Inflammatory
cytokines in the herniated disc of the lumbar spine." Spine
(Phila Pa 1976) 21(2): 218-224.
Donelson, R. (2004). "Evidence-based low back pain classification.

Improving care at its foundation." Eura Medicophys 40(1): 37-44.
Donelson, R. (2008). "Is your client's back pain "rapidly reversible"?
Improving low back care at its foundation." Prof Case Manag 13(2): 8796.
* All pain is always result of inflammation :universal

law of inflammation
* Cytokines involved in inflammation
* Staging of sciatica
* 3 nerve deficit,
* 2 mechanical compromise,
* 1 inflammation and mechano sensitization
* 80% have inflammation when actively experiencing

pain
* Mobility of nerve root and its assessment
* SLR
* Sitting cross legged [partial slr]
* Inflammation
* Mechano senistization
* Effect of sodium channel blockers
* Distal block
* Proximal block
* Desensitizing nerve
* Minimally invasive targeted intervention

* Surgery thru intervertebral foramen
* Under local anesthesia
* In awake and aware patient
* Answering fundamental question
* Mechanism based treatment of neuropathic
pain
* Hermantin, F. U., T. Peters, et al. (1999). "A
prospective, randomized study comparing the

results of open discectomy with those of videoassisted arthroscopic microdiscectomy." J Bone
Joint Surg Am 81(7): 958-965.
* Kambin, P., E. O'Brien, et al. (1998).
"Arthroscopic microdiscectomy and selective
fragmentectomy." Clin Orthop Relat Res(347):
150-167.
* Knight, M. T., A. Goswami, et al. (2001).
"Endoscopic foraminoplasty: a prospective
study on 250 consecutive patients with
independent evaluation." J Clin Laser Med Surg
19(2): 73-81.
630
PAPER
Diagnostic value of history and physical examination in

patients suspected of lumbosacral nerve root
compression
P C A J Vroomen, M C T F M de Krom, J T Wilmink, A D M Kester, J A Knottnerus
.............................................................................................................................
J Neurol Neurosurg Psychiatry 2002;72:630634
See end of article for

authors affiliations
.......................
Correspondence to:
Dr Patrick C A J Vroomen,
Department of Neurology,
Maastricht University
Hospital, P Debyelaan 25,
PO box 5800, 6202 AZ
Maastricht, Netherlands;
pvr@sneu.azm.nl
Received 10 April 2000
In revised form
7 August 2001
Accepted
22 January 2002
.......................
Objective: To evaluate patient characteristics, symptoms, and examination findings in the clinical
diagnosis of lumbosacral nerve root compression causing sciatica.
Methods: The study involved 274 patients with pain radiating into the leg. All had a standardised
clinical assessment and magnetic resonance (MR) imaging. The associations between patient characteristics, clinical findings, and lumbosacral nerve root compression on MR imaging were analysed.
Results: Nerve root compression was associated with three patient characteristics, three symptoms,
and four physical examination findings (paresis, absence of tendon reflexes, a positive straight leg
raising test, and increased finger-floor distance). Multivariate analysis, analysing the independent
diagnostic value of the tests, showed that nerve root compression was predicted by two patient characteristics, four symptoms, and two signs (increased finger-floor distance and paresis). The straight leg
raise test was not predictive. The area under the curve of the receiver-operating characteristic was 0.80
for the history items. It increased to 0.83 when the physical examination items were added.
Conclusions: Various clinical findings were found to be associated with nerve root compression on
MR imaging. While this set of findings agrees well with those commonly used in daily practice, the tests
tended to have lower sensitivity and specificity than previously reported. Stepwise multivariate analysis
showed that most of the diagnostic information revealed by physical examination findings had already
been revealed by the history items.
isc herniation often does not cause symptoms.1 On the

other hand, it may cause sciatica by compressing the
nerve roots. Diagnostic procedures such as magnetic
resonance (MR) imaging help to establish disc herniation as
the anatomical basis for sciatica. Several treatments, especially
discectomy, have been advocated for patients with sciatica, but
are indicated only if nerve root compression is considered to be
the cause.24 Therefore, an accurate initial clinical diagnosis of
nerve root compression is highly desirable.5 6
In one systematic review of the value of history and physical examination in radicular syndromes it was concluded that
none of the tests used had a high sensitivity or specificity.7
Unfortunately, various symptoms and some commonly
assessed clinical signs were not reviewed in that study. It was
concluded in two other reviews8 9 that the diagnostic value of
many signs and symptoms had not been thoroughly
investigated.
The most common methodological drawbacks in previous
studies have been the choice of a suboptimal gold standard,
selection bias, and univariate analysis.9 In many studies disc
herniation rather than nerve root compression was used as the
gold standard. However, disc herniation need not result in
nerve root compression and has been found to be asymptomatic in many subjects.1 10 Also, in several previous studies the
history and physical examination findings probably affected
the selection of the patients for the study.9 This so called
sequential ordering bias occurs when patients with positive
findings are more likely to be selected for study than patients
with negative findings.1114 Finally, previous analytical methods
have used univariate analysis; multivariate analysis, however,
allows one to assess the contribution of separate clinical findings to the overall diagnosis, taking into account the high
degree of correlation between clinical findings.
With these factors in mind, we undertook a cross sectional
study examining the value of history and physical examina-
www.jnnp.com
tion in the diagnosis of nerve root compression. We studied

patients presenting to a primary care physician with a new
episode of pain radiating into the leg, and we used MR imaging to establish the presence of nerve root compression.
METHODS
Study population
Fifty general practitioners in Maastricht and surrounding villages referred patients with a new episode of pain radiating
into the leg below the gluteal fold to the neurology
department of the Maastricht University Hospital. In this
study we only included patients with pain sufficiently severe
to justify further action (defined as pain that might justify bed
rest for 14 days, because part of the study population was
involved in a trial of bed rest15). Exclusion criteria were previous spinal surgery, pregnancy, severe comorbidity, or contraindication to MR imaging (metal containing prostheses,
pacemakers).
Investigations
Eligible patients gave their written informed consent for the
study within two days of the first general practitioner consultation. Clinical findings were then established in a standardised fashion based on good clinical practice, standard textbook
sections, and published reports. The methods and interobserver consistency of the history and physical examination
have been reported elsewhere.16
The gold standard in all patients was MR imaging of the
lumbar spine within 24 hours after the clinical examination.17
This was performed using a 0.5 T system according to the following scanning protocol: first, sagittal and transverse T1
weighted sequences (TR/TE 400600/20 ms) with 4 and 5 mm
slice thickness, respectively; and second, a sagittal dual echo
proton density and T2 weighted sequence (fast spin echo
History and examination in nerve root compression
631
Table 1 Baseline patient characteristics and their relation to nerve root compression
(n=274)
Characteristic
Age (years) (mean (SD), 46 (12) years)
1640
4150
5181
Male sex
Duration of disease (median 19 days)
14 days or less
1530 days
>30 days
Living alone
High education level
Job type
No job
Cognitive
Standing/walking/lifting
Physically demanding
Any comorbidity
Smoking
Sports activities
Exercised back/abd muscles
Family history sciatica
Quetelet index (mean (SD))
MRI+ (n=152)
MRI (n=122)
Odds ratio (95% CI)
43
50
59
67
48
44
30
72
1.3 (0.7 to 2.3)

2.2 (1.2 to 4.0)
1.8 (1.1 to 3.0)
70
41
41
29
45
55
19
48
19
25
1.7 (0.9 to 3.2)

0.7 (0.4 to 1.2)
1.3 (0.7 to 2.4)
1.6 (0.9 to 2.9)
66
42
28
16
64
65
67
60
51
25.5 (5.1)
43
26
36
17
44
63
51
54
38
25.6 (4.0)
1.1 (0.6 to 2.0)

0.5 (0.3 to 0.95)
0.6 (0.3 to 1.3)
1.3 (0.8 to 2.1)
0.7 (0.4 to 1.1)
1.1 (0.7 to 2.2)
0.8 (0.5 to 1.3)
1.1 (0.7 to 1.9)
p=0.79
Values in bold indicate significant effect.

Abd, abdominal; CI, confidence interval; MRI+/, magnetic resonance imaging positive or negative.
TR/TE 4500/25150 ms) with 5 mm slice thickness. We also

carried out MR radiculography, consisting of two heavily T2
weighted fast spin echo sequences (TR/TE 6000/450 ms) with
4 mm slice thickness, oriented parallel to the emerging L5
root, about 20 left and right oblique to the coronal plane,
reformatted with a maximum intensity projection protocol.18
A standardised assessment of all MR imaging studies was
done by a neuroradiologist (JW) experienced in spinal
magnetic resonance imaging. The assessment focused on the
presence or absence of nerve root (sleeve) compression. Criteria used for grading included the presence of a protruding
annulus or extruded nucleus material, or lateral recess
narrowing on standard MR imaging, and flattening and compression of the ventrolateral border of the dural sac or emerging nerve root sleeve, with obliteration of the surrounding
epidural fat. In the MR radiculography images, positive criteria included dural impressions, kinking, and swelling of the
intradural nerve root and cut off of the root sleeve filling.
Table 2
The clinical investigator was unaware of the MR findings,

while the neuroradiologist was unaware of the clinical
findings.
Statistical analysis
For the analysis the statistical package for the social sciences
(SPSS) was used. A bivariate analysis was based on 2 2
tables relating history and physical examination items to
nerve root compression on MR imaging. Sensitivity, specificity,
and likelihood ratios for positive and negative test results
(LR+ and LR) were calculated, as well as the diagnostic odds
ratio (DOR, with DOR = LR+/LR).19 20 The statistical significance of the association was assessed using Pearsons 2
statistic.
In a backward stepwise logistic regression analysis,21 22 the
likelihood ratio test was used for each step at a significance
level of 0.05. First, a set of general patient characteristics (all
variables in table 1) was modelled, leading to model A.
Diagnostic accuracy of the history (n=274)
Characteristic
MRI+ (n=152)
MRI (n=122)
Odds ratio (95% CI)
Pain worse in leg than in back

Typically dermatomal distribution
Pain worse on coughing/sneezing/
straining
Dermatomal cold sensations in leg
More pain on sitting
Less pain standing or walking
Less pain on lying down
Sudden onset
Paroxysmal pattern
Pain worse at night
With known cause
Subjective muscle weakness
Subjective sensory loss
Dermatomal paraesthesiae
Previous back pain episodes
Previous sciatica
History indicating root compression
according to investigator
125
136
56
84
5.5 (3.2 to 9.4)

3.8 (2.0 to 7.3)
76
47
82
31
91
60
67
47
38
41
60
78
113
55
40
24
69
26
69
51
47
42
37
46
51
72
85
52
2.1 (1.3 to 3.4)

1.8 (1.0 to 3.2)
0.9 (0.6 to 1.5)
0.9 (0.5 to 1.7)
1.1 (0.7 to 1.9)
0.9 (0.6 to 1.5)
1.3 (0.8 to 2.0)
0.9 (0.5 to 1.4)
0.8 (0.5 to 1.3)
0.6 (0.4 to 1.0)
0.9 (0.6 to 1.5)
0.7 (0.5 to 1.2)
1.3 (0.7 to 2.1)
0.8 (0.5 to 1.2)
118
64
3.1 (1.9 to 5.3)

CI, confidence interval; MRI+/, magnetic resonance imaging positive or negative.
www.jnnp.com
632
Vroomen, de Krom, Wilmink, et al
Table 3
Diagnostic accuracy of the physical examination (n=274)
Characteristic
MRI+ (n=152)
MRI (n=122)
Odds ratio (95% CI)
Paresis
Finger-floor distance >25 cm
Absence of ankle/knee tendon reflex
Positive SLR
Sensory loss
Hypesthesia
Hypalgesia
History and examination indicating root
compression according to investigator
41
68
22
97
8
32
8
53
5.2
2.4
2.4
2.3
43
26
42
19
0.8 (0.5 to 1.3)

1.2 (0.6 to 2.1)
123
59
4.5 (2.6 to 7.8)
(2.4
(1.4
(1.0
(1.4
to
to
to
to
11.7)
4.0)
5.6)
3.7)

CI, confidence interval; MRI+/, magnetic resonance imaging positive or negative; SLR, straight leg raise.
Second, a set of history items (all variables in table 2) was

modelled (model B), also including the variables in model A
that were significantly predictive. Third, all physical examination findings in table 3 and the significant predictors of model
B were modelled into the final reduced model C (presented in
table 4).
The neuroradiologist assessed 60 scans twice to allow
calculation of a value for intraobserver variability.21
The probability of nerve root compression on MR imaging
predicted by the various reduced models was calculated for
each patient. Subsequently, to evaluate the predictive power of
each model, receiver-operating characteristic (ROC) curves
were plotted, displaying the sensitivity v (1 specificity) for
each cut off point of predicted posterior probability.23 24 The
areas under the ROC curves were calculated. The probability
cut off with the maximum expected gain was determined as
the point with the highest sum of sensitivity and specificity.25
As a reference, the sensitivity and specificity of the observers
summary statement on the presence of nerve root compression are shown (at the bottom of tables 2 and 3) .
RESULTS
In all, 338 patients were referred for the diagnostic study. Sixty
four were excluded (35 because of insufficient pain and 29
because of previous spinal surgery or contraindications to MR
imaging). Thus the investigations were carried out in 274
patients. The intraobserver consistency of the MR imaging
diagnosis of nerve root compression was high ( value 0.83).
Table 1 shows the most important patient characteristics.
Root compression was found on 56% of the MR imaging studies. The pain radiating into the leg was clinically diagnosed as
sciatica in 67% of patients, while other diagnoses included
coxarthrosis, spondylolisthesis, regional neoplastic growth,
peripheral neuropathy, and pain of tendomyogenous or other
origin. The sample included sciatica patients both with and
without various degrees of neurological deficit. Two patients
suffered from urinary incontinence and saddle anaesthesia.
In the univariate analysis, there was an association between
nerve root compression on MR imaging and three patient
1.0
Ethics
The procedures of this study were in accordance with the
ethical standards of the revised Helsinki declaration of 1983
and were approved by the Maastricht University Hospital ethics committee.
Test
History
Age (years)
4150 v 1640
5181 v 1640
Duration of disease (days)
1530 v <15
>30 v <15
Paroxysmal pain
Pain worse in leg than in back
Typical dermatomal distribution
Pain worse on
coughing/sneezing/straining
Adjusted
diagnostic OR
0.6
0.4
0.2
95% CI
0.0
0.0
1.8
2.8
1.3 to 2.6
1.9 to 4.2
2.2
0.8
1.8
4.5
3.2
1.5
0.6
1.3
3.3
2.2
2.0
1.4 to 2.7
Physical examination
Finger-floor distance (cm)
524 v 04
>25 v 04
Missing v 04
Paresis
1.1
2.8
1.0
5.2
0.7
1.9
0.4
3.3
Intercept
3.511
CI, confidence interval; OR, odds ratio.
www.jnnp.com
Sensitivity
Table 4 Predictors of nerve root compression on

magnetic resonance imaging: results of multiple logistic
regression analysis (n=274)
0.8
to
to
to
to
to
to
to
to
to
3.3
1.1
2.5
6.2
4.7
1.6
4.3
2.1
11.6
0.2
0.4
0.6
0.8
1.0
1 Specificity
Figure 1 Upper curve: diagnostic value of history and physical

examination (variables in table 4; area under the curve = 0.83).
Lower curve: diagnostic value of history (area under the
curve = 0.80). Maximum diagnostic gain of model according to
Connell and Koepsell.25 n Sensitivity and 1 specificity for the
observers diagnosis after history. m Sensitivity and 1 specificity
for the observers diagnosis after history and physical examination.
A physician makes a diagnosis of nerve root compression when he
feels that the clinical findings indicate disease with a high enough
probability. The latter is the physicians intrinsic cut off probability of
disease. For example, the intrinsic cut off probability for the observer
is shown by the black triangle in the figure. The logistic models
allows an estimation of diagnostic properties for all possible probability cut off points. Plotting these properties results in the receiveroperating characteristic. The area under the curve represents the
overall diagnostic value of the model regardless of cut off probability. Maximum diagnostic gain might be estimated as the point in the
upper left hand corner or as the highest sum of sensitivity and
specificity as proposed by Connell and Koepsell.19 25
History and examination in nerve root compression
633
characteristics: age, sex, and having a job with a predominance of standing, walking, or lifting activities (table 1). MR
imaging was also associated with three symptoms: typical
dermatomal pain, coldness in the leg, and increased pain on
coughing, sneezing, or straining (table 2). Four physical
examination items were discriminative: paresis, a finger-floor
distance of more than 25 cm, absence of knee or ankle tendon
reflex, and a positive straight leg raise test (table 3).
However, in diagnosing nerve root compression clinical
findings are not considered separately but in combination.
This is reflected in multiple logistic regression models, which
allow calculation of the independent predictive value of
patient characteristics and clinical findings and predict the
probability of nerve root compression. Table 4 shows that two
general patient characteristics (age and duration of disease),
four symptoms from the history, and two signs from the
physical examination were independent predictors of nerve
root compression. The straight leg raise test was not a significant predictor, while an increased finger-floor distance and
paresis were significant predictors.
The area under the curve of the ROC for the model using
history findings alone was 0.80. This increased to 0.83 when
the examination findings were added (fig 1). Maximum
predictive gain of the model occurred at a predicted probability value of 0.625 with a sensitivity and specificity of 72% and
80%, respectively.
nerve root compression. It is possible that subjective weakness

and sensory loss have no neurological basis in most patients.
Table 3 shows that four physical examination items were
related to nerve root compression, and that even before the
physical examination, the a priori likelihood of disease is
altered by the history. Rather than considering only one or two
tests, one should use history and physical examination as two
batteries of tests, and interpret the items in each battery
simultaneously. The independent and simultaneous contributions of tests to the diagnostic work up of the sciatica patient
have not been studied previously. Table 4 and the ROC curve in
fig 1 indicate that, after the history has been taken, few signs
in the physical examination contribute to a more accurate
diagnosis. Typically, a dermatomal distribution of pain, an
increase in pain on coughing, sneezing, or straining, paroxysmal pain, and predominant leg pain are indicators of nerve
root compression. This is in agreement with clinical experience. The predictive value of paresis also accords with general
beliefs.8 A surprising predictor was an increased finger-floor
distance. The action of bending over to touch the floor with the
fingers not only stretches the nerve roots and the sciatic nerve
but also cancels the lordosis of the lumbosacral spine; the latter action may accentuate the mechanical effect of the disc
herniation on the nerve root. We were struck by the fact that
the straight leg raise test was not a predictor of root compression. This test may indicate nerve root tension or irritation, but
not necessarily nerve root compression.
DISCUSSION
Conclusions
The main component in the diagnosis of sciatica caused by
disc herniation is the history. Few physical signs add useful
additional information or result in alteration of a diagnosis
made on the basis of the history.
In our 274 primary care patients with leg pain, three patient
characteristics, three symptoms, and four signs were associated with nerve root compression on MR imaging. However,
the sensitivity and specificity values we found in this study
were lower than previously reported.7 Different study populations and designs may explain this.13
Positive clinical findings were not the reason for referral in
our study and therefore we have avoided the verification
bias25 26 and spectrum bias27 of previous studies. There are also
indirect clues that the participating patients were indeed an
unbiased primary care population. For example, both sexes
were equally represented, while previous secondary care
patient series have included nearly twice as many men as
women. Also, neurological deficits were far less common in
our patient sample than in previous series.9 To avoid including
asymptomatic or minor conditions, we accepted only those
patients who had severe pain radiating into the leg. We felt
that a clinical diagnosis of nerve root compression in patients
with no leg pain was probably rare and in any case should not
lead to discectomy.
MR imaging was used as the state of the art procedure to
demonstrate nerve root compression.17 2830 Sensitivity and
specificity values of MR imaging in the diagnosis of disc herniation range from 71% to 100% and from 50% to 86%,
respectively.17 31 32 Several investigators have reported disc herniation in asymptomatic subjects using MR imaging,1 33 computed tomography,34 and caudography.35 However, none of
these related the disc herniation to the presence of nerve root
compression. Some false negative diagnoses may be explained
by changes in the pathological anatomy of the nerve root with
posture and over time.36 The additional value of MR radiculography has yet to be unequivocally demonstrated.18
The only history item that could be compared with a previous report was the typical dermatomal pain distribution. This
had a 90% sensitivity in our study, compared with 99% sensitivity in a study by Kerr and colleagues.37 Strikingly, subjective
muscle weakness and sensory loss actually diminished the
likelihood of nerve root compression. These findings are at
variance with current opinion and with our previous beliefs.
The selection bias in previous studies may have affected our
understanding of the true relation of these complaints to
.....................
Authors affiliations
P C A J Vroomen, M C T F M de Krom, Department of Neurology,
Maastricht University Hospital, Maastricht, The Netherlands
J T Wilmink, Department of Diagnostic Radiology, Division of
Neuroradiology, Maastricht University Hospital
A D M Kester, Department of Methodology and Statistics, Maastricht
University
J Knotterus, Department of General Practice, Maastricht University
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Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y O r i g i n a l R e s e a r c h
Fritz et al.
MRI-Guided Spinal Injection
Vascular and Interventional Radiology
Original Research
Freehand Real-Time MRIGuided Lumbar Spinal Injection

Procedures at 1.5 T: Feasibility,
Accuracy, and Safety
Jan Fritz1,2
Christoph Thomas 2
Stephan Clasen2
Claus D. Claussen2
Jonathan S. Lewin1
Phillipe L. Pereira2
Fritz J, Thomas C, Clasen S, Claussen CD, Lewin
JS, Pereira PL
Keywords: epidural injection, facet joint injection,

interventional MRI, nerve root injection, spinal injection
DOI:10.2214/AJR.08.1569
Received July 21, 2008; accepted after revision
October 19, 2008.
1
Russell H. Morgan Department of Radiology and

Radiological Science, Johns Hopkins University School
of Medicine, 600 N Wolfe St., Baltimore, MD 21287.
Address correspondence to J. Fritz (jan.fritz@gmx.net).
2
Department of Diagnostic Radiology, Eberhard-KarlsUniversity Tbingen, Tbingen, Germany.
CME
This article is available for CME credit.
See www.arrs.org for more information.
WEB
This is a Web exclusive article.
AJR 2009; 192:W161W167
0361803X/09/1924W161
American Roentgen Ray Society
AJR:192, April 2009
OBJECTIVE. The purpose of this study was to test the hypothesis that freehand real-time
MRI-guided lumbar spinal injection procedures are feasible, accurate, and safe when performed with a clinical open-bore 1.5-T MRI system.
MATERIALS AND METHODS. A retrospective analysis was made of spinal injection
procedures performed over an 18-month period. Forty-nine procedures were performed on 37
patients (23 women, 14 men; mean age, 36 years; range, 1848 years). A rapid FLASH 2D
MRI sequence (TR/TE, 9.3/3.5; slice thickness, 5 mm; acquisition time, 1 second) was used
for real-time needle placement with freehand technique. Data assessed were type of procedure,
qualitative and quantitative image quality, dimensions of needle artifact, rate of successful
drug delivery, rate of vascular uptake, time requirements, and occurrence of complications.
RESULTS. Among the 49 procedures, 22 (45%) were nerve root injections, 18 (37%)
were facet joint injections, and nine (18%) were epidural injections. The quality of real-time
FLASH 2D MR images was sufficient in all cases. Contrast-to-noise ratios were sufficiently
high for good delineation of relevant structures. The needle artifact made was remarkably
constant with an average overestimation of length of 1.0 0.2 [SD] mm. Drug delivery was
successful in all selective nerve root injections and epidural injections. The rate of successful
drug delivery was 89% (16 of 18) for facet joint injections. No complete intravascular injections occurred. The mean table time was 36 minutes (range, 2375 minutes). The mean realtime MRI time was 38 seconds (range, 12185 seconds). No major complications occurred.
CONCLUSION. We accept the hypothesis that freehand real-time MRI-guided lumbar
spinal injection procedures are feasible, accurate, and safe when performed with a clinical
open-bore 1.5-T MRI system. We note that real-time MRI guidance has the additional advantage of a complete absence of patient and operator exposure to ionizing radiation.
umbar spinal injections are widely performed procedures with an

annual volume of 576,318 procedures in 1999 in the United States
alone [1]. These procedures may be part of
the diagnostic evaluation of lower back pain
and lower extremity pain or may be part of
pain therapy regimens [24]. The procedures most frequently performed are selective perineural injection, nonselective epidural injection, and facet joint injection [1].
Although injection procedures traditionally have been performed under conventional x-ray fluoroscopic guidance, CT and
real-time CT have been increasingly used
for needle guidance [510]. In particular,
real-time CT guidance has been found beneficial for improved targeting because it provides cross-sectional visualization of relevant anatomy, facilitates freehand real-time
needle guidance, takes less time than intermittent CT guidance, and has the potential
for increased effectiveness in facet joint injections [810]. However, like x-ray fluoroscopy, real-time CT guidance has the disadvantage of patient and operator exposure to
ionizing radiation [1113].
Interventional MRI is an emerging technique that has several advantages, including
the absence of ionizing radiation [1419].
Various spinal injection procedures have
been found feasible, accurate, and safe [2,
2022]. In the past, MRI-guided spinal injection procedures were performed with dedicated low-field-strength MRI systems, which
were of limited availability and had limited
capability for real-time MRI fluoroscopic
guidance [14, 20, 2327]. However, the use
of clinical open-bore 1.5-T MRI systems
with CT-like dimensions has the potential for
W161
Fritz et al.
reducing and overcoming these limitations
[28]. The purpose of this investigation was to
test the hypothesis that freehand real-time
MRI-guided lumbar spinal injection procedures are feasible, accurate, and safe when
performed with a clinical open-bore 1.5-T
MRI system.
Materials and Methods
Subjects and Procedures
Our institutional review board approved this
retrospective case series and waived the require
ment for informed consent. We selected a retro
spective cohort by searching our radiology inform
ation system from July 2006 to December 2007.
Search parameters included the specific descriptor
for the MRI system and the main procedure code
for spinal injection procedure at our institution.
The derived cohort consisted of 37 patients (23
women, 14 men; mean age, 36 years; range, 1848
years). Referral for MRI-guided spinal injection
was based solely on the referring physicians
discretion and patients preference. Patient selection
was not influenced by the interventional group,
except for screening for contraindications to MRI.
Procedures were categorized as selective nerve
root injection, defined as percutaneous trans
foraminal injection of drug into the circumneural
sheath of spinal nerves; facet joint injection,
defined as percutaneous drug delivery into the
lumbar facet joint space; and epidural injection,
defined as percutaneous translaminar injection of
drugs into the epidural space through a posterior
intervertebral approach [2, 3].
Technique
Procedures were performed with an open
1.5-T MRI system (Magnetom Espree, Siemens
Medical Solutions) with patients in the prone
position. All studies were performed without
premedication. Procedures were performed by an
operator with 5 years of experience in MRI-guided
intervention. For the diagnostic imaging phase
of the session, a body matrix coil with parallel
imaging technology was used. This coil was
exchanged for a flexible loop coil with a diameter
of 15 cm for the interventional phase. During the
MRI intervention, an in-room monitor allowed
review of images and real-time MRI guidance.
A commercially available MRI-compatible rigid
21-gauge, 10-cm needle (CH Ultra, Somatex)
made of grade 2 titanium (Unified Numbering
System R50400) was used in all patients.
Each procedure started with acquisition of axial
T1-weighted turbo spin-echo images (TR/TE,
400/17; slice thickness, 4 mm; field of view, 22
cm2; field-of-view phase, 100%; base resolution,
320; phase resolution, 75%) for planning of a
W162
suitable needle path for direct access to target

structures. Continuously acquired and displayed
single-slice T1/T2*-weighted FLASH 2D MRI
images (9.3/3.5; slice thickness, 5 mm; field of
view, 36 cm2; field-of-view phase, 75%; base reso
lution, 256; phase resolution, 56%; bandwidth, 180
Hz; acquisition time, 1 second) or T2-weighted fast
imaging with steady-state precession (FISP) images
(4.5/2.2; slice thickness, 5 mm; field of view, 25 cm;
field-of-view phase, 100%; base resolution, 128;
phase resolution, 100%; bandwidth, 560 Hz; ac
quisition time, 0.5 second) was used for MR fluoro
scopic determination of skin entry sites. The slice
was prescribed to the slice position of the T1weighted turbo spin-echo images chosen for plan
ning. A syringe (filled with saline solution or gado
linium-enhanced saline solution) was moved over
the skin during real-time MRI for determination of
skin entry sites. After antiseptic preparation of the
skin, draping, and induction of local anesthesia, the
T1/T2*-weighted FLASH 2D MRI sequence was
used to navigate the puncture needle to the target
structure, again with real-time MRI guidance.
The injectants consisted of various aliquots of
a local anesthetic or steroid depending on the type
and purpose of procedure. In all cases, aspiration
was performed before injection to exclude an
intravascular position of the needle. All mixtures
contained 0.5% gadolinium-based contrast mater
ial for visualization of fluid distribution on T1weighted images. Injections to nerve roots and
into facet joints were performed with the patient
moved out of the bore of the MRI unit. The correct
location of the injectant was confirmed on fatsaturated T1-weighted spin-echo images (480/17;
slice thickness, 4 mm; field of view, 22 cm 2;
field-of-view phase, 100%; base resolution, 320;
phase resolution, 70%) acquired after injection.
For nonselective epidural injections, injections
were performed with the patient inside the bore.
The procedure was monitored with continuously
acquired and displayed single-slice T1-weighted
FISP images (4.5/2.2; slice thickness, 5 mm;
field of view, 25 cm; field-of-view phase, 100%;
base resolution, 128; phase resolution, 100%;
bandwidth, 560 Hz; acquisition time, 0.5 second).
Assessment of Outcome Variables

The image quality of real-time MRI was
evaluated qualitatively and quantitatively. Two
experienced observers categorized image quality
qualitatively as sufficient or insufficient for accu
rate and safe needle guidance for the procedure.
Using a PACS workstation, the observers analyzed
images independently, randomly, and blinded to
patient data, clinical information, date, and time.
Assessment differences between the two observers
were resolved by subsequent consensus interpre
tation. Image quality was assessed quantitatively

by calculation of contrast-to-noise ratio (CNR)
including the needle artifact, anatomic structures
relevant for all procedures, and anatomic structures
relevant for the individual procedure. Signal
intensity values were obtained by use of the
measurement tool of the MRI workstation (Syngo
5, Siemens Medical Solutions). CNR was defined
as CNR = SNR1 SNR2, where SNR is signal-tonoise ratio. SNR was obtained with the following
formula: SNR = SROI/SDbackground, where SROI is the
mean signal intensity of the region of interest of the
respective tissue or the needle and SDbackground is
the SD of the background signal intensity.
Measurements on MR images were performed by
one observer. The arithmetic mean of three
measurements was used.
The dimensions and accuracy of the needle
artifact on the T1/T2*-weighted FLASH 2D im
ages were assessed with an 11 8 8 cm raw beef
model. Needle artifacts were evaluated for the
presence of sharply demarcated margins with a
method similar to that for assessment of image
quality of real-time MRI. Length and width of the
needle artifact were measured by one observer
using the distance measurement tool of the MRI
workstation. MR images were magnified by a
factor of 6. Measurements were performed three
times during three sessions separated in time. The
length of the needle artifact was recorded as a
relative value compared with the true depth. Arti
fact widths were measured at the center of each
third of the needle artifact. Comparison was made
with the true dimensions of the needle. Needle
width was 0.72 cm. Width of the needle artifact
was recorded as absolute values. Measurements
were obtained at 3- to 7-cm needle depth in 0.5cm increments at different angles (0, 10, 20,
30, 45, 60, and 90) relative to the patients
y-axis. Angle to z-axis and B0 were always 90.
The rate of successful drug delivery was
determined on the basis of the distribution of
the injectant, which was assessed qualitatively
on postintervention fat-saturated T1-weighted
spin-echo MR images. Successful drug delivery
was defined for selective nerve root injections as
accumulation of the injectant in the circumneural
sheath of the targeted spinal nerve, for facet joint
injections as accumulation of injectant in the joint
cavity, and for epidural injections as accumulation
of the injectant in the epidural space. For
epidural injections, T1-weighted FISP images
were assessed for partial vascular uptake during
injection, defined as temporary enhancement of
local vessels during injection. MR images were
assessed independently by two readers using a
method similar to that for assessment of image
quality of real-time MRI.
AJR:192, April 2009

TABLE 1: Contrast-to-Noise Ratios of Relevant Structures on FLASH 2D MR Images Used for Real-Time Guidance
Contrast-to-Noise Ratio (CNRSNR1 SNR2)
on FLASH 2D Sequence
SNR1
SNR 2
Contrast-to-Noise Ratio
p (SNR1 vs SNR 2)
Needle fat
10.3 8.2
117.1 85.5
106.7 77.9
< 0.05
Needle muscle
10.3 8.2
68.3 52.6
58.0 v45.1
< 0.05
Needle epidural space
10.3 8.2
63.0 43.8
52.7 35.6
< 0.05
Needle spinal nerve
10.3 8.2
36.6 25.5
26.3 18.1
< 0.05
Cortex fat
22.7 16.4
117.1 85.5
94.3 70.1
< 0.05
Cortex muscle
22.7 16.4
68.3 52.6
45.6 38.8
< 0.05
Fat ligamentum flavum
117.1 85.5
38.2 23.6
78.9 63.2
< 0.05
Epidural space ligamentum flavum
63.0 43.8
38.2 23.6
24.8 20.6
< 0.05
Epidural space spinal nerve
63.0 43.8
36.6 25.5
26.4 19.8
< 0.05
NoteSNR = signal-to-noise ratio.
Time requirements were calculated for each

procedure type and per patient. Table time was
defined as beginning of MRI to end of imaging.
Real-time MRI time was defined as the duration
of real-time MRI for determination of skin entry
points plus the duration of real-time MRI during
needle placement. Time points were derived from
the DICOM headers of the respective studies.
Major complications were defined, according
to American College of Radiology guidelines, as
complications resulting in admission to the hos
pital for therapy (for outpatient procedures), an
unplanned increase in the level of care, prolong
ed hospitalization, permanent adverse sequelae,

and death.
Statistical Evaluation
assess differences between SNR values. A value

of p < 0.05 or less was considered significant.
All statistical analysis was performed with SPSS
software (version 11.5, SPSS).
Descriptive statistics were applied for fre

quencies. Values were recorded as the median
with the minimum and maximum values in
parenthesis or the arithmetic mean with first SD
[29]. Intrarater variability was assessed by use
of coefficient of variation (CV) as CV = ,
where is the first SD and is the arithmetic
mean [30]. One-way between-groups analysis of
variance with Tukey post hoc testing was used to
Results
A total of 49 freehand real-time MRIguided spinal injection procedures were
identified. Of these 49 procedures, 22 (45%)
were selective nerve root injections (Fig. 1)
with one site treated in eight patients and two
sites treated in seven patients; 18 (37%) were
facet joint injections (Fig. 2) with one site
Fig. 128-year-old man with left-sided pain radiating to thigh treated with selective steroid injection of L4 nerve root.
A, Axial T1-weighted turbo spin-echo MR image shows planned needle path (long arrow) to left L4 nerve root (short arrow).
B, Axial real-time fast imaging with steady-state precession MR image shows determination of skin entry site with syringe (arrow).
CE, Real-time FLASH 2D MR images show placement of needle (arrow) to nerve root.
F, Axial fat-saturated T1-weighted turbo spin-echo MR image after injection of 3 mL of anesthetic steroid mixture shows injectant (white arrow) in circumneural sheath of
spinal nerves and in epidural space (black arrow). See also Figure S1G, cine loop, in supplemental data online at www.ajronline.org.
AJR:192, April 2009
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Fritz et al.
treated in eight patients and two sites treated
in five patients, and nine (18%) were nonselective epidural injections (Fig. 3). (Figures
S1S3 can be viewed from the information
box in the upper right corner of the article at
www.ajronline.org.)
Qualitatively, the image quality of the
FLASH 2D sequence used for real-time MRI
guidance was found sufficient in all cases.
There were no assessment differences between
observers. For quantitative analysis, the SNR
of the FLASH 2D images was calculated as
SNRfat = 117.1 85.5 (CV = 4.5%), SNRneedle =
10.3 8.2 (CV = 9.3%), SNRmuscle = 68.3
52.6 (CV = 4.2%), SNRcortex = 22.7 16.4
(CV = 6.9%), SNRligamentum flavum = 38.2 23.6
(CV = 9.4%), SNRepidural space = 63.0 43.8
(CV = 3.9%), SNRspinal nerve = 36.6 25.5
(CV = 8.6%). Statistical comparison of relevant SNRs showed statistically significant differences, and the resulting relevant CNRs were
sufficiently high for all structures for sufficient
differentiation of structures (Table 1).
In all cases, needle artifacts were sharply delineated. There were no assessment differences
between observers. Average overestimation of
length of the needle artifact was 1.0 0.2 mm
(range, 0.71.3 mm) (CV = 3.6%). The average
width of the needle artifact was 6.0 0.2 mm
(range, 5.76.4 mm) (CV = 2.7%).
Successful drug delivery was achieved in

96% (47 of 49) of targets. In 11% (two of 18)
of facet joint injections, the injectant accumulated periarticularly, whereas in 89% (16 of
18) of the facet joint injections, the injectant
accumulated intraarticularly. One assessment
difference required consensus reading. Selective nerve root and epidural injections had
a success rate of 100% in drug delivery. No
complete intravascular injections occurred.
In epidural injections, no partial vascular uptake occurred. There were no assessment differences between observers. Aspiration performed to exclude an intravascular position of
the needle did not return blood in any case.
The overall mean table time was 36 minutes (range, 2375 minutes). The mean table
time was 42 minutes (range, 2675 minutes)
for selective nerve root injections, 36 minutes (range, 2355 minutes) for facet joint injections, and 28 minutes (range, 2445 minutes) for nonselective epidural injections.
Mean real-time MRI time was 38 seconds
(range, 12185 seconds) for all procedures.
The mean real-time MRI time was 35 seconds (range, 15135 seconds) for selective
nerve root injections, 50 seconds (range, 20
185 seconds) for facet joint injections, and 38
seconds (range, 12124 seconds) for nonselective epidural injections.
There were no major complications. One patient reported temporary mild transient vasovagal reactions during selective nerve root injection and needed no treatment. Another patient
experienced facial flushing after nonselective
epidural injection that resolved after 1 hour of
observation and also needed no treatment.
Discussion
This study shows the feasibility of freehand real-time MRI-guided spinal injection
procedures on the lumbar spine with use of a
clinical wide-bore MRI system. The FLASH
2D real-time sequence provides good image
contrast and produces sharp and symmetric
needle artifacts for high accuracy of drug delivery and safe procedures.
Fluoroscopic image acquisition is generally
helpful in spinal injection procedures because it
improves needle navigation and shortens needle
time compared with needle placement navigated by intermittent imaging. Different concepts
exist for MR fluoroscopic image acquisition
[23, 3133]. In general, gradient-echo MR sequences are well suited to achieve fast image
acquisition because of the use of lower flip angles and the lack of 180 refocusing pulse, as is
used in spin-echo pulse sequences. The spoiled
gradient-echo pulse sequence (FLASH 2D) used
in this study was characterized by a temporal
Fig. 245-year-old man with facetogenic back pain treated with intraarticular steroid injection of right L4L5 facet joint.
A, Axial T1-weighted turbo spin-echo MR image shows planned needle path (long arrow) for puncture of facet joint (short arrow).
B, Axial real-time fast imaging with steady-state precession MR image shows guidance for determination of skin entry site with syringe (arrow).
CE, Real-time FLASH 2D MR images show placement of needle (arrow) and puncture of facet joint.
F, Axial fat-saturated T1-weighted turbo spin-echo MR image acquired after injection of 0.8 mL shows injectant (arrow) in joint cavity. See also Figure S2G, cine loop, in
supplemental data online.
W164
AJR:192, April 2009
Fig. 335-year-old man with nonspecific lower back pain treated with nonselective epidural steroid injection.
A, Axial T1-weighted turbo spin-echo MR image shows planned needle path (arrow) into epidural space.
B, Axial rapid T1/T2*-weighted FLASH 2D image for continuous real-time MRI guidance shows determination of skin entry points with syringe (arrow).
CE, Real-time FLASH 2D MR images show placement of needle (arrow) into epidural space.
FI, Axial T1-weighted real-time fast imaging with steady-state precession MR images for monitoring of injection show continuous distribution of injectant (arrow) in
epidural space. See also Figure S3J, cine loop, in supplemental data online.
resolution of 1 frame/s and produced reliable

and well-demarcated needle visualization and
sufficiently different SNR and high CNR for
good anatomic delineation of relevant structures. With such a real-time FLASH 2D sequence, interventional MRI at 1.5 T resulted in
a higher CNR (24.8106.7) than the CNR (6.3
18.1) of a FLASH 2D sequence at 0.2 T, which
was not feasible for real-time MRI owing to an
acquisition time of 32 seconds, or the CNR of a
FISP sequence at 0.2 T (0.629.9), which was
feasible for real-time MRI but resulted in a partially insufficient CNR of 0.6 [21].
Reliable visualization of the puncture needle
is important for accurate and safe procedures.
Real-time MRI guidance in this study was
characterized by a remarkably constant and reliable needle artifact regardless of needle depth
and angle to the patients y-axis. In contrast to
AJR:192, April 2009
real-time CT guidance, which produces accurate needle artifacts on the basis of density differences, the susceptibility artifact made by the
needle resulted in an average overestimation
of the true needle length of 1 mm on FLASH
2D images. Our results are in accordance with
previously published results [15]. Despite this
small overestimation, needle visualization was
found reliable for accurate and safe spinal injection procedures with an overall high success
rate and an absence of major complications.
Interventional MRI resulted in an overall
high rate of successful drug delivery. Drug
delivery was successful in all selective nerve
root injections and nonselective epidural injections, suggesting accuracy similar to that
achieved with real-time CT guidance [9, 10].
Interventional MRI achieved successful intraarticular facet joint injections in 89% of
joints, which is higher than the 75% for realtime MRI-guided facet joint injections during
0.2-T interventional MRI [21]. This difference
may be related to the improved spatial resolution of interventional MRI at 1.5 T compared
with 0.2 T. Comparison, however, is limited
by numeric differences in treated joints and
possible differences in patient population and
operator experience. Although we did not find
published data on the accuracy of real-time
CT-guided intraarticular facet joint injections,
a success rate of 90% appears comparable
with CT guidance in our experience. Because
of the presence of facet joint osteophytes of
varying degrees, some facet joints may be inaccessible for intraarticular injection regardless of the technique used.
Monitoring of the distribution of the injectant
is common practice to increase the validity of
W165
Fritz et al.
clinical response and to detect injection into
nontargeted structures, such as the subarachnoid
space in nonselective epidural injections [2, 3,
34]. The addition of gadolinium-based contrast
material in a ratio of 1:200 facilitated precise
localization of the injectant in all procedures.
This approach can be advantageous in the treatment of patients with hypersensitivity to iodine,
for whom iodine-based contrast agents such as
those used in CT and x-ray fluoroscopy are contraindicated. The safety of injection of gadolinium-based contrast material in a variety of spinal
injection procedures has been confirmed [35,
36]. Gadolinium also has been safely used in
combination with steroids [3739].
Detection of vascular uptake is important
to ensure drug delivery to the target structure
and for validation of clinical response [2].
Aspiration can be performed before injection
to detect intravascular needle location. This
technique, however, has been found less sensitive than continuous monitoring of injections with fluoroscopic imaging, which has
depicted partial vascular uptake and complete intravascular injections in 8.18.9% of
lumbar spinal injection procedures [4043].
In our study, results of all aspiration tests
were negative, and no complete vascular injections occurred. MR fluoroscopic monitoring of injections showed absence of partial
vascular uptake in epidural injections. Partial vascular uptake, however, may have gone
undetected in nerve root and facet injections
because injections were not monitored. Further studies are needed to assess the overall
rate of partial vascular uptake in MRI-guided spinal injections
In this study, the mean table time was 36
minutes (range, 2375 minutes), which may
be more than required for real-time CT-guided procedures. A considerable portion of the
time requirement in this initial study was related to the duration of the T1-weighted turbo spin-echo MR sequences used for anatomic evaluation and planning and detection
of the injectant. The average acquisition time
for each of these sequences was 58 minutes
depending on the use of fat-saturation technique and number of slices. Table time can
be reduced with use of a real-time MRI sequence for monitoring of the distribution of
the injectant, such as the FISP sequence in
nonselective epidural injections, which obviates postinjection T1-weighted turbo spinecho MR sequences, and by substitution of
T1-weighted turbo spin-echo MR sequences
with less time-consuming T1-weighted gradient-echo sequences.
W166
In this study, no major complications occurred. The two minor complications necessitated no treatment. Such sporadically occurring minor complications have also been
encountered in real-time CT-guided procedures [9] and probably are not related to the
specific imaging technique used for guidance.
MRI-guided spinal injection procedures
can be beneficial because they are not associated with exposure to ionizing radiation, as is CT [12]. Although radiation dose
with CT can be reduced with use of intermittent technique and low energy settings, the
vicinity of the reproductive organs in lumbar spinal injection procedures may warrant
use of a technique that does not involve ionizing radiation, such as interventional MRI.
MRI guidance can be of further advantage
because it avoids exposure to ionizing radiation for the operator compared with x-ray
fluoroscopy and real-time CT guidance [12].
Furthermore, interventional MRI appears
well suited to repeated and multilevel injections, which are not rare in the management
of chronic lower back pain.
Although the results are encouraging, this
study did have several limitations. The results
of this initial report may be limited by its retrospective character and the number of procedures evaluated. The average age of the study
population might have been younger than expected, possibly because the referring physicians preferentially refer younger patients, for
whom exposure to ionizing radiation is of increased concern, for MRI-guided procedures.
We also have noticed increasing patient awareness of the effects of ionizing radiation, especially among the younger population. There
is likely an association between patient age
and patient preference in that younger patients
more frequently choose MRI guidance. Comparison with data on real-time CT guidance is
based on previously published data and therefore also is limited. Controlled studies with a
larger number of patients in which both techniques are compared are desirable for confirmation of effectiveness and for further evaluation of accuracy and safety.
In the past, the use of interventional MRI
was limited by the availability of dedicated
interventional MRI systems. The introduction of clinical wide-bore MRI systems with
a distance of approximately 60 cm from the
outer edge of the bore to the isocenter of the
magnet, as used in this study, allows access
to the patient and needle guidance similar
to those of real-time CT guidance. It can be
speculated that with increasing acceptance
of this new design, the availability of interventional MRI will increase.

In conclusion, on the basis of the results of
this investigation, we accept the hypothesis
that freehand real-time MRI-guided lumbar
spinal injection procedures are feasible, accurate, and safe when performed with a clinical
open-bore 1.5-T MRI system. Furthermore,
real-time MRI guidance has the additional
advantage of a complete absence of patient
and operator exposure to ionizing radiation.
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F O R YO U R I N F O R M AT I O N
The data supplement accompanying this Web exclusive article can be viewed
from the information box in the upper right corner of the article at: www.
ajronline.org.
This article is available for CME credit. See www.arrs.org for more information.
AJR:192, April 2009
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J Neurosurg (Spine 3) 99:320323, 2003

Posterolateral percutaneous endoscopic lumbar foraminotomy

KEY WORDS endoscopy foraminotomy foraminal stenosis disc protrusion

stenosis, which can anatomically be divided

Percutaneous endoscopic lumbar foraminotomy

were definite segmental angular instability, spondylytic

The patient was placed prone, with the back mildly

tous material were removed using endoscopic forceps, as

* The patient underwent simultaneous L45 and L5S1 surgery.

walking, mild neurological deficits, and the absence of the

laser was more effective and time-saving than the use of a

Percutaneous endoscopic lumbar foraminotomy

1. Bose K, Balasubramaniam P: Nerve root canals of the lumbar

J. Neurosurg: Spine / Volume 99 / October, 2003

Manuscript received February 29, 2003.

Eur Spine J (2010) 19:181204

Transforaminal endoscopic surgery for symptomatic lumbar disc

and outcome measures and the methodological quality of

minimally invasive surgery has gained a growing interest.

Eur Spine J (2010) 19:181204

The indications for transforaminal endoscopic treatment

What is the effectiveness of transforaminal endoscopic

What is the effectiveness of the older intradiscal

Fig. 1 Different posterolateral approaches to the lumbar disc. a The

What is the effectiveness of transforaminal endoscopic

Eur Spine J (2010) 19:181204

patient series). To be included, studies had to report on

Surgical procedures, minimally

Spinal cord compression

Eur Spine J (2010) 19:181204

Table 2 Criteria list for quality assessment of controlled studies

Was the method of randomization adequate?

Was the treatment allocation concealed?

Was the patient blinded to the intervention?

Was the care provider blinded to the intervention

Was the outcome assessor blinded to the intervention?

Were co-interventions avoided or similar?

Was the compliance acceptable in all groups?

Was the drop out rate described and acceptable?

Was the timing of the outcome assessment in all groups similar?

Did the analysis include an intention to treat analysis?

Patient selection/inclusion adequately described?

Drop out rate described?

Was the timing of the outcome assessment similar?

Eur Spine J (2010) 19:181204

were described in more than one article. In these cases, all

What is the effectiveness of transforaminal endoscopic

No randomized controlled trials were identified. Outcomes

What is the effectiveness of the older intradiscal

No randomized controlled trials were identified. In Table 9

What is the effectiveness of transforaminal endoscopic

Hoogland et al. [16], not

Hermantin et al. [11],

Previous surgery (same

Previous surgery (same

Main inclusion criteria,

Table 4 Prospective controlled studies

Level: single level,

Type: all LDH

Level: single level,

Type: intracanal LDH

Index: transforaminal endoscopic

Pure intradiscal technique Kambin

Index: arthroscopic microdiscectomy