Endoscopic Translaminar Approach for Resection of Migrated Lumbar Disc Herniation

Lumbar disc herniation (LDH) is a common degenerative disease, and up to 10% of LDH migrates into the so-called "hidden zone." The traditional interlaminar approach carries the risk of subsequent instability due to osseous destruction by reaching the hidden zone and exposing the nerve root. In the 1990s, the first reports were published on the open microsurgical "translaminar approach" (TLA) for the resection of migrated LDH with the intention to minimize osseous destruction. However, the open technique still had the disadvantage of soft-tissue and muscle dissection. Endoscopic tubular procedures were developed to reduce approach-related muscle trauma. Endoscopic tubular surgery combines the bimanual microsurgical technique with continuous endoscopic visualization of the surgical field. The high-definition endoscopic visualization allows for excellent illumination and identification of tissue and anatomical structures. The rate of clinical success for the treatment of migrated LDH via endoscopic TLA has been reported to be up to 95%. However, endoscopic TLA has not been analyzed extensively, and reports with a detailed description are rare. The purpose of the present video is to demonstrate endoscopic tubular TLA and resection of a migrated LDH. This is the case of a 62-year-old man with right-sided leg pain and quadriceps paresis due to LDH that migrated behind the L3 vertebral body. Special focus is given to the planning of the skin incision and the trajectory toward the disc herniation. Furthermore, the dissection and extraction of large disc herniation are explained in detail.