Interlaminar Versus Transforaminal Full-Endoscopic Lumbar Discectomy for L4-L5 Disc Herniation: Operative Time,...

Area of Science:

• Neurosurgery
• Minimally Invasive Spine Surgery
• Orthopedic Surgery

Background:

• L4-L5 disc herniation frequently causes radiculopathy, with ongoing debate regarding the optimal full-endoscopic surgical approach.
• Interlaminar endoscopic lumbar discectomy (IELD) and transforaminal endoscopic lumbar discectomy (TELD) present distinct advantages and disadvantages influenced by spinal anatomy.

Purpose of the Study:

• To compare the operative efficiency, radiation exposure, complication rates, and clinical outcomes of IELD and TELD specifically at the L4-L5 spinal level.
• To evaluate the learning curve and temporal trends associated with the adoption of these full-endoscopic techniques.

Main Methods:

• Retrospective analysis of 131 consecutive L4-L5 full-endoscopic discectomies (42 IELD, 89 TELD) performed between 2021 and 2023.
• Data collected included operative time, fluoroscopic dose-area product, anesthesia type, complications, and patient-reported outcomes (Visual Analog Scale [VAS] and Oswestry Disability Index [ODI]) at baseline, 3, and 12 months.

Main Results:

• A significant shift towards TELD was observed, comprising 90% of cases by 2023, with 94% performed under conscious analgesia.
• Operative times improved for both techniques, plateauing at 47 minutes for IELD and 42 minutes for TELD.
• Radiation exposure decreased for both approaches, but TELD consistently showed higher exposure than IELD, especially during the early adoption phase. All complications occurred early in the study period, with no recurrences after 2022.
• Both IELD and TELD resulted in significant and comparable improvements in VAS and ODI scores at 12 months.

Conclusions:

• Both IELD and TELD provide significant and sustained improvements in pain and function for L4-L5 disc herniation, with no discernible differences in long-term clinical outcomes.
• TELD exhibits a steeper learning curve and faster operative times post-proficiency, with increasing use of conscious analgesia.
• While fluoroscopy dose decreased over time for both, TELD's higher radiation requirement warrants consideration. Surgical approach selection should be guided by patient anatomy, surgeon expertise, and perioperative goals.