Full-endoscopic lumbar foraminoplasty and discectomy to manage a recurrent disc in a patient with previous percutaneous lumbo-sacral stabilization - A case report and literature review

Endoscopic spine surgery is the ultimate frontier of the minimally invasive approaches. While considerable experience exists in the 1st World, in South Africa the service remains limited to a handful of centers. The minimal tissue disturbance, negligible intra-operative blood loss, yet effective management of herniated disc material with 3-D high definition visualization confirming complete nerve root decompression, makes it a valuable adjunct to the minimally invasive spinal surgeon managing degenerative lumbar spine disease. The small surgical corridors associated with endoscopic spine surgery make the posterior interlaminar approach, and the transforaminal approach, both viable options by which to effectively access the spinal canal. Regarding the full endoscopic transforaminal approach to address recurrent disc in patients with previous spinal fusion, several papers have been published reporting successful outcomes. The technique is commonly combined with a preceding foraminoplasty, where-after the widened foramen makes the transforaminal discectomy easier to perform. Discs is all locations namely, central, paracentral, lateral, and even contra-lateral can all be addressed through this technique, as long as they remain in the nerve axilla. With regards disc herniations rostral to the nerve axilla, or migrated discs, more specialized endoscopic techniques are needed. We report a young male patient who presented to our unit with a recurrent left-sided L5/S1, combined posterolateral and foraminal, disc herniation 2-years post undergoing L4/L5 and L5/S1 lumbar tubular microdiscectomies and percutaneous L4-S1 pedicle screw and rod stabilization. Utilizing a full-endoscopic transforaminal approach we were able to successfully address the disc herniation and report a successful outcome. We recommend the full-endoscopic transforaminal approach as an effective and safe means by which to manage recurrent disc in patients with instrumentation in situ. Our recommendation is in line with reports from the larger 1st World Endoscopic spine centers.