In recent years, full-endoscopic discectomy (FED) has expanded its range of indications with the development of devices and various techniques. The advantage of FED over conventional surgery is that it is a minimally invasive procedure. However, intraoperative and postoperative precautions must be taken to prevent complications. It is necessary to avoid complications that could compromise the outcome of the procedure. Effective perioperative management is necessary to avoid complications; however, there is no set view for perioperative management in FED. In this study, we perform a literature review to examine the effectiveness of perioperative management methods for FED. The key to ensuring the efficacy and minimal invasiveness of FED is prevention of complications. Based on the result and literature review, we believe that the most manageable postoperative management after FED is prevention of recurrent disc herniation and hematoma formation. A drain should be placed to prevent postoperative hematoma formation. It is advisable to evaluate the patient’s symptoms and monitor C-reactive protein and erythrocyte sedimentation rate levels during the first week after surgery. Postoperative antibiotics were administered for 1 day.
In recent years, full-endoscopic discectomy (FED) has expanded its range of indications with the development of devices and various techniques. The advantage of FED over conventional surgery is that it is a minimally invasive procedure. However, intraoperative and postoperative precautions must be taken to prevent complications. The minimally invasiveness of FED is one of its advantages; therefore, it is necessary to avoid complications that could compromise the outcome of the procedure. Effective perioperative management is necessary to avoid complications; however, there is no set view for perioperative management in FED, which is left to the discretion of each institution and surgeon.
In this study, we perform a literature review to examine the effectiveness of perioperative management methods for FED.
The key to ensuring the efficacy and minimal invasiveness of FED is prevention of complications. Perioperative management and special care should be taken during surgery to prevent complications. There is a paucity of literature describing the perioperative management of FED in detail.
The major complications of FED are (1) postoperative hematoma, (2) dural tear, (3) infection, (4) nerve root injury, (5) recurrent disc herniation, and (6) intracranial hypertension.
FED is characterized by a limited surgical field because it does not invade the muscles or soft tissues, and bone removal is limited to a small area. This is the reason why FED is a minimally invasive treatment. However, because of this limited space, even a small amount of hematoma can easily compress and damage the nerves [
There are 2 types of postoperative hematoma: epidural hematoma and retroperitoneal hematoma. Ahn et al. [
Great care should be exercised to avoid hemorrhagic complications in patients with medical problems, and an adequate technique for the transforaminal approach should be used.
Intraoperative dural tears have been reported to occur at a frequency of 0.6%–6.9% [
If a dural injury can be recognized intraoperatively, it can be repaired on the spot; however, it may not be recognized intraoperatively and may be recognized several days after surgery as intractable radicular pain.
This may be due to the fact that a minor intraoperative dural tear may expand over time, causing root herniation and delayed appearance of symptoms. If symptoms improve immediately after surgery but worsen a few days later and magnetic resonance imaging (MRI) shows no evidence of recurrent disc herniation, a dural tear should be considered. Therefore, changes in symptoms should be monitored several days after surgery [
The gold standard method for repairing a dural tear is to perform open conversion followed by direct repair [
Park et al. [
When neurological deficits due to dural tears occur, they may be permanent if not treated at the appropriate time. If neurological deficit develops after surgery, it should be evaluated and managed appropriately.
In FED, the skin incision is small, a sterile environment is easily maintained, and potential sources of infection are eliminated, thus reducing the possibility of infection. Postoperative infection is rare [
Ahn and Lee [
The frequency of worsening neurological symptoms (motor deficit, dysesthesia, and paresthesia) after FED has been reported to be 0.7%–3.1% [
Choi et al. [
If the exiting nerve root is close to the superior articular process, consider adding a foraminoplasty to prevent exiting nerve root injury due to sheath manipulation. Similarly, in the interlamina approach, it is necessary to consider methods to prevent root injury when the width of the interlamina is narrow.
If the herniated disc is located further away from the interlamina window, the cranial laminotomy for a shoulder type and upward migration or caudal laminotomy for downward migration. By performing bone removal until the lateral aspect of the traversing nerve can be seen, pressure on the root can be minimized. Recently, a newly designed endoscope for lumbar spinal stenosis has been reported, which has a 5.7-mm working channel and is effective for bone removal, especially when the interlamina space is less than 8 mm [
Xie et al. [
The frequency of disc herniation recurrence after FED has been reported to be approximately 3.6% [
Unlike microdiscectomy, FED does not require laminectomy. Therefore, the posterior elements were retained postoperatively. This is believed to prevent postoperative pressure buffering of the disc [
Risk factors for postoperative disc herniation recurrence in FED include old age (> 50 years), obesity (body mass index > 25 kg/m2), upper disc (L1/2, L2/3, and L3/4) [
Hao et al. [
Miller et al. [
Based on the association between annular defect size and symptom recurrence, Chen et al. [
The annular sealing method is used to prevent recurrence by coagulating and shrinking the area around annular fissure with a bipolar coagulator and sealing the annular defect [
Wang et al. [
Patients with a risk factor for recurrent disc herniation or those who have undergone a Modic change require careful postoperative management.
Based on the above, we believe that the most manageable postoperative management after FED is prevention of recurrent disc herniation and hematoma formation. A drain should be placed to prevent postoperative hematoma formation. It is advisable to evaluate the patient’s symptoms and monitor CRP and ESR levels during the first week after surgery. Postoperative antibiotics were administered for 1 day. Postoperative FED patients are allowed bed rest for 24 hours after surgery and then allowed to leave the bed with a lumbar brace. The lumbar brace was kept in place for 1 month after surgery (
The authors have nothing to disclose.
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Writing - original draft: TH; Writing - review & editing: TH, YO.
Summary of perioperative management in full-endoscopic discectomy
Preoperative | Intraoperative | Postoperative |
---|---|---|
Evaluation of preoperative imaging | 1–2 Days of drain placement | • Bed rest for 24 hours |
Determine the extent of bone removal to prevent nerve root injury. | Dural tear occurrence | • Lumbar brace for 1 month |
• Dural repair using endoscopy | • Weight control | |
• Convert open surgery and direct repair | • Avoidance of heavy work and activity | |
Consider MRI imaging and CRP and ESR monitors when postoperative symptoms worsen. |
MRI, magnetic resonance imaging; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate.