Percutaneous Endoscopic Lumbar Discectomy (PELD)

PELD is performed with the patient in the prone or lateral position on a radiolucent frame. A C-arm is positioned to ensure reproducible AP and lateral imaging. A marker is placed on the skin to determine the desired surgical level in the AP projection. The procedure is performed under local anaesthesia, typically a 1% Xylocaine solution in the skin and subcutaneous tissue. Care must be taken not to anesthetize the periannular space and, particularly, the nerve root thus potentially predispose it to intraoperative injury. To avoid entry into the spinal canal, PELD is performed through a posterolateral approach, typically 9 to 11 cm from the midline on the patient?? symptomatic side, with an angle of 35° to 45°. Initially, a needle is introduced and its tip should approach the annulus just in the so-called ??riangular working zone??formed anteriorly by the descending spinal nerve, inferiorly by the proximal plate of the inferior vertebrae and posteriorly by the proximal articular process of the lower lumbar segment. The needle?? position is controlled either by the AP and/or lateral projections. Once the needle has been properly placed, the stylet is withdrawn and a guide-wire inserted. The spinal needle is then withdrawn, leaving only the guide-wire in place. A cannulated obturator is passed over the guide-wire and advanced towards the disc. The guide-wire is removed and a universal access cannula is passed over the cannulated obturator and advanced until it reaches the annulus. The obturator is then removed, leaving the cannula in place. Compression of the cannula against the annulus typically reproduces the patient?? radicular pain. The endoscope is now introduced to inspect the annulus?? surface and to unequivocally confirm the absence of neural tissue. Once this is confirmed, fenestration of the annulus is started, but, in order to prevent pain, additional anaesthesia is required. Fenestration of the annulus is then performed using first a 3 mm and subsequently a 5 mm trephine. At this point the annular pathway is defined and, with a laser and micro-forceps, fragments of the herniated disc can be removed under direct visualization of the endoscope. A single suture is used to close the skin and a small dressing applied. Postoperative antibiotics are administered. The patient is discharged on the same day of the procedure.