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Yoshihiko Ioroi1, Toshinari Kawasaki1, Jun Hashimoto1, Tamaki Kobayashi1, Hisashi Koga2, Motohiro Takayama1
  1. Department of Spinal Neurosurgery, Kyoto Katsura Hospital, Kyoto, Japan
  2. Department of Neurosurgery, Iwai Full-Endoscopic Spine Surgery (FESS) Clinic, Tokyo, Japan

Correspondence Address:
Yoshihiko Ioroi, Department of Spinal Neurosurgery, Kyoto Katsura Hospital, Kyoto, Japan.

DOI:10.25259/SNI_508_2024

Copyright: © 2024 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Yoshihiko Ioroi1, Toshinari Kawasaki1, Jun Hashimoto1, Tamaki Kobayashi1, Hisashi Koga2, Motohiro Takayama1. Full-endoscopic discectomy utilizing an interlaminar approach for gas-containing herniation at L5–S1. 26-Jul-2024;15:265

How to cite this URL: Yoshihiko Ioroi1, Toshinari Kawasaki1, Jun Hashimoto1, Tamaki Kobayashi1, Hisashi Koga2, Motohiro Takayama1. Full-endoscopic discectomy utilizing an interlaminar approach for gas-containing herniation at L5–S1. 26-Jul-2024;15:265. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=13005

Date of Submission
25-Jun-2024

Date of Acceptance
11-Jul-2024

Date of Web Publication
26-Jul-2024

Abstract

Background: Intradiscal gas is frequently observed in older patients with disc degeneration and can occasionally result in nerve root compression.

Case Description: A 79-year-old male patient presented with increasing left lower extremity sciatica. Lumbar computed tomography (CT) and magnetic resonance (MR) images revealed a left paramedian L5–S1 gas-containing disc herniation. Utilizing an interlaminar approach, a full-endoscopic discectomy (FED) was performed at L5–S1. During disc removal, we countered intradiscal gas bubbles. Postoperatively, the patient’s symptoms/signs fully resolved, and follow-up MR and CT images revealed total resection of the disc herniation, and no further gas.

Conclusion: Through an interlaminar FED, we effectively removed an L5–S1 MR/CT-documented gas-containing disc herniation.

Keywords: Discectomy, Full-endoscopic spine surgery, Gas-containing disc herniation, Interlaminar approach

INTRODUCTION

An intervertebral gas-containing disc herniation (i.e., vacuum phenomenon [VP]) is a relatively common radiographic finding observed in older individuals with disc degeneration, and the gas may further contribute to nerve root compression. Here, we performed an interlaminar full-endoscopic discectomy (FED) to resect a magnetic resonance (MR)/computed tomography (CT)-documented gas-containing L5–S1 disc herniation.

CASE DESCRIPTION

A 79-year-old male patient presented with left lower back pain/lower extremity sciatic that has been persistent for 6 months, without a focal neurological deficit. MR imaging revealed left S1 nerve root compression due to a left paramedian disc herniation at L5–S1 [ Figure 1a and b ]. CT confirmed a low-density disc herniation that contained gas continuous with the L5–S1 disc space [ Figure 1c and d ]. Conservative treatment was unsuccessful for 9 months, and the patient underwent FED to resect the L5–S1 gas-containing disc herniation. Intraoperative gas leakage from the herniated disc was visible (i.e., bubbles) [ Figure 2 and Video 1 ]. The highly degenerated disc tissue was removed in a piecemeal manner, and ultimately, the S1 root was decompressed.


Figure 1:

Preoperative magnetic resonance and computed tomography (CT) images. (a, b) Sagittal view and axial view T2-weighted images show disc herniation at L5-S1. Figure 1a is at the level of the yellow line in figure 1b. Figure 1b is at the level of the red line in figure 1a. (c, d) CT of the sagittal and axial views reveal a low-density lesion, which indicates gas within the herniated disc. Figure 1c is at the level of the yellow line in figure 1d. Figure 1d is at the level of the red line in figure 1c.

 

Figure 2:

Intraoperative endoscopic view showing gas leaking from the herniated disc as bubbles (arrows).

 

Video 1


Postoperatively, the patient’s symptoms immediately resolved, and the postoperative MR and CT images revealed no residual disc herniation or gas [ Figure 3a - d ]. At 15 months postoperatively, no recurrence was observed.


Figure 3:

Postoperative magnetic resonance and computed tomography (CT) images. (a, b) Sagittal view and axial view T2-weighted images show a decrease in disc herniation at L5-S1. Figure 1a is at the level of the yellow line in figure 1b. Figure 1b is at the level of the red line in figure 1a. (c, d) CT of the sagittal and axial views revealed no low-density lesion within the herniated disc. Figure 1c is at the level of the yellow line in figure 1d. Figure 1d is at the level of the red line in figure 1c.

 

DISCUSSION

“VP” or “intradiscal gas” (i.e., the radiolucent visualization of gas within the intervertebral disc space) is observed in 1–3% of lumbar spinal radiographs and most frequently in older adults (20%).[ 6 ] Gas analysis of these discs revealed a composition of 90–92% nitrogen.[ 2 ] The prevalence of VP in older adults is possibly due to the reduced water content in the intervertebral discs due to degeneration. Several cases of gas-containing disc herniation have been reported [ Table 1 ].[ 1 , 3 , 7 , 9 ]


Table 1:

Summary of studies reporting gas-containing disc herniation.

 

No significant differences have been reported regarding clinical efficacy between percutaneous endoscopic lumbar discectomy and posterior open lumbar microdiscectomy.[ 4 , 5 , 8 ] Full-endoscopic spine surgery has numerous advantages over open microscopic discectomy, including smaller skin incisions, reduced scarring and muscle damage, decreased postoperative infection risk, and decreased blood loss.[ 4 ] We identified one prior case that utilized FED to treat a gas-containing disc herniation.[ 3 ] In our case, we effectively utilized an interlaminar FED to remove an L5–S1 MR/CT-documented gas-containing disc herniation that did not recur within 15 months postoperatively.

CONCLUSION

FED for gas-containing disc herniation may be effective and minimally invasive because of its ability to visualize nerve root decompression.

Ethical approval

The research/study was approved by the Institutional Review Board at Otsu City Hospital, number 100, dated June 13, 2022.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Choi KC, Kim JS, Lee SH. Surgical experience of gas-containing disk herniation. Neurol Med Chir (Tokyo). 2010. 50: 905-9

2. Ford LT, Gilula LA, Murphy WA, Gado M. Analysis of gas in vacuum lumbar disc. AJR Am J Roentgenol. 1977. 128: 1056-7

3. Inokuchi T, Tezuka F, Yamashita K, Morimoto M, Sugiura K, Fujitani J. Transforaminal full-endoscopic discectomy for gas-containing herniated nucleus pulposus at L5-S1 under local anesthesia: A case report. J Med Invest. 2022. 69: 328-31

4. Kim JS, Lee JH, Bae J, Lee DC, Shin SH, Keum HJ. Comparative study of the efficacy and safety of minimally invasive interlaminar full-endoscopic discectomy versus conventional microscopic discectomy in single-level lumbar herniated intervertebral disc (ENDO-F Trial): A multicenter, prospective, randomized controlled trial protocol. J Orthop Surg Res. 2022. 17: 187

5. Qin R, Liu B, Hao J, Zhou P, Yao Y, Zhang F. Percutaneous endoscopic lumbar discectomy versus posterior open lumbar microdiscectomy for the treatment of symptomatic lumbar disc herniation: A systemic review and meta-analysis. World Neurosurg. 2018. 120: 352-62

6. Resnick D, Niwayama G, Guerra J, Vint V, Usselman J. Spinal vacuum phenomena: Anatomical study and review. Radiology. 1981. 139: 341-8

7. Righini A, Lucchi S, Reganati P, Zavanone M, Bettinelli A. Percutaneous treatment of gas-containing lumbar disc herniation: Report of two cases. J Neurosurg. 1999. 91: 133-6

8. Sivakanthan S, Hasan S, Hofstetter C. Full-endoscopic lumbar discectomy. Neurosurg Clin N Am. 2020. 31: 1-7

9. Tsitouridis I, Sayegh FE, Papapostolou P, Chondromatidou S, Goutsaridou F, Emmanouilidou M. Disc-like herniation in association with gas collection in the spinal canal: CT evaluation. Eur J Radiol. 2005. 56: 521-6

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