OBJECTIVES: To evaluate the effectiveness and safety of interlaminar versus transforaminal endoscopic lumbar discectomy (IELD versus TELD) in treating L4/5 highly migrated lumbar disc herniation (HM-LDH), and to analyze factors influencing surgical approach selection. METHODS: From January 2022 to June 2024, patients with L4/5 HM-LDH treated with IELD or TELD were retrospectively included. Patients were divided into two groups based on the approach used: IELD (under general anesthesia) and TELD (under local anesthesia with intravenous sedation). Baseline data, perioperative data, radiological data, patient-reported outcomes (PROs) including the visual analogue scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria were recorded. All data were compared and analyzed by independent t-tests and χ² tests. RESULTS: There were 50 patients in the IELD group and 80 patients in the TELD group respectively. The baseline data between the two groups did not show significant difference. The IELD group had relatively wider interlaminar window and thinner intervertebral foramen at L4/5, while there is no significant difference in the height of the intervertebral foramen between the two groups. No significant differences were found in intraoperative blood loss and postoperative length of stay. However, IELD had a shorter operation time (86.6 ± 12.6 min vs.99.4 ± 27.4 min, P < 0.001) and less fluoroscopy times (4.3 ± 1.1 vs. 11.6 ± 1.9, P < 0.001) compared to TELD. Both groups achieved a significant improvement in VAS and ODI after surgery. Satisfaction rates were 92.0% for IELD and 91.3% for TELD (P = 0.816) according to the modified MacNab criteria. As compared to preoperative measurements, both groups showed a significant reduction in the anteroposterior diameter of the intervertebral disc (APDID) and a significant increase in dural sac cross-sectional area (DSCA) at 12 months postoperatively. No significant differences in complications were observed between the two groups. Regarding residual symptoms, there were more patients in the TELD group who reported residual back pain (VAS ≥ 2) during the follow-up periods (33.8% vs. 16.0%, P = 0.026). CONCLUSION: Both IELD and TELD can achieve satisfactory clinical and radiological outcomes in treating L4/5 HM-LDH. IELD has advantages of shorter operation time, less fluoroscopy times and fewer residual back pain compared with TELD. Selection of surgical approach for L4/5 HM-LDH depends on anatomical structure, migration characteristics, and the operative skills of the surgeon.
Zheng et al. (Mon,) studied this question.