Efficacy analysis of different approaches of percutaneous transforaminal endoscopic local anesthesia in the treatment of L5- S1 disc herniation

Efficacy analysis of different approaches of percutaneous transforaminal endoscopic local anesthesia in the treatment of L5- S1 disc herniation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy analysis of different approaches of percutaneous transforaminal endoscopic local anesthesia in the treatment of L5- S1 disc herniation Dongwei Feng, Wei Jian, Yaxin Zhang, Baoliang Jiao, Weize Wu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4697296/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Both transforaminal and interlaminar approaches are effective methods for the treatment of L5-S1 disc herniation. Few studies have compared the efficacy and complications of two approaches under local anesthesia in the treatment of L5-S1 disc herniation Methods: From May 2018 to July 2021, 72 patients with L5-S1 disc herniation were randomized to the transforaminal endoscopic lumbar discectomy (TELD, n = 36) or interlaminar endoscopic lumbar discectomy (IELD, n = 36). Both procedures were performed under 1% lidocaine local anesthesia. The baseline data, puncture time, radiation time, operative time unde the endoscope, total operation time, hospitalization time, bed rest time, and complications were compared between the two groups. In addition, Likert five-point scale was used for evaluation of patients experience to local anesthesia and tolerance to re-operation was assessed as well. The efficacy of surgery was assessed according to Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and modified MacNab score. Results: All patients with an average follow-up of 27.5 months. Compared to the IELD group, the TELD group had a longer puncture time (15.31±2.53>5.11±1.67, P 4.61±1.27, P < 0.001) but a shorter total operative time(52.22±5.44<58.53±0.69, P=0.001) , operative time unde the endoscope(36.92±5.79<53.42±9.60, P < 0.001) and lower VAS scores for intraoperative back pain (P < 0.001) and leg pain (P<0.001). The postoperative VAS score and ODI score in both groups were significantly lower than those before operation(P 0.05). The postoperative survey showed that the satisfaction rate of TELD group was higher than that of IELD group(P=0.026), TELD group was superior to IELD group in tolerance to re-operation(P =0.007). According to MacNab criteria, the excellent and good rate rates of TELD group and IELD group were 93.3% and 90.0%, and the difference was not statistically significant (P > 0.05). Conclusion: For L5/S1 DH, Both TELD and IELD can achieve good clinical efficacy under local anesthesia. Compared with PETD, PEID had lower puncture time, total operation time, and radiation exposure, but higher incidence of intraoperative low back pain and patients satisfactory rates less. lumbar disc herniation local anesthesia transforaminal discectomy minimally invasive Background Symptomatic lumbar disc herniation (LDH) is a common disease in spinal surgery, waist and leg pain caused by this condition has long affected the work and daily life of people from all walks of life[ 1 ]. Generally, spinal surgery is necessary when conservative treatment for LDH fails[ 2 ]. Although traditional posterior lumbar discectomy has achieved some results in the field of LDH, it is restricted by factors such as longer operative time, more blood loss, more paravertebral muscle injury and slower function recovery[ 3 ]. With the development of minimally invasive techniques and concepts, percutaneous endoscopic lumbar discectomy (PELD) has gradually emerged as the preferred surgical modality for treating neural compression due to single-segment uncomplicated LDH, PELD techniques reduce injury to paravertebral soft tissues and maintain the biomechanical stability of the normal spinal sequence, accelerating the recovery time and return to work[ 4 ]. Transforaminal full endoscopic lumbar diskectomy (TELD) and Interlaminar endoscopic lumbar discectomy(IELD) are 2 prominent surgical techniques gaining traction in this context, both approaches have advantages[ 5 ]. For L5-S1 DH, due to its special anatomy characteristics, some scholars believe that IELD is the preferred treatment for L5-S1 segment[ 6 ]. IELD is prone to cause severe pain due to cutting tissues such as the ligamentum flavum and posterior longitudinal ligament, which often needs to be performed under general anesthesia, while TELD can be accomplished under local anesthesia[ 7 ]. Recently, IELD under local anesthesia has been demonstrated to be a safe and effective method[ 8 ]. At present, few studies have compared the clinical efficacy of IELD and TELD in the treatment of L5-S1 DH under local anesthesia. In this paper, we present the first preliminary RCT results comparing IELD and TELD for L5–S1 DH under local anesthesia to assess the clinical outcomes, complications, and patient satisfaction rates associated with each surgical approach, providing an initial foundation for future research and guiding clinical decision-making. Methods This prospective, noncrossover, RCT was conducted in the The First Affiliated Hospital of Hebei North University from May 2018 to July 2021. This study was approved by the Ethics Committee of our institution. Informed written consent was obtained from the participants. In addition, this study was performed in line with the international ethical guidelines for studies involving human subjects according to the Declaration of Helsinki. Patients Inclusion criteria: [ 1 ]. age between 17-70years; [ 2 ]. Imaging findings confirming L5-S1 one-level DH, and failure of standard conservative treatment for at least 3 months; [ 3 ]. After more than 6 months of conservative treatment and poor results; [ 4 ]. The follow-up period was longer than 24 months. Exclusion criteria: [ 1 ]. Multiple segments of disc herniation; [ 2 ]. LDH combined with lumbar instability, or other spinal diseases; [ 3 ]. Far lateral lumbar disc herniation; [ 4 ]. Recurrent disc herniation; [ 5 ]. Infection of the lumbar spine;[ 6 ]. Other lumbar diseases(inflammation, tuberculosis, tumour, etc) precluded surgey. During the study period, 80 patients who were treated for L5-S1 DH using percutaneous endoscopic lumbar discectomy were identified. After application of the exclusion criteria, 72 patients were included in the study, of whom 36 were assigned to the TELD group and 36 to the IELD group. Surgical technique TELD The patient was placed in a prone position after local anesthesia, and the responsible segment was identified by C-arm X-ray fluoroscopy. The puncture needle was punched toward the disc at 12 to 15cm from the midline with an angle of 30° to 45° with the horizontal surface, and the puncture point was anesthetized with 0.5% lidocaine injection. At the same time, The foramen, extraforamen, and facet joint were injected with 5 mL 1% lidocaine, respectively. With the scalpel made a 0.8-cm incision was made at the skin entry point. The dilator and catheter were inserted under fluoroscopy.The dilator and catheter were subsequently inserted. If the catheter was blocked by the superior articular process, the Kirschner wire was fixed, and the trephine enlarged the intervertebral foramen. The bipolar radiofrequency ablator were used to clear muscles and extruded tissue, and calcified disc and herniated nucleus pulposus was removed together with interlaminar tissues. The ruptured annulus fibrosus was ablated and shrunken with bipolar radiofrequency until the nerve root was fully decompressed and the endoscope and working catheter were removed. Finally, the incision was sutured intradermally and covered with a sterile dressing. IELD The PEID procedure was performed under local anaesthesia in the prone position. After marking the puncture site on the body surface, routine disinfection was performed. 1% lidocaine was injected layer-by-layer into the skin, subcutaneous tissue, fasciae, muscle, upper lamina, lower lamina, and ligamentum flavum. Locating needle punctured through ligamentum flavum into epidural space and 10 ml of 1% lidocaine was injected slowly. For axillary LDH, the skin entry point was closer to the midline of the lesion side of the interlaminar space. For shoulder LDH, the skin entry point was closer to the articular process. With the scalpel made, a 0.8-cm incision was made at the skin entry point. The endoscopic system was then introduced through the working cannula. To expose the ligamentum flavum clearly under endoscopic view, soft tissues like muscle and fascia should be removed using grasping forceps. If the catheter was blocked by the articular process or vertebral plate, the dynamic bur enlarged the interlaminar space appropriately. The protruded nucleus pulposus was removed, and the hypertrophic or calcified ligamentum flavum was removed or recessed. The ruptured annulus fibrosus was ablated and shrunken with bipolar radiofrequency until the nerve root was fully decompressed and the endoscope and working catheter were removed. Finally, the incision was sutured intradermally and covered with a sterile dressing. Effectiveness Evaluation All patients were recorded demographic data, surgical-related parameters, such as puncture time, radiation time, operative time unde the endoscope, total operation time, hospitalization timeb and bed rest time. Patients were asked to indicate their experience with local anesthetics on a 5-point Likert-type scale postoperatively, with a score of 0 indicating a very bad experience and a score of 5 a very good experience. Tolerance to re-operation was assessed on postoperative day 1. Visual Analog Scale (VAS)score and Oswestry Disability Index (ODI) were used to assess the degree of pain on day 1, 3 months, 6 moths and 1 year after surgery, and the surgical effectiveness was evaluated at the last follow up according to the modified MacNab criteria. All surgical complications were recorded during treatment period. Statistical analysis SPSS version 22.0 (IBM Corp, USA) was used to analyse all data. Continuous variables (age, puncture time, radiation time, VAS Score, ODI Score, etc) were compared by using t tests, and Pearson’s chi-square test or Fisher’s exact test was used to compare categorical variables (sex, side, DH type, Likert scale, etc). P values < 0.05 were considered statistically significant. Result A total of 72 patients underwent follow-up for 24–35 months, with an average of 29.7 months. Patients in both groups successfully completed the operation, and no serious complications such as dural rupture or nerve root injury occurred. The baseline characteristics of both groups were similar ( P > 0.05) The details are shown in Table 1 Table 1 ༎Patient demographics at baseline and intraoperative parameter between TELD and IELD group TELD IELD t/ \(\:{x}^{2}\) P Sex Male 21(47.73) 23(52.27) 0.234 0.629 Female 15(53.57) 13(46.43) Side Left 20(54.05) 17(45.95) 0.500 0.479 Right 16(45.71) 19(54.29) DH Type Shoulder 21(48.84) 22(51.16) 0.058 0.810 Axillar 15(51.72) 14(48.28) Puncture time(min) 15.31 ± 2.53 5.11 ± 1.67 -20.191 P < 0.001 Operative Time unde the endoscope 36.92 ± 5.79 53.42 ± 9.60 8.832 P < 0.001 Total Time (min) 52.22 ± 5.44 58.53 ± 0.69 3.404 P = 0.001 Radiation Time (s) 8.44 ± 2.01 4.61 ± 1.27 -9.684 P < 0.001 Hospitalization Time (d) 2.69 ± 0.92 2.42 ± 0.94 -1.269 0.209 Bed Rest Time (h) 4.94 ± 1.01 5.22 ± 0.99 1.178 0.243 VAS Score 7.12 ± 0.46 7.08 ± 0.47 -0.431 0.668 Intraop VAS of back 3.67 ± 0.50 4.71 ± 0.39 9.894 P < 0.001 Intraop VAS of leg 3.48 ± 0.50 4.44 ± 0.49 8.174 P 5.11 ± 1.67, P 4.61 ± 1.27, P < 0.001) in the TELD group. However, operative time (52.22 ± 5.44 < 58.53 ± 0.69, P = 0.001) and the operative time unde the endoscope(36.92 ± 5.79 < 53.42 ± 9.60, P < 0.001) were significantly reduced in this group. The details are shown in Table 1 The intraoperative VAS scores of both back and leg pain in the TELD group were significantly lower than those in the IELD group ( P < 0.05). The satisfaction rate of TELD group was 94.44%, which was significantly higher than that of IELD group (75%) ( P = 0.026). And TELD group was superior to IELD group in tolerance to re-operation( P = 0.007). Overall, all included patients in the two groups demonstrated significant improvement in the VAS and ODI scores compared with the preoperative scores at the final follow-up. For different data collection time, there was no significant difference in VAS and ODI scores between the two groups (P > 0.05) The details are shown in Table 2 and Table 3 Table 2 VAS and ODI between TELD and IELD group TELD IELD t P VAS Pre-op 7.12 ± 0.46 7.08 ± 0.47 -0.431 0.668 1 d post-op 3.08 ± 0.41 2.96 ± 0.37 -1.294 0.200 3month post-op 2.02 ± 0.31 1.92 ± 0.22 -1.575 0.120 6month post-op 1.55 ± 0.25 1.68 ± 0.38 1.761 0.083 12month post-op 1.14 ± 0.26 1.03 ± 0.27 -1.721 0.090 ODI Pre-op 59.83 ± 4.16 60.19 ± 4.11 0.374 0.710 1 d post-op 35.44 ± 2.69 34.38 ± 2.61 -1.699 0.094 3month post-op 23.10 ± 3.66 21.76 ± 3.11 -1.677 0.098 6month post-op 18.30 ± 1.85 17.84 ± 2.09 -0.992 0.324 12month post-op 12.17 ± 2.18 11.48 ± 2.20 -1.324 0.190 Table 3 Likert scale of 2 groups TELD IELD \(\:{x}^{2}\) p Likert scale Strongly Good 7 1 9.297 0.026 Good 27 26 Fine 2 7 Poor 0 2 Strongly Poor 0 0 Five patients across the two groups suffered complications. There were three cases in the IELD group that suffered Postoperative dysesthesia which were successfully treated with the application of dexamethasone and neurotrophic drugs. whereas 1 patient had fragment omissions and 1 patient had a recurrent disc herniation 3 months postoperation in the TELD group, and all recovered after conservative treatment. There was no difference in the complications rate between the two groups( P < 0.05) The details are shown in Table 4 . Table 4 Comparision complications between TELD and IELD group TELD IELD \(\:{x}^{2}\) p Complications Fragment Omissions 1 0 0.215 0.643 Nerve root injury 0 0 Wound infections 0 0 Postoperative dysesthesia 0 3 Dural tears 0 0 Recurrence 1 0 Clinical efficacy assessed at last follow-up using modified MacNab criteria classification There was no statistically significant difference between the two groups (excellent/good/fine/poor, 25/9/2/0 vs 25/8/3/0, P < 0.05) The details are shown in Table 5 . Table 5 Modified MacNab criteria between TELD and IELD group TELD IELD \(\:{x}^{2}\) p MacNab Excellent 25 25 0.259 0.879 Good 9 8 Fine 2 3 Poor 0 0 Discussion Forst and Hausmann[ 9 ] first applied modified arthroscopy to decompression in 1983, greatly improving the efficiency and safety of spinal surgery. More than anything, Kambin 's anatomical description of the neural foramen (Kambin triangle) is one of the cornerstones in developing of a fully endoscopic transforaminal approach[ 10 ]. On this basis, significant progress has been made in techniques for minimally invasive treatment of lumbar disc herniation, such as intradiscal injection of chymopapain[ 11 ], foraminoplasty[ 12 ], automatic nucleotomy aspiration via transforaminal approach with auxiliary catheter[ 13 ], laser decompression, and radiofrequency ablation[ 14 ]. In 1997, Yeung[ 15 ] et al developed a new generation of spinal endoscopic YESS system for intradiscal decompression through the Kambin safe trigone into the intervertebral disc, which has multiple channels and a wider angle, improved the nature of percutaneous endoscopic discectomy[ 16 ]. Since then, with the continuous development of spinal endoscopic techniques, tools and the transformation of concepts. Currently, PELD plays an irreplaceable role in the treatment of LDH. During the process of shearing ligamentum flavum, rotating working channel and removing annulus fibrosus, stimulation of sinovertebral nerve and spinal nerve toot may cause intolerable lumbago and leg pain, and IELD has stronger traction on dura mater and nerve root during operation, which may lead to severe neuropathic pain. Therefore, most scholars recommend general anesthesia (GA) when performing PELD via the interlaminar approach[ 17 ][ 18 ]. However, some studies have found that the risk of nerve root injury is higher during general anesthesia, and nerve electromyography monitoring should be used during surgery to prevent nerve root injury[ 19 ]. Ye[ 20 ] et al treated 60 patients with LDH using the IELD technique and showed no significant difference in ODI and VAS scores between LA and GA, whereas 1 patient in GA group had intraoperative nerve root injury. At the same time, it has also been shown that GA is associated with postoperative cognitive dysfunction in elderly patients[ 21 ]. Currently, PELD with local anesthesia has been proven to be a safe and effective method. Local anesthesia has the advantages of a faster recovery, shorter hospital stay and fewer complications. In this study, all patients were given local anesthesia, and the operation was successfully completed. There was no significant difference in postoperative bed rest time and hospitalization time between the two groups. 7 patients in the IELD group developed pain intraoperative, pain was controlled after intravenous sufentanil infusion. So IELD had a higher VAS scores for intraoperative back pain and leg pain than in the TELD group(P < 0.01). This could be a reason for the lower satisfaction rate in the IELD group. However, more intraoperative pain did not affect the clinical outcomes. At each follow-up of 3, 6, and 12 months after surgery, and the VAS and ODI score were significantly lower than preoperative (P < 0.01). At the last follow-up, According to MacNab criteria, the excellent and good rate rates of TELD group and IELD group were 93.3% and 90.0%, separately. Therefore, the efficacy of PELD under LA is similar to that of traditional surgery, but it has the advantages of less trauma, lower medical expense and faster recovery. However, PELD via the transforaminal route is challenging at the L5-S1 level due to obstruction of the anatomy. The iliac crest and inclination of the L5-S1 levels frequently impedes the transforaminal approach, resulting in steeper trajectory angles away from the extruded disc. The location and angle of the working channel are key factors for successful PELD. Choi DJ[ 22 ] established a pathway through iliac drilling for the first time to treat L5-S1DH intervertebral disc herniation with high iliac spine, but this method is easy to cause iliac fracture, superior gluteal nerve and superior gluteal artery and vein injury, so it is difficult to popularize widely. But definition of high iliac crest is vague. Choi KC [ 23 ] et al first proposed a grading system for high iliac crest based on the relationship between the highest point of the iliac crest and the adjacent bony markers, They recommended that the iliac height grade ≥ 5 is the threshold of foraminoplasty for transforaminal endoscopic L5-S1 discectomy. We believe that whether or not foraminoplasty is performed is also associated with the severity of foraminal stenosis and the size of facet joints. Therefore, foraminoplasty was performed in this group of patients as appropriate, which not only increased the safe working area of the working catheter, but also reduced the risk of nerve root injury. Similar to previous studies[ 24 ][ 25 ], we also found that patients in the TELD group had a greater puncture time and radiation time than patients in the IELD group (P < 0.001). Analysis of the reasons: It is well known that the intervertebral foramen becomes progressively smaller in the lumbar spine, especially at the L5-S1 segment. In addition, the iliac crest usually conceals the L5-S1 foramen, which makes the puncture process difficult; therefore, a sufficient foraminoplasty is necessary to reveal axillar herniation. Conversely, the wider L5-S1 intervertebral disc space lowered the difficulty of PEID and thereby reduced the puncture time and radiation time. In the process of localization and puncture, the surgeon fully understand the spinal anatomy, master the puncture technique, can reduce the fluoroscopy time to a certain extent and shorten the puncture time. L5-S1 has the largest interlaminar space distance and provides adequate operating space for the IELD. The majority of S1 nerve roots origin of the L5-S1disc level, and some may even originated superior L5-S1disc level[ 26 ]. There is a certain space between the S1 nerve root and the dural sac, and axillary type of herniation will increase the space. And, it is easy to remove the herniation by placing the working catheter under the nerve root axilla. In contrast to axillary type of herniation, the shoulder space is relatively small as well as the restriction of the articular process, and the working catheter is difficult to reach to the shoulder of the nerve root. it is risky to rotate the working catheter directly in towards the disc. Therefore, a laminectomy is therefore needed to create operating space to reduce the risk of nerve root injury. In this study, a laminectomy was required in 23.5% of patients. We believe that the difficulty of the IELD approach with a huge central LDH. Which leads to greater tension of the dura and nerve roots, and the rotating working catheter is easy to damage the dura mater and nerve roots. Therefore, in this study, the position of the tongue of the working catheter was first placed in the disc under the axillary herniated disc, part of the herniation was removed for intraspinal decompression, and then the catheter was rotated to the shoulder of the nerve root under the protection of a nerve dissector for subsequent procedures. At the same time, Nie[ 27 ] et al found that PETD total operation time was higher than PEID in their study, which was contrary to our present study. In the study, we found that operative time unde the endoscope PEID group was longer than that of the PETD group. This is because PEID was done under general anesthesia in their study, whereas this study was done under local anesthesia. And some patients required more time to add intravenous sufentanil because of severe intraoperative pain caused by cutting the ligamentum flavum and laminectomy[ 28 ]. Although this technique is widely used in the treatment of LDH, some unavoidable complications that may affect the final treatment outcome have also been reported[ 29 ]. In this study, the most common complication was postoperative dysesthesia, which we speculated was associated with excessive intraoperative traction of the nerve root, The patients’ symptoms were improved by mecobalamin, gabapentin. In addition, complications such as recurrence of LDH and fragment Omissions were also observed in this study, but they were finally solved by various methods. There was no significant difference in complications between the two groups, and no serious complications such as nerve root injury and dural tear occurred. Surgeons should carefully consider appropriate technical factors and have a thorough understanding of patient anatomy to avoid complications. The treatment results showed that both PEID and PETD could obtain satisfactory results for L5-S1 DH. PEID has shorter puncture time and less radiation exposure, but longer operative time unde the endoscope and greater intraoperative pain. Therefore, in clinical practice, operators should strictly grasp the indications, combined with patient anatomical variation and operator experience to choose a personalized surgical approach. The present study had several limitations. Because TELD approach is the preferred approach for far-LDH, such patients were not included in this study. This was a preliminary analysis of the treatment results, without a detailed discussion of the relevant influencing factors or a comparative analysis with other surgical methods. Further investigations, especially muti-centered trails with a larger sample size should be conducted to overcome the limitations of our study. Declarations Acknowledgments Not applicable. Authors’ contributions DF: Conducted the study. Collected, analyzed, and interpreted the data. Wrote the manuscript. WJ: Designed the study, and interpreted the data, and edited the manuscript. YZ: Interpreted the data, and edited the manuscript. BJ: Interpreted the data. WW: Interpreted the data. JD: Interpreted the data. YW: Interpreted the data. ZL: Planned the project. Interpreted the data. HJ: Planned the project. Interpreted the data. All authors read and approved the final manuscript. Funding information This study was not funded by any foundation. Availability of data and materials The datasets analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This retrospective study was approved by the Ethics Committee of The First Affiliated Hospital of Hebei North University and carried out in accordance with the ethical standards set out in the Helsinki Declaration. Informed consent was received from all participating. Competing interests The authors declare that they have no conflict of interest. Consent for publication Not applicable. Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. References Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976). 2002;27(7):722-731. Kim M, Lee S, Kim HS, Park S, Shim SY, Lim DJ. A Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Lumbar Disc Herniation in the Korean: A Meta-Analysis. Biomed Res Int. 2018;2018:9073460. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. doi:10.1016/S0140-6736(18)30489-6. He DW, Xu YJ, Chen WC, et al. Meta-analysis of the operative treatment of lumbar disc herniation via transforaminal percutaneous endoscopic discectomy versus interlaminar percutaneous endoscopic discectomy in randomized trials. Medicine (Baltimore). 2021;100(5):e23193. doi:10.1097/MD.0000000000023193. Li P, Yang F, Chen Y, Song Y. Percutaneous transforaminal endoscopic discectomy for different types of lumbar disc herniation: A retrospective study. J Int Med Res. doi:10.1177/03000605211055045. Gu YT, Cui Z, Shao HW, Ye Y, Gu AQ. Percutaneous transforaminal endoscopic surgery (PTES) for symptomatic lumbar disc herniation: a surgical technique, outcome, and complications in 209 consecutive cases. J Orthop Surg Res. 2017;12(1):25. doi:10.1186/s13018-017-0524-0. Yeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am. 2007;38(3):363-vi. doi:10.1016/j.ocl.2007.04.005. Feng WL, Yang JS, Wei D, et al. Gradient local anesthesia for percutaneous endoscopic interlaminar discectomy at the L5/S1 level: a feasibility study. J Orthop Surg Res. 2020;15(1):413. Published 2020 Sep 15. doi: 10.1186/s13018-020-01939-5. Hausmann B , Forst R .Shaving of the lumbar disk space? a new technique in lumbar nucleotomy[J]. Archives of Orthopaedic & Traumatic Surgery, 1984, 103(4): 284-285. doi: 10.1007/BF00387335. Sencer A, Yorukoglu AG, Akcakaya MO, et al. Fully endoscopic interlaminar and transforaminal lumbar discectomy: short-term clinical results of 163 surgically treated patients. World Neurosurg. 2014;82(5):884-890. doi:10.1016/j.wneu.2014.05.032. Fraser RD. Chymopapain for the treatment of intervertebral disc herniation. A preliminary report of a double-blind study. Spine (Phila Pa 1976). 1982;7(6):608-612. doi:10.1097/00007632-198211000-00016. Hoogland T, Schubert M, Miklitz B, Ramirez A. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976). 2006;31(24):E890-E897. doi:10.1097/01.brs.0000245955.22358.3a. Onik G, Helms CA, Ginsburg L, Hoaglund FT, Morris J. Percutaneous lumbar diskectomy using a new aspiration probe. AJR Am J Roentgenol. 1985;144(6):1137-1140. doi:10.2214/ajr.144.6.1137. Knight MT, Goswami A, Patko JT, Buxton N. Endoscopic foraminoplasty: a prospective study on 250 consecutive patients with independent evaluation. J Clin Laser Med Surg. 2001;19(2):73-81. doi:10.1089/104454701750285395. Yeung AT. The evolution of percutaneous spinal endoscopy and discectomy: state of the art. Mt Sinai J Med. 2000;67(4):327-332. Choi G, Lee SH, Bhanot A,et al. Percutaneous endoscopic discectomy for extraforaminal lumbar disc herniations: extraforaminal targeted fragmentectomy technique using working channel endoscope. Spine (Phila Pa 1976). 2007;32(2):E93-E99. doi:10.1097/01.brs.0000252093.31632.54. Chen HT, Tsai CH, Chao SC, et al. Endoscopic discectomy of L5-S1 disc herniation via an interlaminar approach: Prospective controlled study under local and general anesthesia. Surg Neurol Int. 2011;2:93. doi:10.4103/2152-7806.82570. Guan Y, Huang T, An G, et al. Percutaneous Endoscopic Interlaminar Lumbar Discectomy with Local Anesthesia for L5-S1 Disc Herniation: A Feasibility Study. Pain Physician. 2019;22(6):E649-E654. Wu K, Zhao Y, Feng Z, et al. Stepwise Local Anesthesia for Percutaneous Endoscopic Interlaminar Discectomy: Technique Strategy and Clinical Outcomes. World Neurosurg. 2020;134:e346-e352. doi:10.1016/j.wneu.2019.10.061. Ye XF, Wang S, Wu AM, et al. Comparison of the effects of general and local anesthesia in lumbar interlaminar endoscopic surgery. Ann Palliat Med. 2020;9(3):1103-1108. doi:10.21037/apm-20-623. Feng WL, Yang JS, Wei D, et al. Gradient local anesthesia for percutaneous endoscopic interlaminar discectomy at the L5/S1 level: a feasibility study. J Orthop Surg Res. 2020;15(1):413. doi:10.1186/s13018-020-01939-5. Choi DJ, Jung JT, Lee SJ, et al. Biportal Endoscopic Spinal Surgery for Recurrent Lumbar Disc Herniations. Clin Orthop Surg. 2016;8(3):325-329. doi:10.4055/cios.2016.8.3.325. Choi KC, Park CK. Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation: Consideration of the Relation between the Iliac Crest and L5-S1 Disc. Pain Physician. 2016;19(2):E301-E308. Chen J, Jing X, Li C, et al. Percutaneous Endoscopic Lumbar Discectomy for L5S1 Lumbar Disc Herniation Using a Transforaminal Approach Versus an Interlaminar Approach: A Systematic Review and Meta-Analysis. World Neurosurg. 2018;116:412-420.e2. doi:10.1016/j.wneu.2018.05.075. Mo X, Shen J, Jiang W, et al. Percutaneous Endoscopic Lumbar Diskectomy for Axillar Herniation at L5-S1 via the Transforaminal Approach Versus the Interlaminar Approach: A Prospective Clinical Trial. World Neurosurg. 2019;125:e508-e514. doi:10.1016/j.wneu.2019.01.114. Arslan M, Cömert A, Açar Hİ, et al. Neurovascular structures adjacent to the lumbar intervertebral discs: an anatomical study of their morphometry and relationships. J Neurosurg Spine. 2011;14(5): 630-638. doi: 10.3171/2010.11.SPINE09149. Nie H, Zeng J, Song Y, et al. Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation Via an Interlaminar Approach Versus a Transforaminal Approach: A Prospective Randomized Controlled Study With 2-Year Follow Up. Spine (Phila Pa 1976). 2016;41 Suppl 19:B30-B37. doi:10.1097/BRS.0000000000001810. Chen Z, Wang X, Cui X, et al. Transforaminal Versus Interlaminar Approach of Full-Endoscopic Lumbar Discectomy Under Local Anesthesia for L5/S1 Disc Herniation: A Randomized Controlled Trial. Pain Physician. 2022;25(8):E1191-E1198. Shi C, Kong W, Liao W, et al. The Early Clinical Outcomes of a Percutaneous Full-Endoscopic Interlaminar Approach via a Surrounding Nerve Root Discectomy Operative Route for the Treatment of Ventral-Type Lumbar Disc Herniation. Biomed Res Int. 2018;2018:9157089. Published 2018 Feb 12. doi:10.1155/2018/9157089. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4697296","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":334358275,"identity":"83f83480-e5d0-43ed-9ae1-5e2372d7fbf1","order_by":0,"name":"Dongwei Feng","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"Dongwei","middleName":"","lastName":"Feng","suffix":""},{"id":334358276,"identity":"beefebe1-6083-403e-8462-45df5177e5f6","order_by":1,"name":"Wei Jian","email":"","orcid":"","institution":"The Chinese People's Liberation Army 309 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Jian","suffix":""},{"id":334358277,"identity":"5f1afb89-0c68-4787-a504-5c3e89abc5b2","order_by":2,"name":"Yaxin Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"Yaxin","middleName":"","lastName":"Zhang","suffix":""},{"id":334358278,"identity":"5ba25152-38af-43e4-bfcc-d14b94ffae74","order_by":3,"name":"Baoliang Jiao","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"Baoliang","middleName":"","lastName":"Jiao","suffix":""},{"id":334358279,"identity":"7dd13020-b4d6-48d3-aa19-4e0ab2ef4528","order_by":4,"name":"Weize Wu","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"Weize","middleName":"","lastName":"Wu","suffix":""},{"id":334358280,"identity":"2d3d99f5-f4a0-4a85-9c88-dd938d3c68c6","order_by":5,"name":"Jianan Ding","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"Jianan","middleName":"","lastName":"Ding","suffix":""},{"id":334358281,"identity":"00d47792-d8c4-4b56-94cf-0c59704b4795","order_by":6,"name":"Yunhe Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":false,"prefix":"","firstName":"Yunhe","middleName":"","lastName":"Wang","suffix":""},{"id":334358282,"identity":"a89e31d9-d888-49e1-8155-07ad9f8e1545","order_by":7,"name":"Heping Jia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIie3RMQrCMBiG4b8EMgWzJiD1CoWCOHiYZOmk0LFDByFiBxWv0tFRCGSKuHZsb2C3jhZBF6Wpm0OeuS/plwB43h/CVOnm3rGQItrWIsvdyYSZJOaHZcwLiKPaGncSwipiBCeyvMGcN1s04sfAiL7RMVeQZHKDgRZ7MZwgdanThe63gKnkeQrMXsuxpwS7SloMEVu7kucWLUuNcCp3aHTSz9cYw7jkfcmKICasIc4ts9PrKakN2i7LQ1och5MP5LfPPc/zvK8engZG4x0kkbgAAAAASUVORK5CYII=","orcid":"","institution":"The First Affiliated Hospital of Hebei North University","correspondingAuthor":true,"prefix":"","firstName":"Heping","middleName":"","lastName":"Jia","suffix":""},{"id":334358283,"identity":"6fabffd5-f8be-4988-a9a8-5f0d8f3f90bc","order_by":8,"name":"Zhaowei Li","email":"","orcid":"","institution":"Qinghai University Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhaowei","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-07-06 14:54:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4697296/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4697296/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62721674,"identity":"4178e325-0842-4e37-a2ce-39f13fddbd89","added_by":"auto","created_at":"2024-08-18 16:01:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":486210,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4697296/v1/8ee515ed-b800-4657-9234-1624aeb861f8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy analysis of different approaches of percutaneous transforaminal endoscopic local anesthesia in the treatment of L5- S1 disc herniation","fulltext":[{"header":"Background","content":"\u003cp\u003eSymptomatic lumbar disc herniation (LDH) is a common disease in spinal surgery, waist and leg pain caused by this condition has long affected the work and daily life of people from all walks of life[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Generally, spinal surgery is necessary when conservative treatment for LDH fails[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although traditional posterior lumbar discectomy has achieved some results in the field of LDH, it is restricted by factors such as longer operative time, more blood loss, more paravertebral muscle injury and slower function recovery[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. With the development of minimally invasive techniques and concepts, percutaneous endoscopic lumbar discectomy (PELD) has gradually emerged as the preferred surgical modality for treating neural compression due to single-segment uncomplicated LDH, PELD techniques reduce injury to paravertebral soft tissues and maintain the biomechanical stability of the normal spinal sequence, accelerating the recovery time and return to work[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Transforaminal full endoscopic lumbar diskectomy (TELD) and Interlaminar endoscopic lumbar discectomy(IELD) are 2 prominent surgical techniques gaining traction in this context, both approaches have advantages[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor L5-S1 DH, due to its special anatomy characteristics, some scholars believe that IELD is the preferred treatment for L5-S1 segment[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. IELD is prone to cause severe pain due to cutting tissues such as the ligamentum flavum and posterior longitudinal ligament, which often needs to be performed under general anesthesia, while TELD can be accomplished under local anesthesia[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Recently, IELD under local anesthesia has been demonstrated to be a safe and effective method[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. At present, few studies have compared the clinical efficacy of IELD and TELD in the treatment of L5-S1 DH under local anesthesia. In this paper, we present the first preliminary RCT results comparing IELD and TELD for L5\u0026ndash;S1 DH under local anesthesia to assess the clinical outcomes, complications, and patient satisfaction rates associated with each surgical approach, providing an initial foundation for future research and guiding clinical decision-making.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis prospective, noncrossover, RCT was conducted in the The First Affiliated Hospital of Hebei North University from May 2018 to July 2021. This study was approved by the Ethics Committee of our institution. Informed written consent was obtained from the participants. In addition, this study was performed in line with the international ethical guidelines for studies involving human subjects according to the Declaration of Helsinki.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eInclusion criteria: [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. age between 17-70years; [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Imaging findings confirming L5-S1 one-level DH, and failure of standard conservative treatment for at least 3 months; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. After more than 6 months of conservative treatment and poor results; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The follow-up period was longer than 24 months.\u003c/p\u003e \u003cp\u003eExclusion criteria: [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Multiple segments of disc herniation; [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. LDH combined with lumbar instability, or other spinal diseases; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Far lateral lumbar disc herniation; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Recurrent disc herniation; [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Infection of the lumbar spine;[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Other lumbar diseases(inflammation, tuberculosis, tumour, etc) precluded surgey.\u003c/p\u003e \u003cp\u003eDuring the study period, 80 patients who were treated for L5-S1 DH using percutaneous endoscopic lumbar discectomy were identified. After application of the exclusion criteria, 72 patients were included in the study, of whom 36 were assigned to the TELD group and 36 to the IELD group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eTELD\u003c/h2\u003e \u003cp\u003eThe patient was placed in a prone position after local anesthesia, and the responsible segment was identified by C-arm X-ray fluoroscopy. The puncture needle was punched toward the disc at 12 to 15cm from the midline with an angle of 30\u0026deg; to 45\u0026deg; with the horizontal surface, and the puncture point was anesthetized with 0.5% lidocaine injection. At the same time, The foramen, extraforamen, and facet joint were injected with 5 mL 1% lidocaine, respectively. With the scalpel made a 0.8-cm incision was made at the skin entry point. The dilator and catheter were inserted under fluoroscopy.The dilator and catheter were subsequently inserted. If the catheter was blocked by the superior articular process, the Kirschner wire was fixed, and the trephine enlarged the intervertebral foramen. The bipolar radiofrequency ablator were used to clear muscles and extruded tissue, and calcified disc and herniated nucleus pulposus was removed together with interlaminar tissues. The ruptured annulus fibrosus was ablated and shrunken with bipolar radiofrequency until the nerve root was fully decompressed and the endoscope and working catheter were removed. Finally, the incision was sutured intradermally and covered with a sterile dressing.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIELD\u003c/h2\u003e \u003cp\u003eThe PEID procedure was performed under local anaesthesia in the prone position. After marking the puncture site on the body surface, routine disinfection was performed. 1% lidocaine was injected layer-by-layer into the skin, subcutaneous tissue, fasciae, muscle, upper lamina, lower lamina, and ligamentum flavum. Locating needle punctured through ligamentum flavum into epidural space and 10 ml of 1% lidocaine was injected slowly. For axillary LDH, the skin entry point was closer to the midline of the lesion side of the interlaminar space. For shoulder LDH, the skin entry point was closer to the articular process. With the scalpel made, a 0.8-cm incision was made at the skin entry point. The endoscopic system was then introduced through the working cannula. To expose the ligamentum flavum clearly under endoscopic view, soft tissues like muscle and fascia should be removed using grasping forceps. If the catheter was blocked by the articular process or vertebral plate, the dynamic bur enlarged the interlaminar space appropriately. The protruded nucleus pulposus was removed, and the hypertrophic or calcified ligamentum flavum was removed or recessed. The ruptured annulus fibrosus was ablated and shrunken with bipolar radiofrequency until the nerve root was fully decompressed and the endoscope and working catheter were removed. Finally, the incision was sutured intradermally and covered with a sterile dressing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness Evaluation\u003c/h2\u003e \u003cp\u003eAll patients were recorded demographic data, surgical-related parameters, such as\u003c/p\u003e \u003cp\u003epuncture time, radiation time, operative time unde the endoscope, total operation time, hospitalization timeb and bed rest time. Patients were asked to indicate their experience with local anesthetics on a 5-point Likert-type scale postoperatively, with a score of 0 indicating a very bad experience and a score of 5 a very good experience. Tolerance to re-operation was assessed on postoperative day 1. Visual Analog Scale (VAS)score and Oswestry Disability Index (ODI) were used to assess the degree of pain on day 1, 3 months, 6 moths and 1 year after surgery, and the surgical effectiveness was evaluated at the last follow up according to the modified MacNab criteria. All surgical complications were recorded during treatment period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eSPSS version 22.0 (IBM Corp, USA) was used to analyse all data. Continuous variables (age, puncture time, radiation time, VAS Score, ODI Score, etc) were compared by using t tests, and Pearson\u0026rsquo;s chi-square test or Fisher\u0026rsquo;s exact test was used to compare categorical variables (sex, side, DH type, Likert scale, etc). \u003cem\u003eP\u003c/em\u003e values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eA total of 72 patients underwent follow-up for 24\u0026ndash;35 months, with an average of 29.7 months. Patients in both groups successfully completed the operation, and no serious complications such as dural rupture or nerve root injury occurred. The baseline characteristics of both groups were similar (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) The details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e༎Patient demographics at baseline and intraoperative parameter between TELD and IELD group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et/\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{x}^{2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(47.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23(52.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.629\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(53.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(46.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(54.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(45.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.479\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(45.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(54.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDH Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShoulder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(48.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22(51.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAxillar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(51.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(48.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePuncture time(min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-20.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOperative Time unde the endoscope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.92\u0026thinsp;\u0026plusmn;\u0026thinsp;5.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.42\u0026thinsp;\u0026plusmn;\u0026thinsp;9.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTotal Time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.22\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRadiation Time (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-9.684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHospitalization Time (d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBed Rest Time (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVAS Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.431\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIntraop VAS of back\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.894\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIntraop VAS of leg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eODI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.19\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTolerance to re-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28/36(77.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17/36(47.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe puncture time was significantly longer (15.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u0026thinsp;\u0026gt;\u0026thinsp;5.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the radiation time was significantly higher (8.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u0026thinsp;\u0026gt;\u0026thinsp;4.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in the TELD group. However, operative time (52.22\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44\u0026thinsp;\u0026lt;\u0026thinsp;58.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) and the operative time unde the endoscope(36.92\u0026thinsp;\u0026plusmn;\u0026thinsp;5.79\u0026thinsp;\u0026lt;\u0026thinsp;53.42\u0026thinsp;\u0026plusmn;\u0026thinsp;9.60, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly reduced in this group. The details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003eThe intraoperative VAS scores of both back and leg pain in the TELD group were significantly lower than those in the IELD group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The satisfaction rate of TELD group was 94.44%, which was significantly higher than that of IELD group (75%) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026). And TELD group was superior to IELD group in tolerance to re-operation(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007). Overall, all included patients in the two groups demonstrated significant improvement in the VAS and ODI scores compared with the preoperative scores at the final follow-up. For different data collection time, there was no significant difference in VAS and ODI scores between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) The details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVAS and ODI between TELD and IELD group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eVAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.431\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 d post-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3month post-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.575\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6month post-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.761\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12month post-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.721\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eODI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.19\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 d post-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.38\u0026thinsp;\u0026plusmn;\u0026thinsp;2.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.699\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3month post-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.10\u0026thinsp;\u0026plusmn;\u0026thinsp;3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.677\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6month post-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.30\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.84\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12month post-op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.17\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLikert scale of 2 groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{x}^{2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eLikert scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrongly Good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e9.297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrongly Poor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFive patients across the two groups suffered complications. There were three cases in the IELD group that suffered Postoperative dysesthesia which were successfully treated with the application of dexamethasone and neurotrophic drugs. whereas 1 patient had fragment omissions and 1 patient had a recurrent disc herniation 3 months postoperation in the TELD group, and all recovered after conservative treatment. There was no difference in the complications rate between the two groups(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) The details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparision complications between TELD and IELD group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{x}^{2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFragment Omissions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNerve root injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative dysesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDural tears\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eClinical efficacy assessed at last follow-up using modified MacNab criteria classification There was no statistically significant difference between the two groups (excellent/good/fine/poor, 25/9/2/0 vs 25/8/3/0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) The details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eModified MacNab criteria between TELD and IELD group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIELD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{x}^{2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMacNab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eForst and Hausmann[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] first applied modified arthroscopy to decompression in 1983, greatly improving the efficiency and safety of spinal surgery. More than anything, Kambin 's anatomical description of the neural foramen (Kambin triangle) is one of the cornerstones in developing of a fully endoscopic transforaminal approach[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. On this basis, significant progress has been made in techniques for minimally invasive treatment of lumbar disc herniation, such as intradiscal injection of chymopapain[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], foraminoplasty[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], automatic nucleotomy aspiration via transforaminal approach with auxiliary catheter[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], laser decompression, and radiofrequency ablation[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In 1997, Yeung[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] et al developed a new generation of spinal endoscopic YESS system for intradiscal decompression through the Kambin safe trigone into the intervertebral disc, which has multiple channels and a wider angle, improved the nature of percutaneous endoscopic discectomy[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Since then, with the continuous development of spinal endoscopic techniques, tools and the transformation of concepts. Currently, PELD plays an irreplaceable role in the treatment of LDH.\u003c/p\u003e \u003cp\u003eDuring the process of shearing ligamentum flavum, rotating working channel and removing annulus fibrosus, stimulation of sinovertebral nerve and spinal nerve toot may cause intolerable lumbago and leg pain, and IELD has stronger traction on dura mater and nerve root during operation, which may lead to severe neuropathic pain. Therefore, most scholars recommend general anesthesia (GA) when performing PELD via the interlaminar approach[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, some studies have found that the risk of nerve root injury is higher during general anesthesia, and nerve electromyography monitoring should be used during surgery to prevent nerve root injury[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Ye[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] et al treated 60 patients with LDH using the IELD technique and showed no significant difference in ODI and VAS scores between LA and GA, whereas 1 patient in GA group had intraoperative nerve root injury. At the same time, it has also been shown that GA is associated with postoperative cognitive dysfunction in elderly patients[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Currently, PELD with local anesthesia has been proven to be a safe and effective method. Local anesthesia has the advantages of a faster recovery, shorter hospital stay and fewer complications.\u003c/p\u003e \u003cp\u003eIn this study, all patients were given local anesthesia, and the operation was successfully completed. There was no significant difference in postoperative bed rest time and hospitalization time between the two groups. 7 patients in the IELD group developed pain intraoperative, pain was controlled after intravenous sufentanil infusion. So IELD had a higher VAS scores for intraoperative back pain and leg pain than in the TELD group(P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). This could be a reason for the lower satisfaction rate in the IELD group. However, more intraoperative pain did not affect the clinical outcomes. At each follow-up of 3, 6, and 12 months after surgery, and the VAS and ODI score were significantly lower than preoperative (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). At the last follow-up, According to MacNab criteria, the excellent and good rate rates of TELD group and IELD group were 93.3% and 90.0%, separately. Therefore, the efficacy of PELD under LA is similar to that of traditional surgery, but it has the advantages of less trauma, lower medical expense and faster recovery.\u003c/p\u003e \u003cp\u003eHowever, PELD via the transforaminal route is challenging at the L5-S1 level due to obstruction of the anatomy. The iliac crest and inclination of the L5-S1 levels frequently impedes the transforaminal approach, resulting in steeper trajectory angles away from the extruded disc. The location and angle of the working channel are key factors for successful PELD. Choi DJ[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] established a pathway through iliac drilling for the first time to treat L5-S1DH intervertebral disc herniation with high iliac spine, but this method is easy to cause iliac fracture, superior gluteal nerve and superior gluteal artery and vein injury, so it is difficult to popularize widely. But definition of high iliac crest is vague. Choi KC [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] et al first proposed a grading system for high iliac crest based on the relationship between the highest point of the iliac crest and the adjacent bony markers, They recommended that the iliac height grade\u0026thinsp;\u0026ge;\u0026thinsp;5 is the threshold of foraminoplasty for transforaminal endoscopic L5-S1 discectomy. We believe that whether or not foraminoplasty is performed is also associated with the severity of foraminal stenosis and the size of facet joints. Therefore, foraminoplasty was performed in this group of patients as appropriate, which not only increased the safe working area of the working catheter, but also reduced the risk of nerve root injury. Similar to previous studies[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e][\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], we also found that patients in the TELD group had a greater puncture time and radiation time than patients in the IELD group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Analysis of the reasons: It is well known that the intervertebral foramen becomes progressively smaller in the lumbar spine, especially at the L5-S1 segment. In addition, the iliac crest usually conceals the L5-S1 foramen, which makes the puncture process difficult; therefore, a sufficient foraminoplasty is necessary to reveal axillar herniation. Conversely, the wider L5-S1 intervertebral disc space lowered the difficulty of PEID and thereby reduced the puncture time and radiation time. In the process of localization and puncture, the surgeon fully understand the spinal anatomy, master the puncture technique, can reduce the fluoroscopy time to a certain extent and shorten the puncture time.\u003c/p\u003e \u003cp\u003eL5-S1 has the largest interlaminar space distance and provides adequate operating space for the IELD. The majority of S1 nerve roots origin of the L5-S1disc level, and some may even originated superior L5-S1disc level[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. There is a certain space between the S1 nerve root and the dural sac, and axillary type of herniation will increase the space. And, it is easy to remove the herniation by placing the working catheter under the nerve root axilla. In contrast to axillary type of herniation, the shoulder space is relatively small as well as the restriction of the articular process, and the working catheter is difficult to reach to the shoulder of the nerve root. it is risky to rotate the working catheter directly in towards the disc. Therefore, a laminectomy is therefore needed to create operating space to reduce the risk of nerve root injury. In this study, a laminectomy was required in 23.5% of patients. We believe that the difficulty of the IELD approach with a huge central LDH. Which leads to greater tension of the dura and nerve roots, and the rotating working catheter is easy to damage the dura mater and nerve roots. Therefore, in this study, the position of the tongue of the working catheter was first placed in the disc under the axillary herniated disc, part of the herniation was removed for intraspinal decompression, and then the catheter was rotated to the shoulder of the nerve root under the protection of a nerve dissector for subsequent procedures.\u003c/p\u003e \u003cp\u003eAt the same time, Nie[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] et al found that PETD total operation time was higher than PEID in their study, which was contrary to our present study. In the study, we found that operative time unde the endoscope PEID group was longer than that of the PETD group. This is because PEID was done under general anesthesia in their study, whereas this study was done under local anesthesia. And some patients required more time to add intravenous sufentanil because of severe intraoperative pain caused by cutting the ligamentum flavum and laminectomy[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough this technique is widely used in the treatment of LDH, some unavoidable complications that may affect the final treatment outcome have also been reported[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In this study, the most common complication was postoperative dysesthesia, which we speculated was associated with excessive intraoperative traction of the nerve root, The patients\u0026rsquo; symptoms were improved by mecobalamin, gabapentin. In addition, complications such as recurrence of LDH and fragment Omissions were also observed in this study, but they were finally solved by various methods. There was no significant difference in complications between the two groups, and no serious complications such as nerve root injury and dural tear occurred. Surgeons should carefully consider appropriate technical factors and have a thorough understanding of patient anatomy to avoid complications.\u003c/p\u003e \u003cp\u003eThe treatment results showed that both PEID and PETD could obtain satisfactory results for L5-S1 DH. PEID has shorter puncture time and less radiation exposure, but longer operative time unde the endoscope and greater intraoperative pain. Therefore, in clinical practice, operators should strictly grasp the indications, combined with patient anatomical variation and operator experience to choose a personalized surgical approach.\u003c/p\u003e \u003cp\u003eThe present study had several limitations. Because TELD approach is the preferred approach for far-LDH, such patients were not included in this study. This was a preliminary analysis of the treatment results, without a detailed discussion of the relevant influencing factors or a comparative analysis with other surgical methods. Further investigations, especially muti-centered trails with a larger sample size should be conducted to overcome the limitations of our study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDF: Conducted the study. Collected, analyzed, and interpreted the data. Wrote the manuscript.\u003c/p\u003e\n\u003cp\u003eWJ: Designed the study, and interpreted the data, and edited the manuscript.\u003c/p\u003e\n\u003cp\u003eYZ: Interpreted the data, and edited the manuscript.\u003c/p\u003e\n\u003cp\u003eBJ: Interpreted the data.\u003c/p\u003e\n\u003cp\u003eWW: Interpreted the data.\u003c/p\u003e\n\u003cp\u003eJD: Interpreted the data.\u003c/p\u003e\n\u003cp\u003eYW: Interpreted the data.\u003c/p\u003e\n\u003cp\u003eZL: Planned the project. Interpreted the data.\u003c/p\u003e\n\u003cp\u003eHJ: Planned the project. Interpreted the data.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not funded by any foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Ethics Committee of The First Affiliated Hospital of Hebei North University and carried out in accordance with the ethical standards set out in the Helsinki Declaration. Informed consent was received from all participating.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976). 2002;27(7):722-731. \u003c/li\u003e\n\u003cli\u003eKim M, Lee S, Kim HS, Park S, Shim SY, Lim DJ. A Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Lumbar Disc Herniation in the Korean: A Meta-Analysis. Biomed Res Int. 2018;2018:9073460. \u003c/li\u003e\n\u003cli\u003eFoster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. doi:10.1016/S0140-6736(18)30489-6.\u003c/li\u003e\n\u003cli\u003eHe DW, Xu YJ, Chen WC, et al. Meta-analysis of the operative treatment of lumbar disc herniation via transforaminal percutaneous endoscopic discectomy versus interlaminar percutaneous endoscopic discectomy in randomized trials. Medicine (Baltimore). 2021;100(5):e23193. doi:10.1097/MD.0000000000023193.\u003c/li\u003e\n\u003cli\u003eLi P, Yang F, Chen Y, Song Y. Percutaneous transforaminal endoscopic discectomy for different types of lumbar disc herniation: A retrospective study. J Int Med Res. doi:10.1177/03000605211055045.\u003c/li\u003e\n\u003cli\u003eGu YT, Cui Z, Shao HW, Ye Y, Gu AQ. Percutaneous transforaminal endoscopic surgery (PTES) for symptomatic lumbar disc herniation: a surgical technique, outcome, and complications in 209 consecutive cases. J Orthop Surg Res. 2017;12(1):25. doi:10.1186/s13018-017-0524-0.\u003c/li\u003e\n\u003cli\u003eYeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am. 2007;38(3):363-vi. doi:10.1016/j.ocl.2007.04.005.\u003c/li\u003e\n\u003cli\u003eFeng WL, Yang JS, Wei D, et al. Gradient local anesthesia for percutaneous endoscopic interlaminar discectomy at the L5/S1 level: a feasibility study. J Orthop Surg Res. 2020;15(1):413. Published 2020 Sep 15. doi: 10.1186/s13018-020-01939-5.\u003c/li\u003e\n\u003cli\u003eHausmann B , Forst R .Shaving of the lumbar disk space? a new technique in lumbar nucleotomy[J]. Archives of Orthopaedic \u0026amp; Traumatic Surgery, 1984, 103(4): 284-285. doi: 10.1007/BF00387335.\u003c/li\u003e\n\u003cli\u003eSencer A, Yorukoglu AG, Akcakaya MO, et al. Fully endoscopic interlaminar and transforaminal lumbar discectomy: short-term clinical results of 163 surgically treated patients. World Neurosurg. 2014;82(5):884-890. doi:10.1016/j.wneu.2014.05.032.\u003c/li\u003e\n\u003cli\u003eFraser RD. Chymopapain for the treatment of intervertebral disc herniation. A preliminary report of a double-blind study. Spine (Phila Pa 1976). 1982;7(6):608-612. doi:10.1097/00007632-198211000-00016.\u003c/li\u003e\n\u003cli\u003eHoogland T, Schubert M, Miklitz B, Ramirez A. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976). 2006;31(24):E890-E897. doi:10.1097/01.brs.0000245955.22358.3a.\u003c/li\u003e\n\u003cli\u003eOnik G, Helms CA, Ginsburg L, Hoaglund FT, Morris J. Percutaneous lumbar diskectomy using a new aspiration probe. AJR Am J Roentgenol. 1985;144(6):1137-1140. doi:10.2214/ajr.144.6.1137.\u003c/li\u003e\n\u003cli\u003eKnight MT, Goswami A, Patko JT, Buxton N. Endoscopic foraminoplasty: a prospective study on 250 consecutive patients with independent evaluation. J Clin Laser Med Surg. 2001;19(2):73-81. doi:10.1089/104454701750285395.\u003c/li\u003e\n\u003cli\u003eYeung AT. The evolution of percutaneous spinal endoscopy and discectomy: state of the art. Mt Sinai J Med. 2000;67(4):327-332.\u003c/li\u003e\n\u003cli\u003eChoi G, Lee SH, Bhanot A,et al. Percutaneous endoscopic discectomy for extraforaminal lumbar disc herniations: extraforaminal targeted fragmentectomy technique using working channel endoscope. Spine (Phila Pa 1976). 2007;32(2):E93-E99. doi:10.1097/01.brs.0000252093.31632.54.\u003c/li\u003e\n\u003cli\u003eChen HT, Tsai CH, Chao SC, et al. Endoscopic discectomy of L5-S1 disc herniation via an interlaminar approach: Prospective controlled study under local and general anesthesia. Surg Neurol Int. 2011;2:93. doi:10.4103/2152-7806.82570.\u003c/li\u003e\n\u003cli\u003eGuan Y, Huang T, An G, et al. Percutaneous Endoscopic Interlaminar Lumbar Discectomy with Local Anesthesia for L5-S1 Disc Herniation: A Feasibility Study. Pain Physician. 2019;22(6):E649-E654.\u003c/li\u003e\n\u003cli\u003eWu K, Zhao Y, Feng Z, et al. Stepwise Local Anesthesia for Percutaneous Endoscopic Interlaminar Discectomy: Technique Strategy and Clinical Outcomes. World Neurosurg. 2020;134:e346-e352. doi:10.1016/j.wneu.2019.10.061.\u003c/li\u003e\n\u003cli\u003eYe XF, Wang S, Wu AM, et al. Comparison of the effects of general and local anesthesia in lumbar interlaminar endoscopic surgery. Ann Palliat Med. 2020;9(3):1103-1108. doi:10.21037/apm-20-623.\u003c/li\u003e\n\u003cli\u003eFeng WL, Yang JS, Wei D, et al. Gradient local anesthesia for percutaneous endoscopic interlaminar discectomy at the L5/S1 level: a feasibility study. J Orthop Surg Res. 2020;15(1):413. doi:10.1186/s13018-020-01939-5.\u003c/li\u003e\n\u003cli\u003eChoi DJ, Jung JT, Lee SJ, et al. Biportal Endoscopic Spinal Surgery for Recurrent Lumbar Disc Herniations. Clin Orthop Surg. 2016;8(3):325-329. doi:10.4055/cios.2016.8.3.325.\u003c/li\u003e\n\u003cli\u003eChoi KC, Park CK. Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation: Consideration of the Relation between the Iliac Crest and L5-S1 Disc. Pain Physician. 2016;19(2):E301-E308.\u003c/li\u003e\n\u003cli\u003eChen J, Jing X, Li C, et al. Percutaneous Endoscopic Lumbar Discectomy for L5S1 Lumbar Disc Herniation Using a Transforaminal Approach Versus an Interlaminar Approach: A Systematic Review and Meta-Analysis. World Neurosurg. 2018;116:412-420.e2. doi:10.1016/j.wneu.2018.05.075.\u003c/li\u003e\n\u003cli\u003eMo X, Shen J, Jiang W, et al. Percutaneous Endoscopic Lumbar Diskectomy for Axillar Herniation at L5-S1 via the Transforaminal Approach Versus the Interlaminar Approach: A Prospective Clinical Trial. World Neurosurg. 2019;125:e508-e514. doi:10.1016/j.wneu.2019.01.114.\u003c/li\u003e\n\u003cli\u003eArslan M, C\u0026ouml;mert A, A\u0026ccedil;ar Hİ, et al. Neurovascular structures adjacent to the lumbar intervertebral discs: an anatomical study of their morphometry and relationships. J Neurosurg Spine. 2011;14(5): 630-638. doi: 10.3171/2010.11.SPINE09149.\u003c/li\u003e\n\u003cli\u003eNie H, Zeng J, Song Y, et al. Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation Via an Interlaminar Approach Versus a Transforaminal Approach: A Prospective Randomized Controlled Study With 2-Year Follow Up. Spine (Phila Pa 1976). 2016;41 Suppl 19:B30-B37. doi:10.1097/BRS.0000000000001810.\u003c/li\u003e\n\u003cli\u003eChen Z, Wang X, Cui X, et al. Transforaminal Versus Interlaminar Approach of Full-Endoscopic Lumbar Discectomy Under Local Anesthesia for L5/S1 Disc Herniation: A Randomized Controlled Trial. Pain Physician. 2022;25(8):E1191-E1198.\u003c/li\u003e\n\u003cli\u003eShi C, Kong W, Liao W, et al. The Early Clinical Outcomes of a Percutaneous Full-Endoscopic Interlaminar Approach via a Surrounding Nerve Root Discectomy Operative Route for the Treatment of Ventral-Type Lumbar Disc Herniation. Biomed Res Int. 2018;2018:9157089. Published 2018 Feb 12. doi:10.1155/2018/9157089.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"lumbar disc herniation, local, anesthesia, transforaminal discectomy, minimally invasive","lastPublishedDoi":"10.21203/rs.3.rs-4697296/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4697296/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eBoth transforaminal and interlaminar approaches are effective methods for the treatment of L5-S1 disc herniation. Few studies have compared the efficacy and complications of two approaches under local anesthesia in the treatment of L5-S1 disc herniation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom May 2018 to July 2021, 72 patients with L5-S1 disc herniation were randomized to the transforaminal endoscopic lumbar discectomy (TELD, n = 36) or interlaminar endoscopic lumbar discectomy (IELD, n = 36). Both procedures were performed under 1% lidocaine local anesthesia. The baseline data, puncture time, radiation time, operative time unde the endoscope, total operation time, hospitalization time, bed rest time, and complications were compared between the two groups. In addition, Likert five-point scale was used for evaluation of patients experience to local anesthesia and tolerance to re-operation was assessed as well. The efficacy of surgery was assessed according to Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and modified MacNab score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAll patients with an average follow-up of 27.5 months. Compared to the IELD group, the TELD group had a longer puncture time (15.31±2.53\u0026gt;5.11±1.67, P \u0026lt; 0.001) and radiation time (8.44±2.01\u0026gt;4.61±1.27, P \u0026lt; 0.001) but a shorter total operative time(52.22±5.44\u0026lt;58.53±0.69, P=0.001) , operative time unde the endoscope(36.92±5.79\u0026lt;53.42±9.60, P \u0026lt; 0.001) and lower VAS scores for intraoperative back pain (P \u0026lt; 0.001) and leg pain (P\u0026lt;0.001). The postoperative VAS score and ODI score in both groups were significantly lower than those before operation(P\u0026lt;0.001), and there was no significant difference for each data collection time between the two groups (P \u0026gt; 0.05). The postoperative survey showed that the satisfaction rate of TELD group was higher than that of IELD group(P=0.026), TELD group was superior to IELD group in tolerance to re-operation(P =0.007). According to MacNab criteria, the excellent and good rate rates of TELD group and IELD group were 93.3% and 90.0%, and the difference was not statistically significant (P \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor L5/S1 DH, Both TELD and IELD can achieve good clinical efficacy under local anesthesia. Compared with PETD, PEID had lower puncture time, total operation time, and radiation exposure, but higher incidence of intraoperative low back pain and patients satisfactory rates less.\u003c/p\u003e","manuscriptTitle":"Efficacy analysis of different approaches of percutaneous transforaminal endoscopic local anesthesia in the treatment of L5- S1 disc herniation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-01 06:07:45","doi":"10.21203/rs.3.rs-4697296/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"580f754a-f7d0-4c61-8e85-4a31f186d3c1","owner":[],"postedDate":"August 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-20T05:08:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-01 06:07:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4697296","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4697296","identity":"rs-4697296","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}