ENDOSCOPIC LUMBAR DISCECTOMY IN A MORBID OBESE PATIENT: CASE REPORT

DISCECTOMIA LOMBAR ENDOSCóPICA EM PACIENTE OBESO MóRBIDO: RELATO DE CASO

DISCECTOMíA LUMBAR ENDOSCóPICA EN UN PACIENTE CON OBESIDAD MóRBIDA: REPORTE DE CASO

ABSTRACT

In this case report, we present a 44-year-old male patient with a body mass index of 55 kg/m² and severe sleep apnea. He had been experiencing lower back pain radiating to the left lower limb for seven years, worsening over the past four months. Physical examination revealed a sensory deficit in the left L4 and L5 dermatome and a positive Lasègue sign, with an Oswestry Disability Index (ODI) of 38%, indicating moderate disability. After unsuccessful clinical and physiotherapeutic treatment, imaging studies showed disc herniations at L3-L4, L4-L5, and L5-S1. A transforaminal endoscopic discectomy with foraminoplasty at all three levels was chosen. The procedure was performed under general anesthesia, with a surgical time of 78 minutes. The patient was discharged eight hours after surgery. In the immediate postoperative period, there was significant improvement in lumbar and radicular pain, with reduced scores on the Visual Analog Scale (VAS). The ODI decreased to 14% at six and 12 months and 10% at 24 months, indicating minimal disability. At 24 months of follow-up, the patient reported only occasional low back pain and had returned to his normal professional activities. Level of Evidence IV; Case Report.

Keywords:
Obesity; Morbid; Intervertebral Disc Displacement; Endoscopic Surgical Procedures; Minimally Invasive Surgical Procedures.

RESUMO

Neste relato de caso, apresentamos um paciente masculino de 44 anos, com índice de massa corporal de 55 kg/m², portador de apneia do sono grave. Ele apresentava dor lombar irradiada para o membro inferior esquerdo há sete anos, com piora nos últimos quatro meses. O exame físico revelou déficit sensitivo no dermátomo de L4 e L5 à esquerda e sinal de Lasègue positivo, com um Índice de Incapacidade de Oswestry (ODI) de 38%, indicando incapacidade moderada. Após falha no tratamento clínico e fisioterápico, exames de imagem mostraram hérnias discais em L3-L4, L4-L5 e L5-S1. Optou-se pela discectomia endoscópica transforaminal com foraminoplastia nos três níveis. O procedimento foi realizado sob anestesia geral, com tempo cirúrgico de 78 minutos. O paciente recebeu alta hospitalar oito horas após a cirurgia. No pós-operatório imediato, houve melhora significativa da dor lombar e radicular, com redução dos escores na Escala Visual Analógica (EVA). O ODI diminuiu para 14% aos seis e 12 meses, e para 10% aos 24 meses, indicando incapacidade mínima. Com 24 meses de seguimento, o paciente referia apenas dor lombar esporádica e retornou às suas atividades profissionais normais. Nível de Evidência IV; Relato de Caso.

Descritores:
Obesidade Mórbida; Hérnia Discal Lombar; Discectomia Endoscópica Transforaminal; Cirurgia Minimamente Invasiva.

RESUMEN

En este reporte de caso, presentamos a un paciente masculino de 44 años con un índice de masa corporal de 55 kg/m² y apnea del sueño grave. Presentaba dolor lumbar irradiado al miembro inferior izquierdo durante siete años, con empeoramiento en los últimos cuatro meses. El examen físico reveló un déficit sensitivo en el dermatoma de L4 y L5 izquierdo y signo de Lasègue positivo, con un Índice de Discapacidad de Oswestry (ODI) del 38%, indicando discapacidad moderada. Tras el fracaso del tratamiento clínico y fisioterapéutico, las imágenes mostraron hernias discales en L3-L4, L4-L5 y L5-S1. Se optó por una discectomía endoscópica transforaminal con foraminoplastia en los tres niveles. El procedimiento se realizó bajo anestesia general, con un tiempo quirúrgico de 78 minutos. El paciente fue dado de alta ocho horas después de la cirugía. En el postoperatorio inmediato, hubo una mejora significativa del dolor lumbar y radicular, con reducción de los puntajes en la Escala Visual Analógica (EVA). El ODI disminuyó al 14% a los seis y 12 meses, y a 10% a los 24 meses, indicando discapacidad mínima. Con 24 meses de seguimiento, el paciente refirió solo dolor lumbar esporádico y retomó sus actividades profesionales normales. Nivel de Evidencia IV; Reporte de Caso.

Descriptores:
Obesidad mórbida; Desplazamiento del Disco Intervertebral; Procedimientos Quirúrgicos Endoscópicos; Procedimientos Quirúrgicos Mínimamente Invasivos.

INTRODUCTION

Morbid obesity (MO) is a medical condition whose prevalence has increased globally, bringing with it a series of clinical and surgical challenges¹. Patients with MO are at greater risk of developing degenerative spinal pathologies, such as lumbar disc herniations, due to the mechanical overload caused by excess weight² . Furthermore, the surgical management of these conditions represents an additional challenge, both due to the associated comorbidities and the technical difficulties inherent in surgical access in obese individuals³.

High-complexity orthopedic surgeries, which involve extensive soft tissue injury, can result in higher complication rates, prolonged surgical time, greater blood loss, and slower postoperative recovery. These factors highlight the need for less invasive methods that can minimize risks and improve clinical outcomes in these patients⁴.

Lumbar endoscopic discectomy emerges as a promising minimally invasive alternative, offering benefits such as less tissue trauma, faster recovery, and lower complication rates. However, the use of endoscopic techniques in the spine in patients with MO is still little explored in the literature⁵.

Given this context, the present work aims to report a case of lumbar disc herniation in a patient with MO treated by the transforaminal endoscopic technique,

CASE REPORT

This study involved the patient signing the Informed Consent Form (ICF). The Research Ethics Committee approved the report (CAAE 70416223.8.0000.5487, opinion number 6.339.106).

Male patient, 44 years old, with severe sleep apnea, weighing 170 kg and standing 1.76 m tall, resulting in a body mass index (BMI) of 55 kg/m², consistent with morbid obesity or class III obesity (BMI ≥ 40 kg/m²). He had a history of lower back pain radiating to the left lower limb (LLL) for seven years, with worsening in the last four months.

The neurological physical examination revealed a sensory deficit in the L4 and L5 dermatome on the left, muscle strength grade V in the lower limbs, and a positive Lasègue sign on the left. The pain intensity was assessed using the Visual Analog Scale (VAS), scoring 6 in the lumbar region, 8 in the gluteal region, and 7 in the left leg. Functional disability was measured by the Oswestry Disability Index (ODI), indicating moderate disability with a score of 38%.

The patient underwent clinical drug treatment and physical rehabilitation for four months without improvement of symptoms. The medication used included dipyrone 1 g every 6 hours, cyclobenzaprine 5 mg every 12 hours, tramadol 100 mg every 6 hours, and pregabalin 75 mg every 8 hours, with little reduction in pain symptoms. Furthermore, he underwent analgesic and motor physiotherapy during this period without improvement of symptoms.

Imaging exams were performed for diagnostic evaluation. Simple X-rays showed reduced disc spaces at L3-L4, L4-L5, and L5-S1, as well as small marginal osteophytes on the vertebral bodies. Dynamic flexion and extension X-rays showed no signs of instability. The computed tomography (CT) showed no evidence of discal or yellow ligament calcifications. The magnetic resonance imaging (MRI) of the lumbar spine revealed multisegmental degenerative spondylodiscoarthrosis, diffuse posterior disc bulge at L3-L4 with left lateral recess stenosis, diffuse posterior disc bulge at L4-L5 with bilateral lateral recess stenosis. It extruded center-lateral and foraminal disc herniation to the left at L5-S1 (Figure 1).

Figure 1
Preoperative MRI: sagittal cuts of the left lateral recess (A,B); axial cut of L3-L4 (C); axial cut of L4-L5 (D); and axial cut of L5-S1 (E).

Due to the persistence of pain, sensory neurological deficit, and functional incapacity, surgical treatment was chosen. The initial strategy consisted of performing left transforaminal endoscopic discectomy with foraminoplasty at the L3-L4, L4-L5, and L5-S1 levels. However, considering the patient’s degree of obesity, there was concern about the length of the transforaminal endoscope being sufficient to access the foramen and lateral recess at the scheduled levels. If it were not possible, the strategy would be changed to a right interlaminar endoscopic approach (contralateral), aiming at the approach and opening of the left foramen and discectomy at the three levels⁶.

The surgical procedure was performed under general anesthesia. Radioscopy guided the marking of the entry points at the addressed levels, followed by the introduction of the dilator and the working cannula (Figure 2).

Figure 2
Images of the patient positioned on the surgical table (A), marking of the entry point (B), and final positioning of the working cannula (B).

After identifying the lateral edge of the superior articular process of the caudal vertebra, foraminalplasty was performed with a cutting drill and endoscopic discectomy at the three levels (Figure 3). Hemostasis was achieved with retractable bipolar, and continuous irrigation of saline solution elevated to 1.5 m in relation to the patient was used. The total surgical time was 78 minutes, and the patient was discharged from the hospital eight hours after the procedure.

Figure 3
Positioning of the working cannula at levels L5-S1 (A), L4-L5 (B), and L3-L4 (C); and final aspect of the foraminoplasty and endoscopic discectomy at L4-L5 (D).

In the immediate postoperative period, there was a significant improvement in the intensity of lower back pain (VAS 2/10), in the gluteal region (VAS 3/10), and in the left leg (VAS 0/10). The patient reported an immediate perception of 95% improvement in numbness in the LLL. Six, 12, and 24 months after the procedure, the Oswestry Disability Index (ODI) was 14%, 14%, and 10%, respectively, indicating minimal disability. With 24 months of follow-up, the patient reports only sporadic lower back pain (VAS 2/10), without gluteal or LLL pain, maintaining his professional routine normally.

DISCUSSION

Obesity is defined by the World Health Organization (WHO) as a BMI equal to or greater than 30 kg/m², being classified into class I obesity (BMI 30-34.9 kg/m²), class II (BMI 35-39.9 kg/m²), and class III or morbid obesity (BMI ≥ 40 kg/m²)⁷-⁹. Morbid obesity is associated with a significant mechanical overload on the spine, especially in the lumbar region, contributing to damage to the integrity of the intervertebral discs and increasing the risk of disc degeneration, radicular pain, and disc herniations¹⁰,¹¹.

Due to the high incidence of comorbidities such as diabetes, hypertension, and sleep apnea in this population, the surgical risk for complications is high¹² . Obese patients undergoing spinal surgeries are at higher risk of infections, dural lacerations, anemia, deep vein thrombosis, and pulmonary embolism, especially in spinal fusion procedures¹³-¹⁶. Furthermore, the technical difficulties inherent to surgery in obese individuals result in longer surgical time, increased risk of contamination, and greater trauma to the paravertebral musculature¹⁷-¹⁹.

In recent years, minimally invasive surgery techniques have gained prominence for offering less blood loss, reduced postoperative pain, shorter hospital stays, and better long-term results compared to classic open techniques²⁰-²⁴. Lumbar endoscopic discectomy emerges as a promising alternative in the treatment of compressive syndromes of the spine, offering advantages such as less tissue trauma, smaller scars, early return to activities, and a lower rate of perioperative complications²⁵,²⁶.

In the present case, transforaminal endoscopic discectomy proved effective in treating lumbar disc herniation in a patient with MO, resulting in a significant reduction in pain intensity and sustained functional improvement over 12 months of follow-up. The technique allowed for a multi-level approach with reduced surgical time and minimal blood loss, even in the face of initial concerns related to surgical access due to the patient’s biotype. These findings are in agreement with previous studies that indicate the feasibility and safety of the endoscopic approach in this population group¹⁷-¹⁹,²⁷-³² .

Haijiang Yu et al. suggest that the decrease in the incidence of complications in obese patients undergoing endoscopic lumbar discectomy can be attributed to technical advances that allow for shorter procedure times and reduce paraspinal muscle trauma.³³ Our report reinforces this perspective, demonstrating that the endoscopic technique is feasible in patients with MO and can minimize the risks associated with conventional surgeries.

However, the literature regarding endoscopic techniques in patients with MO is still scarce, indicating the need for additional studies with larger samples and long-term follow-up. Furthermore, developing instruments and equipment adapted for this patient profile can enhance the observed benefits, providing better clinical outcomes and quality of life.

CONCLUSION

Transforaminal endoscopic lumbar discectomy with a traditional endoscope proved to be a safe and effective option in this report. New studies should be conducted to consolidate the use of this technique in patients with MO.

• Study conducted by the Clínica Atualli, São Paulo, SP, Brazil.

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Edited by

• Reviewed by
  Robert Meves

Publication Dates

• Publication in this collection
  13 Dec 2024
• Date of issue
  2024

History

• Received
  17 Oct 2024
• Accepted
  04 Nov 2024