Role of endoscopic sequestrectomy in the treatment of therapy-resistant radiculopathy in patients with extreme obesity: technical note and case report

Introduction

Extreme obesity is considered a critical condition that requires urgent treatment (1). In addition to metabolic syndrome, this type of obesity has an impact on all organ systems of the body. Pathophysiologically, vicious circles occur when one health condition exacerbates another one, which in turn, by positive feedback mechanisms, exacerbates the first one. This prevents patients from reducing their body weight without undergoing bariatric surgery (2,3). One of the key elements of the vicious circle is reduced mobility (4). Complete immobilization of patients with extreme obesity for various reasons increases mortality due to rapid respiratory and cardiovascular decompensation. One of the reasons for immobilization is pain syndrome caused by herniated discs. Conservative therapy, involving drug therapy and physical therapy, cannot always work in this case. Surgical therapy, namely herniated disc removal and nerve root decompression, is also associated with high intra- and postoperative risks. Anesthesia care during surgery poses risks ranging from difficult intubation of the patient to anesthesia recovery (5-8). Therefore, the surgery duration contributes to these risks. Open microsurgery is difficult due to the abundant adipose tissue and requires a larger approach as opposed to a standard patient. This in turn increases both the surgery duration and the risks of postoperative complications (e.g., impaired wound healing) (9). And any reoperation, even a small one, can have very serious risks for the patient. This means that the neurosurgeon faces a situation in which the patient requires surgery, but the operation must be quick and minimally traumatic. These criteria are met by an endoscopic approach in which the surgeon inserts a trocar up to the spinal canal, thus bypassing the subcutaneous tissue layers and not requiring a large skin incision (10,11). We believe that this technique is the most optimal for the treatment of therapy-resistant radiculopathy in patients with extreme obesity. We present this article in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-24-36/rc).

Case presentation

A 48-year-old patient was admitted with left L4 immobilizing radiculopathy. The patient’s body mass index was 54.3 kg/m² (height: 190 cm, weight: 196 kg). Sleeve gastrectomy was performed 4 years ago for obesity, and the patient lost 50 kg of weight. Acute pain appeared about 3 weeks ago. An magnetic resonance imaging (MRI) scan showed a herniated disc at the L3/L4 level on the left that was the cause of the patient’s L4 radiculopathy (Figure 1). For severe pain, the patient received oxycodone 20 mg twice daily, metamizole 4 g daily, dexamethasone 4 mg three times daily, and morphine 10 mg up to four times daily. Following conservative therapy, which failed to relieve pain, we performed endoscopic sequestrectomy via the interlaminar approach. Decompression of the left L3/4 recessus was also performed intraoperatively (Figure 2; Video 1). The operation duration (incision-dermal suture) was 80 minutes; anesthesia duration was 170 minutes. Laying the patient onto the operating table was not only time-consuming, but also required the participation of seven persons (Figure 3). Radiculopathy completely resolved after the surgery. The patient managed to be mobilized as soon as on the 1st postoperative day and discharged on the 4th postoperative day.

Figure 1 Preoperative T2-weighted MRI images in the sagittal (A) and axial (B) planes show the left L3/L4 herniated disc with L4 nerve root compression and lateral recess stenosis. MRI, magnetic resonance imaging.

Figure 2 Intraoperative images: (A) ligamentum flavum; (B) sequestrum located directly under the L4 nerve root.

Figure 3 Patient positioning on the operating table.

All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The use of an endoscopic approach in the treatment of herniated discs in patients with extreme obesity should be considered as one of the main therapeutic techniques, allowing rapid pain relief and thus increasing the patient’s mobility. Although many studies show equal efficacy of endoscopic and microsurgical approaches in the treatment of lumbar herniated discs (12,13), the endoscopic approach has great advantages when operating on patients with extreme obesity. The microsurgical approach is very difficult due to the abundant subcutaneous adipose tissue, which is associated with a longer surgery duration. A larger surgical approach is also undesirable as it poses a risk of impaired wound healing. The endoscopic approach therefore makes it possible to reach the spinal canal quickly. The range of endoscopic instruments (coagulation, curved scissors, and burrs) allows not only to remove the sequestrum, but also to perform decompression in case of lateral recess stenosis, as we have shown in the case above. It should be noted that the endoscope allows not only to distinguish anatomical structures easily, but also to get a good angle of view. Here this is a great advantage over the microscopic technique, in which the angle of view is limited due to the thick layer of subcutaneous adipose tissue.

The endoscopic surgery duration does not increase, as the spinal canal anatomy is generally not different between normal weight and obese patients. It should be taken into account that the anesthesia duration in any operation on patients with extreme obesity increases, as the patient positioning on the operating table requires additional time. This should also be considered when planning surgical treatment, as prolonged anesthesia may pose cardiorespiratory risks for the patient with extreme obesity. The shorter the surgery duration is, the shorter the total anesthesia duration is, respectively.

However, endoscopic surgery also poses intra- and postoperative risks (14). For example, dural damage can result in serious consequences, such as liquor fistulas and reoperations (15). Damage to nerve roots can disable the patient, drastically reducing mobility and thus critically affecting the patient’s overall condition.

Similar complications are possible when using microsurgical approaches. However, we believe that due to the limited surgical view, microsurgery requires greater access and more time. If the subcutaneous tissue is extensive, there are few opportunities to change the angle of view using microsurgical access. There are also challenges in selecting retractors to support the surgical field. The endoscopic approach does not have the above disadvantages.

If there is pain alone, without neurologic deficits, all risks should be discussed in detail with the patient. Immobilization of patients with extreme obesity even for a few days can result in cardiorespiratory complications, so surgery in this case seems to be a good alternative to long-term conservative treatment. In case of indications for emergency surgery (acute neurologic deficit, cauda equina syndrome) the endoscopic approach seems to be more promising, but this requires clinical trials.

Conclusions

The endoscopic approach can be successfully used for the treatment of therapy-resistant radiculopathy in patients with extreme obesity and can be considered as the main technique of surgical treatment, being both quick and minimally traumatic.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-24-36/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-36/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-36/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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