The Transiliac Approach: A Forgotten Alternative for Transforaminal Endoscopic Decompression at the L5-S1 Level in Patients With High Iliac Crests

Background Transforaminal endoscopic lumbar discectomy (TELD) is a useful approach to tackle ventral compressive pathology in the spine. Its utility at the L5-S1 level is limited by anatomical factors such as a high iliac crest, large L5 transverse processes, large facets, narrow foramen, and the sacral ala. Transiliac transforaminal endoscopic lumbar discectomy (TI-TELD) has been reported to help overcome these obstacles, but has been reported sparsely. Methodology This was a single-center retrospective review of patients who underwent TI-TELD at the last mobile level in view of a high iliac crest at our center between January 2009 and January 2021. Only patients with complete records and a minimum two-year post-procedure follow-up were included. Patient records were scrutinized to note the demographic, surgical procedural details, and patient-reported outcome measures in terms of Visual Analog Scale and Oswestry Disability Index (ODI) scores. Results In total, 93 patients (83 men and 10 women) with a mean age of 41.77 ± 9.34 years were operated on over 12 years. Intraoperatively, it took a mean of 11.69 ± 2.38 minutes to reach the foramen. The mean operative time was 76.9 ± 12.24 minutes. Overall, 89 patients were discharged home on the same day, with decompression confirmed on MRI. The mean preoperative ODI score was 79.8%, and this improved to an average of 5.94% at the two-year follow-up and was maintained at the latest average follow-up of 59.98 months. In total, 82 of the 93 patients reported that they were highly satisfied with the procedure and gave a score of 1 as the patient satisfaction index. Overall, 13 of 16 patients with preoperative neurological deficits recovered Medical Research Council motor power greater than Grade 3. On average, our patients returned to work 19.20 days after surgery. Minor complications included a non-articular facet fracture (n = 1), prodrome to seizure (n = 1), ecchymosis (n = 4), superficial wound necrosis (n = 1), and bending of the obturator (n = 1). One patient required on-table conversion to micro-lumbar decompression. Postoperative MRI revealed an inadequate decompression in two patients, both of whom required fusion surgery. Two patients had a recurrent disc. Fusion was performed for the patient who had a recurrence on the same side, while the other patient was treated by TI-TELD from the opposite side. Conclusions TI-TELD is an under-reported procedure and provides good outcomes sustained over a longer follow-up than previously reported. Although more invasive than traditional TELD, the inherent benefits and advantages of being able to perform the procedure under local anesthesia make it more amenable for ambulatory surgical centers.