Transforaminal Endoscopic Lumbar Discectomy Under Local Anesthesia for Small-Sized Lumbar Disc Herniation in Elite Athletes

BACKGROUND: Symptomatic small-sized lumbar disc herniation (small LDH) presents a significant challenge in elite athletes, where rapid return to competition is paramount. This study aimed to characterize the clinical and imaging features of small LDH in this population and to evaluate the efficacy of transforaminal endoscopic lumbar discectomy (TELD) under local anesthesia. METHODS: We retrospectively reviewed the medical records of 11 elite athletes (12 discs) who underwent TELD for small LDH, defined as a herniation not exceeding 25% of the spinal canal's anteroposterior diameter on magnetic resonance imaging. Preoperative assessments included neurological status and magnetic resonance imaging findings, focusing on T2 hyperintensity within or posterior to the posterior longitudinal ligament (PLL). Outcomes were time to return to sport, recurrence, and patient-reported outcomes by modified MacNab criteria at final follow-up. RESULTS: All athletes presented with function-limiting radiculopathy despite radiographically small herniations (mean anteroposterior diameter, 3.3 ± 1.0 mm; mean canal occupancy ratio, 16.7% ± 6.6%). T2 hyperintensity in or behind the PLL was present in all 12 discs. Following TELD, all athletes returned to unrestricted competition at a median of 2.0 months (range, 1.5-5.0). At a median final follow-up of 26.0 months, modified MacNab outcomes were excellent in 63.6% and good in 36.4%. No recurrences requiring reoperation occurred. CONCLUSIONS: Symptomatic small LDH with associated T2 hyperintensity in the PLL is a distinct clinical entity in elite athletes. TELD under local anesthesia is a safe and effective intervention that facilitates a rapid and reliable return to sport with favorable mid-term outcomes. CLINICAL RELEVANCE: This study provides evidence that TELD under local anesthesia is an effective treatment for elite athletes with symptomatic small LDH, facilitating a predictable and rapid return to high-level competition. The identification of T2 hyperintensity in the PLL as a key imaging marker may help guide surgical decision-making in this specific patient population.