What are the anesthetic considerations for Transforaminal Endoscopic Lumbar Discectomy (TELD)?

Anesthetic Considerations for Transforaminal Endoscopic Lumbar Discectomy (TELD)

Local anesthesia with 1% lidocaine is the preferred anesthetic approach for TELD due to its safety, effectiveness, and ability to keep patients conscious for neurological monitoring during the procedure. 1

Anesthetic Options for TELD

Local Anesthesia (Preferred Approach)

• Advantages:

  • Allows patient to remain conscious for real-time neurological feedback
  • Shorter operative time compared to other anesthetic methods
  • Shorter postoperative bed rest time
  • Avoids risks associated with general anesthesia
  • Enables immediate detection of potential nerve root injuries

• Technique:

  • Local infiltration with 1% lidocaine along the needle trajectory
  • Local infiltration at the entry point and deeper tissues including the facet joint and annulus
  • Consider port-side infiltration with long-acting local anesthetic for postoperative pain control 2

Enhanced Local Anesthesia Options

• Preemptive Analgesia (PA) + Local Anesthesia:

  • Combines preemptive analgesia with standard local anesthesia
  • Provides better intraoperative pain control than local anesthesia alone
  • Shorter operation time compared to epidural anesthesia
  • Higher risk of postoperative nausea and vomiting (7.5% incidence) 3

• Epidural Anesthesia:

  • Higher patient satisfaction rates (91% vs 73.6% with local anesthesia)
  • Better intraoperative pain control
  • No significant difference in neurological complications compared to local anesthesia
  • Longer operative time
  • Risk of transient paresis and urinary retention (3.75% incidence) 4

Perioperative Pain Management

Intraoperative Pain Control

• Local wound infiltration with long-acting local anesthetic
• Consider intravenous lidocaine as an adjunct 2
• For patients experiencing severe pain during the procedure:
  • Additional local anesthetic infiltration
  • Intravenous fentanyl or other opioid in divided doses 2
  • Some patients may require supplemental intravenous sufentanil for intense pain 1

Postoperative Pain Management

• Basic Level:

  • NSAIDs (rectal or oral)
  • Paracetamol (rectal or oral)
  • Local wound infiltration with long-acting local anesthetic 2

• Intermediate Level:

  • Intravenous or rectal NSAIDs
  • Intravenous or rectal paracetamol
  • Consider metamizole if available 2

• Advanced Level:

  • Consider regional anesthesia techniques:
    • Ultrasound-guided bilateral peripheral block (subcostal TAP or quadratus lumborum block) with clonidine as adjunct 2
  • For breakthrough pain:
    • Intravenous fentanyl in PACU
    • Oral or intravenous tramadol as rescue medication 2

Technical Considerations and Pitfalls

Potential Complications

• Exiting nerve root injury during cannula insertion
• Dural tearing
• Incomplete decompression
• Transient paresis of lower limbs
• Postoperative neuropathic pain 1, 5

Safety Measures

• Accurate anatomic understanding of Kambin triangle
• Appropriate endoscopic access angle based on type of disc herniation
• Safe entry point determination
• Careful landing and docking of working sleeve near target
• Complete decompression of symptomatic nerve with free mobilization of neural tissue
• Consider foraminoplasty in difficult cases 5

Adjunctive Measures

• Consider dexamethasone to reduce postoperative swelling 2
• Intraoperative addition of alpha-2 agonists may enhance analgesia 2
• Consider ketamine as co-analgesic drug 2

Choosing the Optimal Technique

For most patients undergoing TELD, local anesthesia with 1% lidocaine should be the first choice due to its safety profile and ability to maintain neurological monitoring. For patients with high anxiety or low pain tolerance, consider preemptive analgesia combined with local anesthesia or epidural anesthesia, weighing the benefits of improved pain control against the risks of increased complications and longer operative time.

The "outside-in" technique after foraminoplasty is recommended over the traditional "inside-out" technique to reduce the risk of exiting nerve injury and postoperative dysesthesia 6.