Fig. 6

Male patient (47 years) of L4/5 disc herniation with extruding fragment underwent the procedure of PTES. a Sagittal and b axial MR images showed L4/5 disc herniation. During the procedure of PTES, The puncture needle was anteromedially inserted at about 45° angle to the horizontal plane and the tip of puncture needle was in the posterior one third intervertebral space on c lateral C-arm view. Over the guiding wire, stepwise-dilating cannulas were introduced to annulus fibrosus through the foramen d. The thick guiding rod was advanced with a mallet into the foramen after removal of the guiding wire e. An 8.8-mm cannula was pushed over the rod to the facet joint area, docked at the superior facet after the rod was  removed, and pressed down to make the angle of the cannula to the horizontal plane smaller. Through this cannula, a 7.5-mm hand reamer was then introduced to ream the ventral part of facet bone until the resistance faded (press-down enlargement of the foramen) f, which was checked with g posteoanterior C-arm image. The reamer was removed, and the thick guiding rod then was reintroduced and advanced with the aid of a mallet until the tip of the guiding rod was into the herniated fragment h. A 7.5-mm working cannula was advanced over the guiding rod directly to the extruding fragment and the spine endoscope was inserted i. Under j, k, and l endoscopic view, the extruding disc fragment could be observed and the freed nerve root could be visualized after the massive nucleus underneath the nerve root were removed