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A clinical case from Professor Iakiv Vitaliiovych Fishchenko's practice
In a 64-year-old woman, an L5–S1 lumbar disc herniation caused severe left leg pain, loss of active foot and toe extension, and urinary incontinence. Professor Iakiv Fishchenko performed biportal endoscopic herniation removal using BESS/UBE through an interlaminar approach.
After surgery, bladder control returned, pain decreased substantially and muscle strength began to recover. Results from the first week of follow-up are presented below.
The symptoms the patient presented with
Left leg pain had lasted more than a week and reached 10 out of 10 on the visual analogue scale (VAS). Before surgery, the patient had taken non-steroidal anti-inflammatory drugs.
Two days before surgery, she lost the ability to actively extend the left foot and toes. The relevant muscles were graded 0/5 on the MRC scale, with no active contraction detected. Urinary incontinence developed at the same time.
The patient had not previously undergone lumbar spine surgery.
Increasing motor impairment and new urinary dysfunction require emergency medical assessment. Severe or progressive motor deficit is an indication to consider surgical treatment of lumbar disc herniation. WFNS Spine Committee recommendations, 2024.
What MRI showed
Preoperative MRI showed a centrally located L5–S1 disc herniation. However, the clinical symptoms — pain and motor deficit — predominated on the left.
The herniated fragment remained connected to the disc; it was not a free sequestrated fragment.
Why an interlaminar endoscopic approach was chosen
Professor Iakiv Fishchenko explains:
“In this case, I selected an interlaminar approach because the herniation was centrally located. I performed the operation using the BESS/UBE biportal endoscopic technique.
During surgery, I removed the herniated fragment compressing the nerve structures, as well as additional fragments from within the disc. This means removal of herniated material, not the entire intervertebral disc.”
The aim of surgery was therefore to relieve compression of the nerve structures at L5–S1.
Initial results after surgery
Bladder control returned immediately after surgery.
The next day, left leg pain was 2/10 on the VAS, compared with 10/10 before surgery. Follow-up MRI was performed that day.
No intraoperative or early postoperative complications were recorded. The patient was discharged the day after surgery.
The result at one week
At one week, pain had decreased to 1/10 on the VAS. Strength in the muscles extending the left foot and toes had improved to 4/5 on the MRC scale.
| Measure | Before surgery | At one week |
|---|---|---|
| Left leg pain, VAS | 10/10 | 1/10 |
| Left foot and toe extensor strength, MRC | 0/5 | 4/5 |
| Bladder control | Urinary incontinence | Restored after surgery |
Motor recovery was substantial but still incomplete: a grade of 4/5 does not mean normal muscle strength. No information beyond the first week is currently available for this account.
What this case demonstrates
In this patient, a central L5–S1 herniation was accompanied by marked neurological impairment. After endoscopic removal of herniated material, rapid pain reduction, restoration of bladder control and substantial improvement in muscle strength were observed during the first week.
This is the outcome of one clinical case. The timing and extent of recovery may differ in other patients.
Clinical discussion author: Professor Iakiv Vitaliiovych Fishchenko.
Source of the original account and MRI: clinical case 3 in the Atlas of Biportal Endoscopic Spine Surgery (original-language resource).
Consent was obtained to publish the clinical case and anonymised MRI images.
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Send a description of symptoms and existing investigations. If MRI/CT has already been performed, include the complete DICOM study and report. Preliminary review by the professor is free; an in-person consultation is also possible without an MRI already available.