Paraspinal approach to the far lateral disc herniations: retrospective study on 42 cases

Minimally Invasive Approaches for Lumbosacral Plexus Schwannomas

BACKGROUND AND OBJECTIVES

Lumbosacral plexus schwannomas (LSPSs) are benign, slow-growing tumors that arise from the myelin sheath of the lumbar or sacral plexus nerves. Surgery is the treatment of choice for symptomatic LSPSs. Conventional retroperitoneal or transabdominal approaches provide wide exposure of the lesion but are often associated with complications in the abdominal wall, lumbar or sacral plexus, ureter, and intraperitoneal organs. Advances in technology and minimally invasive (MIS) techniques have provided alternative approaches with reliable efficacy compared with traditional open surgery. We describe 3 MIS approaches using tubular retractor systems according to the lesion level.

METHODS

This was a multicenter, retrospective observational cohort study to evaluate the use of MIS tubular approaches for surgical resection of LSPSs. We included 23 lumbar and upper sacral plexus schwannomas. Clinical presentation, spinal level, surgical duration, degree of resection, days of hospitalization, pathological anatomy of the tumor, approach-related surgical difficulties, and outcomes were collected.

RESULTS

The posterior oblique approach was used in 43.5% of the cases, the transpsoas approach in 39.1%, and the transiliac in 17.4%. The mean operative time was 3.3 hours, and the mean hospitalization was 2.5 days. All tumors were WHO grade 1 schwannoma. Postoperative MRI confirms gross total resection in 91.3% of the patients. No patient requires instrumentation. The pros and cons of each approach were summarized.

CONCLUSION

The MIS approaches adapted to the lumbar level may improve surgeons' comfort allowing a safe resection of retroperitoneal LSPS.

Minimally Invasive Far Lateral Lumbar Discectomy With Modified Technique: Symptomatic Relief and Intersegmental Stability Study

OBJECTIVE

To evaluate the use of a modified minimally invasive surgery (MIS) technique for far lateral lumbar discectomy (FLDH) that minimizes the degree of bony drilling required for nerve root decompression, increasing postoperative pain reduction rate with reduced risk of iatrogenic spinal instability.

SUMMARY OF BACKGROUND DATA

FLDH accounts for approximately 10% of all lumbar disc herniations and is increasingly recognized in the era of advanced imaging techniques. These disc herniations typically result in extra-foraminal nerve root compression. Minimally invasive spine techniques are increasingly performed with various degrees of foraminal and facet removal to decompress the affected nerve root.

METHODS

The study design involves a single institutional, retrospective cohort technical review. The review was completed of all patients undergoing MIS far lateral lumbar discectomy between 2010 and 2020. Cross-sectional, summary statistics were calculated for all variables. Counts and percentages were recorded for categorical variables and mean and standard deviations were calculated for continuous variables.

RESULTS

A total of 48 patients underwent MIS far lateral lumbar discectomies (FLLD) from 2010 to 2020. The mean age was 63 ± 11.5 years (60.4% males), the mean BMI was 28.5 ± 5.5, and 20.8% smokers. The most common presenting complaint was both low back and radicular pain (79.2%) with 8.3% of patients suffering from motor weakness preoperatively. The mean follow-up time was 4.3 ± 2.7. The mean length of stay was 1.3 ± 1.4 days with 77.1% of patients discharged postoperative day one. Forty-three patients (93.5%) had improvement in their symptoms. Twenty-seven (58.7%) had complete resolution in 2.6 months on average. Six patients (13%) had immediate symptom resolution postoperatively.

CONCLUSIONS

Our modified technique for FLLD allows MIS access to the extra-foraminal site of nerve root compression without the need for bony drilling. This minimizes postoperative pain and reduces the risk of iatrogenic spinal instability without sacrificing symptom resolution.

Long-term follow-up results of surgically treated patients with foraminal and far lateral disc herniations

PURPOSE

Foraminal and far lateral disc herniations are rarer cause of nerve root compression. There are reports regarding the outcome, however long-term follow-up results of surgically treated patients are few. The purpose of this retrospective study is to analyze the clinical characteristics and long-term surgical outcomes of the foraminal and far lateral disc herniations.

MATERIALS AND METHODS

The 114 patients who underwent an operation for foraminal and far lateral disc herniaitions were reviewed. Visual analogue scale of back and leg pain, the ocurrence of motor deficit and sensory dysesthesia before and after operations were used to compare the results of early and long-term outcome.

RESULTS

A total of 114 telephone interviews were conducted. The mean follow up was 134 months. Complete relief of symptoms were reported by 77 patients (67.1%). The average VAS of radicular leg pain was 7.5 Post-operatively the average VAS of radicular pain decreased to 2.2. Preoperatively, 9 patients (7.6%) had motor deficit and 17 (14.4%) patients had sensory dysesthesia. Post-operatively 9 (100%) of the patients showed motor, and 12 (70.6%) of the patients showed sensory improvement. In 17 patients with hypoesthesia the complaints continued during 2 weeks to 6 months. They were given gabapentin as medical treatment, however 5 of these patients still have sensory dysesthesia. The outcome was: 67.1% excellent (77 patients), 26.3% good (30 patients), 6.1% fair (7 patients).

CONCLUSION

The far lateral approach is a minimally invasive and safe procedure with low complication rates.

A transfacet approach to the lumbar nerve root canal: technical note

BACKGROUND

Intraforaminal and extraforaminal nerve root compressions caused by disk herniation or stenosis are relatively common causes of lumbar radiculopathy. Currently, the two available surgical treatment methods are decompression from the spinal canal or lateral decompression via the Wiltse approach.

OBJECTIVE

To describe a novel transosseous approach to the lumbar nerve root canal.

METHODS

Transfacet foraminotomy was performed in 11 patients with intraforaminal or extraforaminal disk herniation. The outcome was measured using the Patient Satisfaction Index (PSI), need for reoperation, radiographic criteria, and finite element analysis.

RESULTS

We noted that at the time of dismissal, PSI scores of 1 and 3 were reported by 10 and one patients, respectively. At the last follow-up, 10 patients reported a PSI score of 1 or 2. Two patients required reoperation because of recurrent disk herniation. Two patients underwent computed tomography (CT) postoperatively, which showed the transfacet approach. Intriguingly, a second postoperative CT after one month showed that the hole through the facet joint had shrunk significantly.

CONCLUSION

A posterior-anterior transfacet approach for intraforaminal or extraforaminal disk herniations using an ellipsoid facetectomy is safe and allows for fast and comfortable decompression of the nerve root without compromising the long-term strength of the facet joint.

Minimally Invasive Far-Lateral Microdiscectomy: A New Retractor for Far-Lateral Lumbar Disc Surgery

Background

To date, a number of approaches have been described for far-lateral disc surgery, including midline, paramedian, and intertransverse approaches. These approaches pose challenges for surgeons due to the difficulty in retraction caused by the anatomy of the foramen. We designed a retractor suitable for the three-dimensional anatomical structure of the foramen. In this study, we aimed to evaluate the surgical outcomes of the patients who were operated on using this retractor in our clinic.

Methods 

The retrospective study included patients who were operated on due to far-lateral disc herniation using the retractor designed in our clinic between February 2013 and December 2018.

Results 

The study included 11 (64.7%) women and 6 (35.3%) men, with a mean age of 56 years (range: 42-70 years). The mean operative time was 49 minutes (range: 40-70 minutes), the mean estimated blood loss was 42 mL (range: 25-60 mL), and the mean follow-up period was 22.6 months (range: 13-48 months). No complication occurred in any patient. A minimally invasive discectomy was performed via the paramedian approach in each patient. The patients were evaluated using the visual analog scale (VAS) for radicular pain, Oswestry Disability Index (ODI), 36-Item Short Form Survey (SF-36), and the modified MacNab criteria.

Conclusion 

The retractor developed in our study provided numerous benefits during the surgical procedure as it led to minimal blood loss and reduced operative times by avoiding bone resection in extraforaminal discs and requiring minimal bone resection in foraminal discs.

Current and Future of Endoscopic Spine Surgery: What are the Common Procedures we Have Now and What Lies Ahead?

The aging population around the world leads to increasing incidence of degenerative spinal conditions. There is a need for a minimally invasive technique in treatment for spinal conditions to meet the medical complexity and comorbidities that comes with aging. Principles of endoscopy are similar to minimally invasive surgery, which is to decrease pressure on soft tissue crushing from prolonged retraction, avoid soft tissue stripping and dissection, and bone and ligamentous preservation for optimal decompression without excessive destruction. Endoscopic spine surgery techniques started slowly in development in the 1970s to 2000s, with a rapid phase of development since the turn of the 21st century with endoscopic solutions developing in cervical, thoracic, and lumbar conditions with increasing complexity in nature of operation. Technological enhancement with progressively supportive literature is pushing boundaries of endoscopy from the early days of soft tissue procedure to current fusion procedures, endoscopic spine surgery techniques is covering more areas of spine than ever previously possible with good clinical results. We present a review on the current techniques available and postulated near future development for endoscopic spine surgery.

Intervertebral Disc Diseases PART 2: A Review of the Current Diagnostic and Treatment Strategies for Intervertebral Disc Disease

With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases.

Minimally invasive surgical techniques for the therapy of far lateral disc herniation in middle-aged and elderly patients

To examine the clinical results of different minimally invasive techniques for the therapy of far lateral disc herniation in middle-aged and elderly patients. An endoscopic approach (percutaneous endoscopic lumbar discectomy; PELD), MIS-TLIF combined with contralateral translaminar screw (MIS-TLIF CTS), and MIS-TLIF combined with bilateral pedicle screws (MIS-TLIF BPS) were evaluated via a retrospective chart review. Data from 74 consecutive middle-aged and elderly patients with far lateral disc herniation were analyzed. All patients underwent surgery; 19 with PELD, 24 with MIS-TLIF CTS, and 31 with MIS-TLIF BPS. Clinical data included the length of the incision, duration of the operation, estimated blood loss, hospitalization time, operation cost, recurrence rate, and fusion rate. Preoperative and postoperative patient outcomes including the VAS, ODI scores and MacNab criteria were assessed and recorded. The mean follow-up time was 26.4 months (range from 14 to 46 months). Compared with the internal fixation groups, the length of the incision, duration of operation, estimated blood loss, and hospitalization time were obviously lower in the PELD group. The difference in operation cost among the three methods was statistically significant. The postoperative VAS scores for LBP and LP decreased significantly as compared with those recorded preoperatively. The postoperative ODI scores were lower than those recorded preoperatively. MacNab criteria rating excellent, good and fair results were in 27, 37 and 10 patients, respectively. Conclusion: PELD, MIS-TLIF CTS, and MIS-TLIF BPS are all effective minimally invasive techniques for the therapy of single segment far lateral lumbar disc herniation in middle-aged and elderly patients. PELD had a shorter operation time and less surgical trauma, being a less invasive and more economical method; however, there was no recurrence of disc herniation after fixation. Compared with MIS-TLIF BPS, MIS-TLIF CTS obtained a similar clinical effect and certain costs were saved.

Clinical Outcome of Minimally Invasive Decompression Without Discectomy in Contained Foraminal Disc Herniation: A Single-Center Study

BACKGROUND

Foraminal disc herniation is rare. When conservative treatment fails, it is often treated with discectomy via a paraspinal or Wiltse approach. In contained foraminal disc herniation, more symptoms arise from the foraminal compression of the exiting nerve root, including the dorsal root ganglion, than from the herniation itself. We aimed to evaluate the benefits of stand-alone decompression without discectomy for patients with contained foraminal disc herniation.

METHODS

This study included 17 patients with unilateral single-level foraminal disc herniation (14 women and 3 men; mean age, 62.8 ± 14.6 years, range, 37-86 years). Disc herniation was confirmed as contained by preoperative magnetic resonance imaging and/or computed tomography and by intraoperative exploration. All patients underwent thorough decompression without discectomy, via a paraspinal approach. Pain was evaluated preoperatively and at 3 and 12 months postoperatively using a visual analog scale (VAS). The Oswestry Disability Index (ODI) and Macnab criteria were used to evaluate final outcomes.

RESULTS

The most commonly affected level was L5-S1. All 17 patients showed significant improvements in VAS and ODI scores at 3 and 12 months postoperatively. According to the Macnab criteria, outcome results were excellent in 13 patients and good in 4. The mean duration of follow-up was 18.4 ± 2.4 months, with no recurrences or lumbar instability at the final follow-up.

CONCLUSIONS

Stand-alone decompression without discectomy is an effective method for relieving symptoms and preserving the disc in contained foraminal disc herniation. A minimally invasive approach with thorough decompression techniques yields good results.

Clinical and radiological outcomes after decompression and posterior fusion in patients with degenerative scoliosis

OBJECTIVE

The prevalence of degenerative scoliosis (DS) increases with age and an overall increase is seen due to the aging population. This study aims to evaluate the clinical and radiological outcomes after decompression and posterior fusion in patients with DS.

METHODS

In this is prospective study, 43 patients with DS, aged 37 to 70 years, were eligible to undergo decompression and posterior fusion. Primary outcomes were low back pain (LBP) with or without radicular pain, which was evaluated preoperatively and at 12 and 24 months after surgery with the use of a visual analog scale (VAS), and the quality of life (QOL), which was assessed at the same time periods by the Oswestry Disability Index (ODI) questionnaire. The Cobb's method was used to measure the degree of scoliosis in each patient preoperatively and at 24 hours, 12 and 24 months after the surgery.

RESULTS

VAS scores improved significantly from a mean of 8.18 preoperatively to 4.48 at 12 months and 3.07 at 24 months postoperatively (P < .001). The mean radicular pain scores also decreased significantly (P < .001). At postoperative 12 months, the mean ODI score was significantly lower than the mean preoperative ODI score (47.81 ± 16.06 vs. 72.18 ± 12.28; P = .001). ODI score at 24 months postoperatively was significantly better than the preoperative ODI (15.53 ± 7.21 vs. 72.18 ± 12.28; P = .016). The mean Cobb angle changed significantly from 31.4° ± 4.88 preoperatively to 3.28° ± 2.10 at 24 months postoperatively (P < .001).

CONCLUSIONS

Our findings suggest that decompression and posterior fusion in the patients with DS is an effective surgical method which is associated with satisfying clinical results in terms of improvement of postoperative LBP, radicular pain, and QOL, and correction of Cobb angle at 12 and 24 months after the surgery and restoration of sagittal alignment at 2 months postoperatively.

Direct Tubular Lumbar Microdiscectomy for Far Lateral Disc Herniation: A Modified Approach

OBJECTIVE

The concept of minimally invasive tubular discectomy is based on precise placement of the retractor over the surgical target to minimize collateral tissue trauma. For far lateral disc herniation, the junction between the pars and the transverse process has generally been adopted as the target for facilitating early nerve root exposure; however, this may limit access to the disc space and increase the risks of iatrogenic neuralgia. An alternative approach to help address these issues involving docking the retractor caudally directly over the disc space with the aid of a microscope is here proposed. The purpose of this study was to evaluate the safety and efficacy of such an approach.

METHODS

Nineteen patients in whom the modified approach was performed over a 35-month period were identified. Direct access to the disc space was attained by directing the retractor against the lateral margin of the facet joint and following the inferior transverse process medially towards the foramen with minimal exposure of the nerve root. Clinical outcomes were assessed by the Oswestry Disability Index, visual analogue scale scores for leg and back pain, Short Form 36 physical functioning (SF36-PF) and bodily pain (SF36-BP) scores and sciatica bothersomeness and frequency indexes (SBI & SFI) and obtained from a prospective patient database. Follow-up data in the first 6 months were compared with preoperative baseline data.

RESULTS

All procedures were successfully completed with the modified approach. Contained disc herniation without sequestrated fragments was found in all but four cases. No perioperative complications or reoperation were recorded and no postoperative dysesthesia was noted. Clinically significant reductions in mean Oswestry Disability Index (32; 95% CI, 21-43) and visual analogue scale scores for leg pain (38 mm; 95% CI, 23-54 mm) and back pain (35 mm; 95% CI, 21-48 mm) scores were noted in the first 6 months. Significant improvements in SF36-PF (40; 95% CI, 30-51) and SF36-BP (35; 95% CI, 26-43), SBI (9; 95% CI, 6-11) and SFI (11; 95% CI, 8-13) were also recorded.

CONCLUSIONS

A modified direct tubular approach is safe and effective for treating far lateral lumbar disc herniation. Our early results suggest that this approach helps safeguard adequate decompression and reduce the risk of postoperative dysesthesia.

Far lateral microdiscectomy: a minimally-invasive surgical technique for the treatment of far lateral lumbar disc herniation

Lumbar disc herniation arises when the annulus fibrosus of the vertebral disc fails, thus allowing displacement of the nucleus pulposus and other tissue. The term far lateral is used variably in the literature and usually refers to an extraforaminal displacement in the peridiscal zone peripheral to the sagittal plane of the most lateral part of the pedicle at the same level. Non-surgical treatments of far lateral disc herniation include physical therapy, anti-inflammatory medication, and corticosteroid injections. Where these conservative measures fail, surgical intervention may be required. Several surgical techniques for the treatment of far lateral herniations have been investigated, including total or medial facetectomy, laminectomy, hemilaminectomy, approaches through the pars interarticularis, and lateral approaches between the transverse processes via the intertransverse muscle and ligament. We present our far lateral microdiscectomy technique which involves accessing the nerve root lateral to the foramen through a small paramedian incision and use of an operating microscope. Far lateral microdiscectomy offers the prospect of better long-term results than other surgical techniques because of less extensive muscle dissection and preservation of the integrity of the facet joint.

Effects of methylene blue on postoperative low-back pain and functional outcomes after lumbar open discectomy: a triple-blind, randomized placebo-controlled trial

OBJECT

Despite advances in surgical and anesthesiology techniques, many patients continue to experience postoperative pain after lumbar disc operations. This study aims to investigate the effects of methylene blue (MB) on preventing postoperative low-back pain (LBP) with or without radicular pain and improving the quality of life (QOL) in patients undergoing lumbar open discectomy.

METHODS

This is a prospective, randomized, triple-blind, placebo-controlled clinical trial, which was conducted at Shiraz University of Medical Sciences between July 2011 to January 2012. Of a total of 130 patients, 115 were eligible for participation; 56 received 1 ml of MB solution at a concentration of 0.5% (MB group) and 59 received an equivalent volume of normal saline (control group). Primary outcomes were the control of LBP with or without radicular pain, which was evaluated preoperatively and at 24 hours and 3 months after surgery with the use of a visual analog scale (VAS), and the improvement of QOL, which was assessed preoperatively and 3 months postoperatively by means of the Persian translation of the Oswestry Disability Index questionnaire.

RESULTS

The mean VAS scores for LBP were significantly lower in the MB group compared with the control group at 24 hours (1.25 ± 0.97 vs 2.80 ± 0.69, p < 0.001) and 3 months (1.02 ± 1.29 vs 2.07 ± 1.10, p = 0.019) after treatment. The mean radicular pain scores decreased significantly in the 2 groups at 24 hours after surgery, but the mean radicular pain score was significantly lower in the MB-treated patients than the control group. However, the difference between radicular pain scores in the MB group (1 ± 1.1) and the control group (1.2 ± 1) was not statistically significant (p = 0.64). The reduction in LBP was greater in the MB group than the control group (8.11 ± 1.74 vs 6.07 ± 1.52, p = 0.023, CI 95% −1.37 to −0.10). The functional QOL improved significantly 3 months after the operation in both groups (p < 0.001). Moderate disability occurred more frequently in the control group than in the MB group (14.5% vs 7.7%, p = 0.004). No toxicity, adverse effects, or complications were found in the group of patients treated with MB injection.

CONCLUSIONS

A single dose of MB (1 ml 0.5%) for coating the dura and surrounding tissues (facet and muscle) shows promising results in terms of safety, reduction of postoperative pain, and functional outcome compared with placebo.

Minimally Invasive Foraminotomy Through Tubular Retractors via a Contralateral Approach in Patients With Unilateral Radiculopathy

BACKGROUND:

Radiculopathy caused by foraminal nerve root compression is a common pathology in the lumbar spine. Surgical decompression via a conventional open foraminotomy is the treatment of choice when surgery is indicated. Minimally invasive tubular foraminotomy through a contralateral approach is a potentially effective surgical alternative.

OBJECTIVE:

The aim of this retrospective cohort study was to evaluate the efficacy and benefits of this approach for treatment of radiculopathy.

METHODS:

Patients with unilaterally dominant lower extremity radiculopathy, who underwent minimally invasive lumbar foraminotomy through tubular retractors via a contralateral approach between 2010 and 2012, were included. Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for back and leg pain were evaluated preoperatively, postoperatively, and at the latest follow-up. Functional outcome was evaluated by using the MacNab criteria.

RESULTS:

For the total 32 patients, postoperatively there was significant improvement in the ODI (P = .006), VAS back pain (P &lt; .001), and VAS leg pain on the pathology and the approach side (P = .004, P = .021, respectively). At follow-up of 12.3 ± 1.7 months, there was also significant improvement in the ODI (P &lt; .001), VAS back pain (P = .001), and VAS leg pain on the pathology and the approach side (P &lt; .001, P = .001, respectively). The functional outcome was excellent and good in 95.2%. One patient required fusion (3.1%).

CONCLUSION:

A minimally invasive, facet-sparing contralateral approach is an effective technique for treatment of radiculopathy due to foraminal compression. It also allows for decompression of lumbar spinal stenosis and bilateral lateral recess decompression without the need for fusion.

Ultra-long-term outcome of surgically treated far-lateral, extraforaminal lumbar disc herniations: a single-center series

PURPOSE

Far-lateral extraforaminal lumbar disc herniation is an uncommon cause of nerve root entrapment, and studies addressing the long-term outcome of surgically treated patients are few. The purpose of this study was to analyze the ultra-long-term outcome of patients who were treated via a lateral approach.

METHODS

The medical reports of 138 consecutive patients were analyzed with regard to signs and symptoms, operative findings, complications, and short-term outcome (6 weeks). To assess long-term results, standardized telephone interviews were performed using a structured questionnaire. The patients were questioned about pain using the verbal rating scale and persisting symptoms, if any. Other queries were related to the Oswestry Disability Index. Subjective satisfaction with the result of surgery was classified as excellent (no pain), good (some pain), fair (moderate pain), and poor (unchanged or worse) based on MacNab classification.

RESULTS

At short-term follow-up, major and moderate leg pain had decreased from 99.3 to 5.1% and low back pain from 97.8 to 2.8%. Sensory and motor deficits, however, were still present in the majority of patients. A total of 87 telephone interviews were conducted, and the mean follow-up was 146 months. As many as 49 patients (56.3%) reported complete relief of symptoms, 14 patients (16.1%) had minor ailments under physical stress, and 24 patients (27.6%) had permanent residual symptoms. The most common complaint was remaining sensory disturbance. Despite residual symptoms, the vast majority of patients expressed satisfaction with the result of surgery. The outcome was subjectively rated as follows: 75.9% excellent (66 patients), 18.4% good (16 patients), 4.6% fair (4 patients), and 1.1% poor (1 patient).

CONCLUSIONS

The lateral approach is a minimally invasive and safe procedure with low complication rates. The profit from surgery is maintained beyond the usual postoperative observation periods. Thus, ultimate outcome at ultra-long-term follow-up is very gratifying in the vast majority of patients.

Surgical results of the oblique paraspinal approach in upper lumbar disc herniation and thoracolumbar junction

OBJECTIVE

This study was conducted to investigate the efficacy of treating central or paramedian disc herniations of the upper lumbar levels, including the thoracolumbar junction, through the oblique paraspinal approach. We published a technical case report on this subject in 2004.

METHODS

Nineteen consecutive patients with intracanalicular disc herniations of the upper lumbar levels underwent the oblique paraspinal approach, which utilizes an operating microscope, from March 2005 through January 2008. Their clinical and radiological data were collected and analyzed. The patients were assessed with standard examinations preoperatively and evaluated with dynamic lumbar x-rays, 3-dimensional computed tomographic scans, magnetic resonance imaging, standard pain and disability measurements, a visual analogue scale, the Oswestry disability index, and a patient satisfaction rate that checked their pain scores postoperatively.

RESULTS

The average follow-up period was 28.1 months, with a maximum of 48 months. The visual analogue scale for back and leg pain and the Oswestry disability index, which recorded a preoperative mean of 6.7%, 7.2%, and 64.7% and a postoperative mean of 3.2%, 3.0%, and 21.47%, respectively, showed statistically significant improvement at the time of the last follow-up evaluation, compared with preoperative scores. There have been neither recurrent disc herniations nor spinal instability during the follow-up period.

CONCLUSION

In this study, 19 cases of intracanalicular disc herniations at the upper lumbar levels, including the thoracolumbar junction, were successfully excised with the oblique paraspinal approach without recurrence or instability. We found that the oblique paraspinal approach, which resulted in satisfactory clinical outcomes with few complications, could be one of the main surgical procedures used to treat intracanalicular disc herniations at the upper lumbar levels.

Minimally invasive approach to extraforaminal disc herniations at the lumbosacral junction using an operating microscope: case series and review of the literature

Surgical access to extraforaminal lumbar disc herniations is complicated due to the unique anatomical constraints of the region. Minimizing complications during microdiscectomies at the level of L5–S1 in particular remains a challenge. The authors report on a small series of patients and provide a video presentation of a minimally invasive approach to L5–S1 extraforaminal lumbar disc herniations utilizing a tubular retractor with microscopic visualization.

Minimally invasive far lateral microendoscopic discectomy for extraforaminal disc herniation at the lumbosacral junction: cadaveric dissection and technical case report

BACKGROUND CONTEXT

Extraforaminal lumbar disc herniations (ELDHs) at the lumbosacral junction are an uncommon cause of L5 radiculopathy. The surgical anatomy of the extraforaminal space at L5-S1 is uniquely challenging for the various open surgical approaches that have been described for ELDHs in general. Reports specifically describing minimally invasive surgical approaches to lumbosacral ELDHs are lacking.

PURPOSE

To report the novel use of a far lateral microendoscopic (FLMED) approach to lumbosacral ELDH. To better define the unique anatomical features of extraforaminal approaches to the lumbosacral junction as they apply to minimal access techniques.

STUDY DESIGN/SETTING

A cadaveric investigation and clinical case were performed at a single institution. A thorough review of the literature was conducted.

PATIENT SAMPLE

A single patient with an extraforaminal disc herniation at the lumbosacral junction underwent evaluation and surgery.

OUTCOME MEASURES

The patient's self-reported pain levels were documented. Physiologic outcome was judged on pre- and postoperative motor and sensory examinations. Functional capacity was assessed by work status and ability to perform activities of daily living.

METHODS

FLMED was performed in two fresh human cadavers at the lumbosacral junction. Qualitative assessments of the surgical anatomy were made, and intraoperative fluoroscopy and endoscopic photographs were obtained to document the findings. A patient with refractory pain and sensorimotor deficits from compression of the L5 nerve root by an ELDH underwent FLMED. The literature was carefully reviewed for the epidemiology of ELDHs at the lumbosacral junction and the surgical techniques used to treat them.

RESULTS

The posterolateral surgical corridor to the lumbosacral disc was consistently constrained by the sacral ala and to a lesser extent the lateral facet and L5 transverse process. Resection of the superior ala exposed the exiting nerve root and provided ample access to the disc. In the clinical case, the patient enjoyed immediate pain relief, was discharged in 3 hours, and returned to full work and social activities. Follow-up neurological examination revealed no sensory or motor deficit.

CONCLUSIONS

FLMED offers a safe and efficacious approach to ELDHs at the lumbosacral junction by combining satisfactory visualization for adequate resection of the sacral ala with the benefits of reduced tissue injury and faster recovery times that accompany minimally invasive techniques.

An oblique paraspinal approach for intracanalicular disc herniations of the upper lumbar spine: technical case report

OBJECTIVE

To present our experience of treating the central or paramedian disc herniations of the upper lumbar levels through a paraspinal approach.

CLINICAL PRESENTATION

We present four patients with intracanalicular disc herniations at the L1-L2 or L2-L3 level. All patients had unilateral or bilateral radicular leg pain and motor weakness.

TECHNIQUE

Considering the unique characteristics of the upper lumbar spine, we performed the oblique paraspinal approach to expose the central portion of disc and removed the herniated disc effectively. Postoperatively, their symptoms were improved. There was no instability during the follow-up period.

CONCLUSION

The oblique paraspinal approach for the treatment of central disc herniations at the upper lumbar levels is an effective nonfusion technique that preserves most of the facet joint and provides a wide surgical field.