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Serifoglu L, Etli MU. Transforaminal Epidural Injection for Far Lateral Lumbar Disc Herniations: An Alternative to Surgery or Just a Delay? Cureus 2024; 16:e52530. [PMID: 38371082 PMCID: PMC10874465 DOI: 10.7759/cureus.52530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
OBJECTIVE Far lateral lumbar disc herniations (FLLDH) are known for causing severe and persistent radicular pain due to direct nerve root and dorsal root ganglion compression. This study evaluates the effectiveness of transforaminal epidural steroid injection (TFSI) in patients with FLLDH, assessing its role as a potential alternative to surgery. METHODS The study retrospectively analyzed 42 patients with radicular pain caused by FLDH, confirmed via lumbar magnetic resonance imaging, who had not benefited from conservative treatment. All patients underwent TFSI, and their pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores were compared with scores at one, two, and three months post-procedure. RESULTS The study group comprised 19 males (45.23%) and 23 females (54.77%), with a mean age of 51.9 ± 11.63 years (range 29-76 years). The most common herniation levels were L4-L5 (22 patients), followed by L5-S1 (15 patients) and L3-L4 (five patients). The mean VAS score decreased significantly from 8.58 ± 0.63 to 2.89 ± 1.87 over three months (p = 0.001). Similarly, the mean ODI score significantly reduced from 61.29 ± 6.72 to 16.88 ± 11.25 (p = 0.001). However, eight of the 42 patients (19.04%) underwent surgery within three months due to lack of benefit from TFSI. CONCLUSION Our study sheds light on the significant potential of TFSI as a treatment option for FLLDH. The marked improvement in pain and functional capacity, as evidenced by the substantial decrease in VAS and ODI scores, suggests that TFSI can be an effective non-surgical intervention for a majority of patients suffering from FLLDH. However, a notable proportion of patients may still require surgery, indicating that TFSI might not be a definitive alternative but can be an effective interim treatment in managing FLLDH.
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Affiliation(s)
- Luay Serifoglu
- Department of Neurosurgery, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, TUR
| | - Mustafa U Etli
- Department of Neurosurgery, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, TUR
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Greil ME, Ogunlade JI, Bergquist J, Williams JR, Kashlan ON, Hofstetter CP. Full-endoscopic trans-pars interarticularis approach for far lateral lumbar discectomy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07698-1. [PMID: 37166550 DOI: 10.1007/s00586-023-07698-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Surgical management of far lateral disc herniations remains challenging. Current transforaminal full-endoscopic approaches require non-visualized docking in the Kambin's triangle and have been associated with significant risk of inadvertent nerve injury. We develop a full-endoscopic approach based on reliable bony landmarks allowing for visualization of the exiting nerve root prior to the far lateral discectomy. METHODS The surgical details of a full-endoscopic trans-pars interarticularis approach for far lateral discectomy are described. These descriptions include high quality intraoperative images and important surgical pearls. A small patient cohort is presented to demonstrate feasibility and safety of the procedure. RESULTS We demonstrate the feasibility of this approach in 14 patients with a mean age of 59.5 ± 14.7 years. At a mean follow up of 21.9 ± 6.8 months, improvement of the visual analogue scale (VAS) for leg pain was 4.3 ± 1.0 resulting in minimally clinically important difference in 78.6% of the patients. The mean improvement in VAS for the back pain was 2.6 ± 0.8 and for Oswestry disability index (ODI) was 20.6 ± 5.3. Nuances of the trans-pars surgical techniques are presented in a patient with a right-sided L4-5 far lateral disc herniation. Preoperative imaging studies, steps of the surgical progression, and intraoperative views are described in detail. CONCLUSION Using the pars interarticularis as the bony target area allows for safe visualized access to the extraforaminal compartment of the exiting nerve root. This novel surgical technique has the potential benefit of decreasing inadvertent neural injury and subsequent postoperative dysesthesias.
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Affiliation(s)
- Madeline E Greil
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA
| | - John I Ogunlade
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Julia Bergquist
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - John R Williams
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA
| | - Osama N Kashlan
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christoph P Hofstetter
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA.
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Dogu H, Ozdemir NG, Yilmaz H, Atci IB. Long-term follow-up results of surgically treated patients with foraminal and far lateral disc herniations. Br J Neurosurg 2023; 37:49-52. [PMID: 33502266 DOI: 10.1080/02688697.2021.1874293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Huseyin Dogu
- Department of Neurosurgery, Istanbul Medicine Hospital, Istanbul, Turkey
| | - Nuriye Guzin Ozdemir
- Department of Neurosurgery, Istanbul Education and Research Hospital, Istanbul, Turkey
| | - Hakan Yilmaz
- Department of Neurosurgery, Usak University Education and Research Hospital, Usak, Turkey
| | - Ibrahim Burak Atci
- Department of Neurosurgery, Istanbul Education and Research Hospital, Istanbul, Turkey
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Clinicians' perceptions around discectomy surgery for lumbar disc herniation: a survey of orthopaedic and neuro-surgeons in Australia and New Zealand. Arch Orthop Trauma Surg 2023; 143:189-201. [PMID: 34216261 DOI: 10.1007/s00402-021-04019-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/24/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Understanding practice-based differences in treatment of lumbar disc herniations (LDHs) is vital for reducing unwarranted variation in the delivery of spine surgical health care. Identifying factors that influence surgeons' decision-making will offer useful insights for developing the most cost-effective and safest surgical strategy as well as developing surgeon education materials for common lumbar pathologies. This study was to capture any variation in techniques used by surgeons in Australia and New Zealand (ANZ) region, and perceived complications of different surgical procedures for primary and recurrent LDH (rLDH). MATERIALS AND METHODS Web-based survey study was emailed to orthopaedic and neurosurgeons who routinely performed spinal surgery in ANZ from Decmber 20, 2018 to February 20, 2020. The response data were analyzed to assess for differences based on geography, practice setting, speciality, practice experience, practice length, and operative volume. RESULTS Invitations were sent to 150 surgeons; 96 (64%) responded. Most surgeons reported microdiscectomy as their surgical technique of choice for primary LDH (73%) and the first rLDH (72%). For the second rLDH, the preferred choice for most surgeons was fusion surgery (82%). A surgeon's practice setting (academic/private/hybrid) was a statistically significant factor in what surgical procedure was chosen for the first rLDH (P = 0.014). When stratifying based on surgeon experience, there were statisfically significant differences based on the annual volume of spine surgeries performed (perceived reherniation rates following primary discectomy, P = 0.013; perceived reherniation rates following revision surgeries, P = 0.017; perceived intraoperative complications rates following revision surgeries, P = 0.016) and based on the annual volume of lumbar discectomies performed (perceived reherniation rates following revision surgeries, P = 0.022; perceived intraoperative complications rates following revision surgeries, P = 0.036; perceived durotomy rates following primary discectomy, P = 0.023). CONCLUSIONS Surgeons' annual practice volume and practice setting have significant influences in the selection of surgical procedures and the perception of surgical complications when treating LDHs.
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Cekov AH, Sailer MHM, Guentchev M. A transfacet approach to the lumbar nerve root canal: technical note. Br J Neurosurg 2022:1-6. [PMID: 36546326 DOI: 10.1080/02688697.2022.2159929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/03/2022] [Accepted: 10/25/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Asen H Cekov
- Department of Neurosurgery, Trinity Medical Center, Sofia, Bulgaria
| | - Martin H M Sailer
- Department of Neurosurgery and Spine Surgery, Salem-Spital, Bern, Switzerland
| | - Marin Guentchev
- Department of Neurosurgery, Trinity Medical Center, Sofia, Bulgaria
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Ran B, Chen R, Song C, Li Y, Wei J, Ye J. Percutaneous Endoscopic Discectomy Via a Transforaminal Approach for L5/S1 Far-Lateral Disc Herniation Assisted by Intraoperative Computed Tomography. World Neurosurg 2022; 166:e823-e831. [PMID: 35926700 DOI: 10.1016/j.wneu.2022.07.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine the clinical outcomes of a percutaneous lumbar transforaminal endoscopic discectomy (PTED) with intraoperative computed tomography (iCT) navigation for the treatment of L5-S1 far-lateral lumbar disc herniation (LDH). METHODS A total of 30 patients with L5-S1 far-lateral LDH who underwent PTED with iCT navigation from September 2016 to October 2020 were enrolled in this study. Outcomes were assessed using the visual analog scale pain score, the Oswestry Disability Index, the Japanese Orthopedic Association score, the EQ-5D-5 L and the modified Macnab criteria. Preoperative and postoperative complications were recorded. RESULTS The mean visual analog scale score for leg pain improved from 8.1 at baseline to 2.3, 0.9, 0.7 and 0.9 at 1 day, 1 week, 6 months, and 12 months postoperatively, respectively (P < 0.01). The mean Oswestry Disability Index improved from 78.1% at baseline to 45.5%, 21.9%, 12.6%, and 11.7% at 1 week, 1 month, 6 months, and 12 months postoperatively, respectively (P < 0.01); and the mean Japanese Orthopedic Association score improved from 8.6 at baseline to 14.2, 20.2, 24.4, and 25.6 at 1 day, 1 week, 6 months, and 12 months postoperatively, respectively (P < 0.01). At 12 months postoperatively, the EQ-5D-5 L value significantly increased, from -0.061 ± 0.138 to 0.903 ± 0.064. The rate of a good or excellent modified Macnab result was 93% (26/28) at 12 months postoperatively. In the present study, combined L5-S1 foraminal stenosis tended to lead poor outcomes, which required more postsurgical treatments. CONCLUSIONS With iCT navigation, PTED is a feasible and effective minimally invasive surgery for L5-S1 far-lateral LDH.
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Affiliation(s)
- Bing Ran
- Suzhou Medical College of Soochow University, Suzhou, China; Pain Department, GanNan Medical University, GanZhou, China; First Affiliated Hospital of GanNan Medical University, GanZhou, China
| | - Rong Chen
- Pain Department, GanNan Medical University, GanZhou, China; First Affiliated Hospital of GanNan Medical University, GanZhou, China
| | - Chanchan Song
- Pain Department, GanNan Medical University, GanZhou, China; First Affiliated Hospital of GanNan Medical University, GanZhou, China
| | - Yi Li
- Suzhou Medical College of Soochow University, Suzhou, China; Pain Department, GanNan Medical University, GanZhou, China; First Affiliated Hospital of GanNan Medical University, GanZhou, China
| | - Jun Wei
- Pain Department, GanNan Medical University, GanZhou, China; First Affiliated Hospital of GanNan Medical University, GanZhou, China
| | - JunMing Ye
- Suzhou Medical College of Soochow University, Suzhou, China; Pain Department, GanNan Medical University, GanZhou, China.
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Mojaz FM, Abdolhoseinpour H, Sigari RA. Unilateral discectomy: outcomes, postoperative pain, complications. Eur J Transl Myol 2019; 29:8545. [PMID: 31908748 PMCID: PMC6926437 DOI: 10.4081/ejtm.2019.8545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 12/02/2022] Open
Abstract
In low back pain management surgery is currently commonly used with a new technique called minimally invasive discectomy, while open discectomy is still preferable in many cases. In this regard, the efficacy of tubular discectomy (TD) were compared with conventional standard lumbar disc procedure (conventional microdiscectomy). This study was performed as a clinical trial conducted on patients who were under TD and conventional microdiscectomy using unilateral retractor at Bou Ali, Mehrad, Laleh Hospitals during the years 2001 to 2017. The pain score was determined based on the use of Visual Analogue Scale (VAS). The Roland Morris Disability Questionnaires (RMQ) and mean Oswestry disability index (ODI) were also calculated. Our findings revealed that the two groups were similar in terms of demographic characteristics (age, sex, body mass index, etc.) (p> 0.05). The findings indicated the superiority of TD over the classic approach. The mean scores of ODI in conventional microdiscectomy and TD groups were reported as 12.53 ± 7.09 and 9.51 ± 7.83, respectively. ODI revealed that patients with TD surgery had less disability in lifting objects, sitting, standing, and traveling. In the conventional microdiscectomy group, 12 (20%) patients were affected by complications of surgery, but no complication was reported in any patient with TD (p = 0.000). The mean index of Roland Morris disability in the conventional microdiscectomy and TD groups were estimated to be 6.033 ± 2.98 and 3.73 ± 3.25 (p = 0.000). However, both groups did not differ in terms of visual scores for pain and relapse (p > 0.05). Our study demonstrates that disease relapse within 6 months after the surgery, the RMQ and the ODI values were significantly better in TD than the other group.
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Affiliation(s)
- Fatemeh Mahboub Mojaz
- Department of Neurosurgery, Bou Ali Hospital, Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Hesam Abdolhoseinpour
- Department of Neurosurgery, Bou Ali Hospital, Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Reza Akhavan Sigari
- Department of Neurosurgery, University Medical Center Tuebingen, Eberhard-Karls University, Tuebingen, Germany
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Khan JM, McKinney D, Basques BA, Louie PK, Carroll D, Paul J, Varthi A, Iyer S, An HS. Clinical Presentation and Outcomes of Patients With a Lumbar Far Lateral Herniated Nucleus Pulposus as Compared to Those With a Central or Paracentral Herniation. Global Spine J 2019; 9:480-486. [PMID: 31431869 PMCID: PMC6686375 DOI: 10.1177/2192568218800055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Examine pre- and postoperative outcomes between patients presenting with a central/paracentral versus a far lateral herniated nucleus pulposus (HNP) and assess whether significantly worse postoperative outcomes, assessed via patient self-reported survey, are associated with far lateral disc herniations. METHODS We performed a retrospective cohort analysis of patients who underwent primary lumbar decompression between January 2008 and December 2015. Groups were divided based on herniation type, central/paracentral or far lateral. Patients with 3 months, or longer, of follow-up were included. Variables analyzed included demographics, American Society of Anesthesiologists (ASA) Score, Charleston Comorbidity Index (CCI), Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and Veterans RAND 12-Item Mental and Physical Survey (VR-12) scores. RESULTS A total of 100 patients met the inclusion criteria. Postoperative ODI scores for central/paracentral HNP were significantly lower compared to far lateral HNP. Patients with a far lateral disc herniation presented with significantly lower preoperative SF-12 and VR-12 scores. The improvement in ODI score from preoperative to final was significantly lower in the patients presenting with a far lateral HNP. CONCLUSIONS Although patients with far lateral HNP present with worse preoperative outcome scores, they can expect similar symptom improvement to central or paracentral herniations following discectomy. This information can be used for future surgeons when weighing conservative versus surgical treatment of far lateral herniations.
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Affiliation(s)
| | | | | | - Philip K. Louie
- Rush University Medical Center, Chicago, IL, USA,Philip K. Louie, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA.
| | | | | | | | | | - Howard S. An
- Rush University Medical Center, Chicago, IL, USA
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