Different Surgical Approaches to Far Lateral Lumbar Disc Herniations

✓ This study was undertaken to determine and compare indications and relative benefits of various surgical approaches in 170 patients (average age 55 years) with far-lateral herniated lumbar discs, identified by magnetic resonance (MR) imaging and computerized tomography (CT) and operated on between 1984 and 1994. Essentially three surgical procedures were performed: complete facetectomy in 73 patients, laminotomy with medial facetectomy in 39 patients, and intertransverse discectomy (also known as ITT) in 58 patients. Follow-up periods averaged 5 years (range 0.5–10 years). Outcomes were scored as excellent (no deficit), good (mild radiculopathy), fair (moderate radiculopathy), and poor (unchanged or worse). Overall, excellent and good results were achieved in 73 and 51 patients, respectively, and fair and poor results in 26 and 20, respectively. There was little difference among the results encountered for the three major surgical groups: 79% of the intertransverse (ITT) group had good-to-excellent outcomes, as compared with 70% of the facetectomy group, and 68% of the group who underwent at minimum laminotomy, and additional hemilaminectomy or laminectomy with medial facetectomy. Results were the same for the 121 patients followed for more than 2 years and for the 49 patients studied for under 2 years. In the management of far-lateral discs, total facetectomy provides the best exposure, but increases the risk of instability. Laminotomy and medial facetectomy uncover the lateral and subarticular recess and preserve stability, but visualization of the far-lateral compartment is often inadequate. The intertransverse approach offers extensive far-lateral but not medial intraforaminal exposure, while also preserving stability. Full facetectomy, laminotomy with medial facetectomy, and the intertransverse approaches yielded nearly comparable outcomes in far-lateral disc surgery. Only the full facetectomy exposes the entire course of the nerve root both medially and laterally, whereas the intertransverse procedure provides direct exposure of the far-lateral compartment alone. It is important to select the correct approach or combination of approaches to address attendant complicating factors such as spinal stenosis, spondyloarthrosis, and degenerative spondylolisthesis identified on CT and MR studies.

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Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine

Journal of Neurosurgery ◽

10.3171/jns.1990.72.3.0378 ◽

1990 ◽

Vol 72 (3) ◽

pp. 378-382 ◽

Cited By ~ 92

Author(s):

Joseph C. Maroon ◽

Thomas A. Kopitnik ◽

Larry A. Schulhof ◽

Adnan Abla ◽

James E. Wilberger

Keyword(s):

Facet Joint ◽

Lumbar Disc ◽

Spinal Nerve ◽

Magnetic Resonance Images ◽

Content Type ◽

Enhanced Ct ◽

Disc Herniations ◽

Microsurgical Approach ◽

Far Lateral ◽

Fine Print

✓ Lumbar-disc herniations that occur beneath or far lateral to the intervertebral facet joint are increasingly recognized as a cause of spinal nerve root compression syndromes at the upper lumbar levels. Failure to diagnose and precisely localize these herniations can lead to unsuccessful surgical exploration or exploration of the incorrect interspace. If these herniations are diagnosed, they often cannot be adequately exposed through the typical midline hemilaminectomy approach. Many authors have advocated a partial or complete unilateral facetectomy to expose these herniations, which can lead to vertebral instability or contribute to continued postoperative back pain. The authors present a series of 25 patients who were diagnosed as having far lateral lumbar disc herniations and underwent paramedian microsurgical lumbar-disc excision. Twelve of these were at the L4–5 level, six at the L5–S1 level, and seven at the L3–4 level. In these cases, myelography is uniformly normal and high-quality magnetic resonance images may not be helpful. High-resolution computerized tomography (CT) appears to be the best study, but even this may be negative unless enhanced by performing CT-discography. Discography with enhanced CT is ideally suited to precisely diagnose and localize these far-lateral herniations. The paramedian muscle splitting microsurgical approach was found to be the most direct and favorable anatomical route to herniations lateral to the neural foramen. With this approach, there is no facet destruction and postoperative pain is minimal. Patients were typically discharged on the 3rd or 4th postoperative day. The clinical and radiographic characteristics of far-lateral lumbar-disc herniations are reviewed and the paramedian microsurgical approach is discussed.

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Microendoscopic Discectomy for Far Lateral Lumbar Disc Herniations

Neurosurgery ◽

10.1097/00006123-199809000-00366 ◽

1998 ◽

Vol 43 (3) ◽

pp. 716-716

Author(s):

Kevin T. Foley ◽

Maurice M. Smith

Keyword(s):

Lumbar Disc ◽

Disc Herniations ◽

Microendoscopic Discectomy ◽

Far Lateral

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Early Postoperative Results after Removal of Cranially Migrated Lumbar Disc Prolapse: Retrospective Comparison of Three Different Surgical Strategies

Advances in Orthopedics ◽

10.1155/2014/702163 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6 ◽

Cited By ~ 3

Author(s):

C. Schulz ◽

U. Kunz ◽

U. M. Mauer ◽

R. Mathieu

Keyword(s):

Lumbar Disc ◽

Leg Pain ◽

Surgical Approaches ◽

Postoperative Results ◽

Retrospective Comparison ◽

Interlaminar Approach ◽

Disc Material ◽

Disc Herniations ◽

Group A ◽

Group B

Background. To compare the early postoperative results of three surgical approaches to lumbar disc herniations that migrated cranially. Minimally invasive techniques such as the translaminar and endoscopic transforaminal approaches are utilized in patients with lumbar disc herniations to gain access to cranially located disc material and to avoid the potentially destabilizing resection of ligament and bone tissue, which is associated with an extended interlaminar approach.Methods. This retrospective study compares the postoperative pain and functional capacity levels of 69 patients who underwent an interlaminar (Group A,n=27), a translaminar (Group B,n=22), or an endoscopic transforaminal procedure (Group C,n=20).Results. Median VAS scores for leg pain decreased significantly from before to after surgery in all groups. Surgical revisions were required in thirteen cases (five in Group A, one in Group B, and seven in Group C;P=0.031). After six weeks, there were significant differences in back pain and functional outcome scores and in the results for the MacNab criteria but not in leg pain scores.Conclusions. The interlaminar and translaminar techniques were the safest and fastest ways of gaining access to cranially migrated disc material and the most effective approaches over a period of six weeks.

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Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral lumbar disc herniations in children

International Orthopaedics ◽

10.1007/s00264-016-3155-x ◽

2016 ◽

Vol 40 (6) ◽

pp. 1099-1102 ◽

Cited By ~ 14

Author(s):

Changkun Zheng ◽

Fei Wu ◽

Lin Cai

Keyword(s):

Lumbar Disc ◽

Endoscopic Discectomy ◽

Disc Herniations ◽

Far Lateral

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Foraminal and far lateral lumbar disc herniations: surgical alternatives and outcome measures

Spinal Cord ◽

10.1038/sj.sc.3101319 ◽

2002 ◽

Vol 40 (10) ◽

pp. 491-500 ◽

Cited By ~ 97

Author(s):

NE Epstein

Keyword(s):

Outcome Measures ◽

Lumbar Disc ◽

Disc Herniations ◽

Far Lateral

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Biportal Endoscopic Excision of Facetal Cyst in the Far Lateral Region of L5S1: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz255 ◽

2019 ◽

Vol 18 (6) ◽

pp. E233-E233

Author(s):

Sagar B Sharma ◽

Guang-Xun Lin ◽

Hussam Jabri ◽

Naveen Davangere Siddappa ◽

Jin-Sung Kim

Keyword(s):

Lumbar Disc ◽

Radicular Pain ◽

Lumbar Spine Surgery ◽

Foraminal Stenosis ◽

Lateral Border ◽

Landing Point ◽

Fusion Procedure ◽

Free Mobility ◽

Disc Herniations ◽

Far Lateral

Abstract Unilateral biportal endoscopy (UBE) is a recently introduced technique that utilizes 2 portals, one for endoscopy and one as a working portal, in contrast to full endoscopy, which utilizes a single portal. The advantages are a favorable learning curve and free mobility of instruments in the operative field. UBE is successful in addressing cervical and lumbar disc herniations, lumbar stenosis, and foraminal/extraforaminal pathologies, such as herniations and foraminal stenosis. However, there is no report of UBE for a far-lateral L5S1 facet cyst. The patient was an 85-yr-old female with a left lower limb radicular pain with magnetic resonance imaging evidence of the facet cyst compressing the L5 nerve root. Conventional treatment of such a condition would either be an L5S1 fusion procedure or a standalone decompression via the Wiltse paramedian approach. Because the patient had no instability, we decided to do a standalone decompression using the UBE technique. The UBE technique has the advantages of any minimal access procedure, including small incisions, minimal tissue dissection, good magnification, and preservation of anatomic structures. A written informed consent was obtained from the patient before the procedure. The procedure was done under general anesthesia using a 30° endoscope, a radiofrequency probe, and standard lumbar spine surgery instruments. The initial landing point of the endoscope and instruments is via triangulation at the lateral border of the isthmus of L5. The postoperative clinical and radiological outcomes were satisfactory (VAS Back and Leg, 0; Oswestry disability index, 15 at 3 mo).

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