The Surgical Treatment of Single Level Multi-Focal Subarticular and Paracentral and/or Far-Lateral Lumbar Disc Herniations: The Single Incision Full Endoscopic Approach

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of patient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

Download Full-text

Microendoscopic approach to far-lateral lumbar disc herniation

Neurosurgical FOCUS ◽

10.3171/foc.1999.7.5.8 ◽

1999 ◽

Vol 7 (5) ◽

pp. E7 ◽

Cited By ~ 76

Author(s):

Kevin T. Foley ◽

Maurice M. Smith ◽

Y. Raja Rampersaud

Keyword(s):

Disc Herniation ◽

Lumbar Disc ◽

Radicular Pain ◽

Motor Deficits ◽

Outpatient Basis ◽

Single Level ◽

Disc Herniations ◽

Far Lateral ◽

Paramedian Incision ◽

Lateral Disc Herniation

The purpose of this study was to determine the feasibility of performing far-lateral lumbar discectomy by using the microendoscopic discectomy (MED) technique. The authors studied 11 consecutive patients with unilateral, single-level radiculopathy secondary to far-lateral disc herniation. There were eight men and three women, with an average age of 43 years. In all patients magnetic resonance imaging and/or computerized tomography scanning documented far-lateral disc herniations. Six patients experienced motor deficits, nine patients sensory abnormalities, and five depressed reflexes. All patients complained of radicular pain, which failed to improve with conservative care. After induction of epidural anesthesia, single-level, unilateral percutaneous discectomies were performed using the MED technique. Five discectomies were performed at L3-4 and six at L4-5. There were four contained and seven sequestered disc herniations. All surgeries were performed on an outpatient basis. Follow up ranged from for 12 to 27 months. Improvement was shown in all patients postoperatively. Using modified Macnab criteria to assess results of surgery, there were 10 excellent results and one good result. None of the patients experienced residual motor deficits, four had residual decreased sensation, and one still had some degree of nonradicular pain. There were no complications. Although various open techniques exist for the treatment of far-lateral disc herniation, MED is unique in that far-lateral pathological entities can be directly visualized and removed via a 15-mm paramedian incision. The percutaneous approach avoids larger, potentially denervating and destabilizing procedures. The need for general anesthesia can be avoided, and surgery is performed on an outpatient basis, thereby reducing hospital cost and length of stay.

Download Full-text

Surgical treatment of intraforaminal/extraforaminal lumbar disc herniations: Many approaches for few surgical routes

Acta Neurochirurgica ◽

10.1007/s00701-017-3198-9 ◽

2017 ◽

Vol 159 (7) ◽

pp. 1273-1281 ◽

Cited By ~ 3

Author(s):

Giorgio Lofrese ◽

Lorenzo Mongardi ◽

Francesco Cultrera ◽

Giorgio Trapella ◽

Pasquale De Bonis

Keyword(s):

Surgical Treatment ◽

Lumbar Disc ◽

Disc Herniations

Download Full-text

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.

Download Full-text

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

Download Full-text

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

Download Full-text

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

Download Full-text

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).

Download Full-text