The Contralateral Approach to intra- and Extraforaminal Lumbar Disk Herniations: Surgical Technique and Review of Surgical Procedures

Background Surgery for intra-/extraforaminal disk herniations (IEDH) is technically demanding due to the hidden location of the compressed nerve root section. Ipsilateral approaches (medial and lateral) are accompanied by extended resection of the facet joint and inadequate visualization of the pathology, especially at the L5–S1 level. Methods We describe a microsurgical interlaminar contralateral approach (MICA) suitable for IEDH at the lumbosacral junction that can also be used at L4–L5 and L3–L4. Conclusion The MICA provides access and sufficient intraforaminal visualization for IEDH in the lumbosacral region without resection of stability-relevant structures or manipulation of the nerve root ganglion.

A case of picking calcified plaque in the common femoral artery with a long needle: the “calc-pick technique”

An 88-year-old man had intermittent claudication of his right leg. Angiography revealed severely calcified plaque in the common femoral artery. Endovascular treatment was performed by contralateral approach. We attempted to penetrate the center of the calcified plaque and perform balloon dilatation. However, a 0.014-inch stiff guidewire could not enter the center of the lesion. Thus, we used an inner cylinder of 15-cm 20G long needle directly through the retrograde femoral sheath and successfully introduced the guidewire into the calcified plaque. Crosser and balloon dilatation resulted in 50 % stenosis. To cross the center of calcified plaque, it is important to obtain sufficient lumen gain at the non-stenting zone.

A Case of Picking Calcified Plaque In The Common Femoral Artery With A Long Needle: The “Calc-Pick Technique”

An 88-year-old male had intermittent claudication of his right leg. Angiography revealed severely calcified plaque in the common femoral artery. Endovascular treatment was performed by contralateral approach. We attempted to penetrate the center of the calcified plaque and perform balloon dilatation. However, a 0.014-inch stiff guidewire could not enter center of the lesion. Thus, we used a inner cylinder of 15-cm 20G long needle directly through the retrograde femoral sheath and successfully introduce the guidewire into the calcified plaque. Crosser and balloon dilatation resulted 50% stenosis. To cross the center of calcified plaque is important to get sufficient lumen gain at the nonstenting zone.

The Novel Technique of Uniportal Endoscopic Interlaminar Contralateral Approach for Coexisting L5-S1 Lateral Recess, Foraminal, and Extraforaminal Stenosis and Its Clinical Outcomes

Background: Multifocal intra-and-extraspinal lumbar stenotic lesions could be decompressed with one endoscopic surgical approach, which has the advantages of functional structure preservation, technical efficacy, and safety. Methods: A retrospective study was performed on 48 patients who underwent uniportal endoscopic contralateral approach due to coexisting lateral recess, foraminal, and extraforaminal stenosis at the L5-S1 level. Foraminal stenosis grade and postoperative dysesthesia (POD) were analyzed. Visual analog scale (VAS) pain scores, modified Oswestry Disability Index (ODI) scores, and MacNab criteria for evaluating pain disability and response were analyzed. Results: The foraminal stenosis grade of the treated spinal levels was grade 1 (n = 16, 33%), grade 2 (n = 20, 42%), and grade 3 (n = 12, 25%). The rate of occurrence of POD grade 2 and above, which may be related to intraoperative dorsal root ganglion (DRG) retraction injury, was revealed to be 4.2% (two with grade 2, none with grade 3). The patients showed favorable clinical outcomes. Conclusions: Uniportal endoscopic interlaminar contralateral approach is an effective procedure to resolve combined stenosis (lateral recess, foraminal, and extraforaminal region) with one surgical approach at the L5-S1 level. It may be a minimal DRG retracting and facet joint preserving procedure in foraminal and extraforaminal decompression.

Ipsilateral Vs Controlateral Approach in Tuberculum Sellae Meningiomas Surgery. A Retrospective Comparative Study

Background: Most of tuberculum sellae meningiomas (TSM) show asymmetric growth. They are usually resected through ipsilateral approaches. The access of the inferior–medial side of the ipsilateral optic nerve might be challenging, which result in increased manipulation of the compromised optic nerve. The contralateral approach has been described to avoid these technical difficulties.Objective: Assessing the long term visual and olfactory outcome, as well as recurrence rate in patients operated for TSM through ipsi- or contralateral approaches.Methods: Single center retrospective cohort study about 94 patients operated on between March 2000 and April 2018.Results: 70% of the preoperative visual acuity loss totally resolved (44%) or showed varying degrees of improvement (26%) after surgery. Seventy-two percent of the preoperative visual field defects evolved favorably (44% recovery, 28% improvement). Eight patients showed aggravated visual disturbances (9%). A contralateral approach seemed to be predictive of visual field defects improvement after surgery (OR=0.4), with borderline significant results (p=.08). There was a higher rate of postoperative olfactory nerve impairment after a contralateral approach (37%vs17%, p=.03). Total removal of the tumor fragment entering the optic canal was accomplished in 96% in the contralateral vs 75% in the ipsilateral group (p=.04). The 2-, 5- & 7-year tumor progression free survival were 100% in the Simpson Grade 2 group, and 85% (n=17), 74% (n=11) & 67% (n=5) in the Simpson Grade 4 group, respectively (p=.00). Conclusion: Resection of tuberculum sellae meningiomas through a contralateral approach seems to provide better visual outcome and tumor control at the cost of increased olfactory nerve disorders.

How I do it? Uniportal full endoscopic contralateral approach for lumbar foraminal stenosis with double crush syndrome

Background Evolution of endoscopic surgery provides equivalent results to open surgery with advantages of minimal invasive surgery. The literature on technique Uniportal Full endoscopic contralateral approach is scarce. Methods The endoscopic contralateral approach technique applies for patients presenting with double crush syndrome with foraminal and extraforminal stenosis. The key steps focus on contralateral ventral overriding superior articular process decompression, foraminal and extraforaminal discectomy, and lateral vertebral syndesmophyte decompression leading to enlargement of the contralateral foramen and extraforamen size. Conclusion The Uniportal Full endoscopic contralateral approach is a good alternative to open surgery or minimally invasive microscopic surgery through direct endoscopic visualization of the entire route of exiting nerve with no neural retraction allowing both lateral recess and foraminal and extraforaminal decompression all in one approach.