Minimally Invasive Approach for Far Lateral Disc Herniations: Results from 20 Patients

Abstract

Background: Far lateral lumbar disc herniations, while infrequent, are a substantial cause of morbidity causing painful radicular syndromes often accompanied by a motor or sensory deficit. Surgical treatment can be challenging technically because of unfamiliar lateral anatomy and the importance of adjacent osseous structures, notably the pars interarticularis and facet joint.

Method: The traditional approach for a far lateral lumbar disc herniation involves a midline incision, wide lateral subperiosteal exposure and partial removal of these structures with the potential for iatrogenic instability. A paramedian approach to the lateral compartment of the disc space is advantageous because it directly targets the pathology. The use of recently developed minimally invasive retractor systems decreases tissue dissection and blood loss and improves postoperative recovery.

Results and Discussion: We present a series of 20 patients who underwent far lateral discectomy using a minimally invasive muscle splitting approach.

far lateral - lumbar disc herniation - minimally invasive surgery

References

• 1 Abdullah AF, Ditto EW, Byrd EB. et al . Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis.  J Neurosurg. 1974;  41 229-234
• 2 Abdullah AF, Wolber PG, Warfield JR. et al . Surgical management of extreme lateral lumbar disc herniations: review of 138 cases.  Neurosurgery. 1988;  22 648-653
• 3 Cervellini P, De Luca GP, Mazzetto M. et al . Micro-endoscopic-discectomy (MED) for far lateral disc herniation in the lumbar spine. Technical note.  Acta Neurochir Suppl. 2005;  92 99-101
• 4 Ehni BL, Benzel EC, Biscup RS. Lumbar discectomy. In: Benzel EC (ed.) Spine Surgery: Techniques, Complication Avoidance, and Management, 2nd edn.. Philadelphia: Elsevier Science; 2004. Vol. 1: 609-611
• 5 Ozveren MF, Bilge T, Barut S. et al . Combined approach for far-lateral lumbar disc herniation.  Neurol Med Chir (Tokyo). 2004;  44 118-122 ; discussion 123
• 6 Porchet F, Chollet-Bornand A, de Tribolet N. Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations.  J Neurosurg. 1999;  90 (1 Suppl) 59-66
• 7 Quaglietta P, Cassitto D, Corriero AS. et al . Paraspinal approach to the far lateral disc herniations: retrospective study on 42 cases.  Acta Neurochir Suppl. 2005;  92 115-119
• 8 Siebner HR, Faulhauer K. Frequency and specific surgical management of far lateral lumbar disc herniations.  Acta Neurochir (Wien). 1990;  105 124-131
• 9 Shao KN, Chen SS, Yen YS. et al . Far lateral lumbar disc herniation.  Zhonghua Yi Xue Za Zhi (Taipei). 2000;  63 391-398
• 10 Tessitore E, de Tribolet N. Far-lateral lumbar disc herniation: the microsurgical transmuscular approach.  Neurosurgery. 2004;  54 939-942 ; discussion 942
• 11 Eichholz KM, Hitchon PW. Far lateral lumbar disc herniation.  Contemporary Neurosurgery. 2003;  25 1-5
• 12 Epstein NE. Different surgical approaches to far lateral lumbar disc herniations.  J Spinal Disord. 1995;  8 383-394
• 13 Epstein NE. Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results.  J Neurosurg. 1995;  83 648-656
• 14 Epstein NE. Foraminal and far lateral lumbar disc herniations: surgical alternatives and outcome measures.  Spinal Cord. 2002;  40 491-500
• 15 Reulen HJ, Muller A, Ebeling U. Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations.  Neurosurgery. 1996;  39 345-350 ; discussion 350–341
• 16 Fessler RG, Khoo LT. Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience.  Neurosurgery. 2002;  51 (S 05) S37-45
• 17 Isaacs RE, Podichetty VK, Santiago P. et al . Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion with instrumentation.  J Neurosurg Spine. 2005;  3 98-105
• 18 Khoo LT, Fessler RG. Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis.  Neurosurgery. 2002;  51 (S 05) S146-S154
• 19 Le H, Sandhu FA, Fessler RG. Clinical outcomes after minimal-access surgery for recurrent lumbar disc herniation.  Neurosurg Focus. 2003;  15 E12
• 20 Perez-Cruet MJ, Kim BS, Sandhu F. et al . Thoracic microendoscopic discectomy.  J Neurosurg Spine. 2004;  1 58-63
• 21 Rosen DS, O’Toole JE, Eicholz KM. et al . Minimally invasive lumbar spinal decompression in the elderly: Outcomes of 50 patients aged 75 years and older.  Neurosurgery. 2007;  60 503-509
• 22 Sandhu FA, Santiago P, Fessler RG. et al . Minimally invasive surgical treatment of lumbar synovial cysts.  Neurosurgery. 2004;  54 107-111
• 23 O’Toole JE, Eichholz KM, Fessler RG. Minimally invasive far lateral microendoscopic discectomy for extraforaminal disc herniation at the lumbosacral junction: cadaveric dissection and technical case report.  Spine J. 2007;  7 414-421
• 24 Epimenio RO, Giancarlo D, Giuseppe T. et al . Extraforaminal lumbar herniation: „far lateral” microinvasive approach retrospective study.  J Spinal Disord Tech. 2003;  16 534-538
• 25 Rust MS, Olivero WC. Far-lateral disc herniations: the results of conservative management.  J Spinal Disord. 1999;  12 138-140
• 26 Foley KT, Smith MM, Rampersaud YR. Microendoscopic approach to far-lateral lumbar disc herniation.  Neurosurgical Focus. 1999;  7 E5
• 27 Hodges SD, Humphreys SC, Eck JC. et al . The surgical treatment of far lateral L3-4 and L4-5 disc herniations. A modified technique and outcome analysis of 25 patients.  Spine. 1999;  24 1243-1246
• 28 Wiltse LL. The paraspinal sacrospinalis-splitting approach to the lumbar spine.  Clin Orthop Relat Res. 1973;  91 48-57
• 29 Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine.  Spine. 1988;  13 696-706
• 30 Obenchain TG. Speculum lumbar extraforaminal microdiscectomy.  Spine J. 2001;  1 415-420 ; discussion
• 31 Greiner-Perth R, Bohm H, Allam Y. A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results.  Eur Spine J. 2003;  12 320-324
• 32 Lew SM, Mehalic TF, Fagone KL. Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations.  J Neurosurg. 2001;  94 (2 Suppl) 216-220
• 33 Yeung AT, Yeung CA. Advances in endoscopic disc and spine surgery: foraminal approach.  Surg Technol Int. 2003;  11 255-263
• 34 Sasani M, Ozer AF, Oktenoglu T. et al . Percutaneous endoscopic discectomy for far lateral lumbar disc herniations: prospective study and outcome of 66 patients.  Minim Invasive Neurosurg. 2007;  50 91-97
• 35 Zhou Y, Zhang C, Wang J. et al . Minimally invasive strategies and options for far-lateral lumbar disc herniations.  Chin J Traumatol. 2008;  11 259-266

Correspondence