Transmuscular Trocar Technique - Minimal Access Spine Surgery for Far Lateral Lumbar Disc Herniations

Abstract

Objective: Minimal access spine surgery (MASS) is gaining increasing importance in microsurgery of the lumbar spine. From a current prospective series we present data on MASS for far lateral lumbar disc herniations (LLDH) via a transmuscular trocar technique (T²). The surgical procedure and operative results are demonstrated in detail. In contrast to conventional percutaneous endoscopic techniques, T² allows one to operate in the typical microsurgical fashion combined with the advantages of a minimal endoscopic approach with three-dimensional visualization of the surgical target using the operating microscope.

Methods: Microsurgery was performed through a 1.6-cm skin incision with an 11.5-mm diameter trocar that is obliquely inserted into the paraspinal muscles pointing at the lateral isthmus of the upper vertebral body. Fifteen patients were evaluated after a median follow-up period of 24 months. Overall outcome according to the modified MacNab criteria, effect of surgery on radicular pain and sensory or motor deficits, duration of surgery, complication rate, and duration of hospital stay were evaluated.

Results: Good to excellent clinical outcomes were achieved in 14/15 patients. Radicular pain and motor deficits improved in all patients postoperatively, while sensory deficits recovered in 13/15 patients. The cosmetic results were excellent in all patients. No aggravation of symptoms after surgery was observed in any of the patients.

Conclusions: The T² technique represents an auspicious alternative to standard open microsurgery for LLDH, which allows achievement of excellent clinical and cosmetic results, preservation of segmental spine stability, and avoidance of excessive soft tissue trauma.

minimal access spine surgery - microsurgical trocar technique

References

• 1 Lew SM, Mehalic TF, Fagone KL. Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations.  J Neurosurg. 2001;  94 216-220
• 2 Porchet F, Chollet-Bornand A, Tribolet N de. Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations.  J Neurosurg. 1999;  90 59-66
• 3 Abdullah AF, Ditto III EW, , Byrd EB, Williams R. Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis.  J Neurosurg. 1974;  41 229-234
• 4 Lorenzo N Di, Porta F, Onnis G, Cannas A, Arbau G, Maleci A. Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach.  Neurosurgery. 1998;  42 87-89
• 5 Garrido E, Connaughton PN. Unilateral facetectomy approach for lateral lumbar disc herniation.  J Neurosurg. 1991;  74 754-756
• 6 Hassler W, Brandner S, Slansky I. Microsurgical management of lateral lumbar disc herniations: combined lateral and interlaminar approach.  Acta Neurochir (Wien). 1996;  138 907-910
• 7 Ryang YM, Rohde I, Ince A, Oertel MF, Gilsbach JM, Rohde V. Lateral transmuscular or combined interlaminar/paraisthmic approach to lateral lumbar disc herniations? A comparative clinical series of 48 patients.  J Neurol Neurosurg Psychiatry. 2005;  76 971-976
• 8 Destandau J. A special device for endoscopic surgery of lumbar disc herniation.  Neurol Res. 1999;  21 39-42
• 9 Haag M. Transforaminal endoscopic microdiscectomy. Indications and short-term to intermediate-term results (Ger).  Orthopäde. 1999;  28 615-621
• 10 Maroon JC. Current concepts in minimally invasive discectomy.  Neurosurgery. 2002;  51 S137-S145
• 11 Siebert W. Percutaneous nucleotomy procedures in lumbar intervertebral disk displacement. Current status (Ger).  Orthopäde. 1999;  28 598-608
• 12 Yeung AT. The evolution of percutaneous spinal endoscopy and discectomy: state of the art.  Mt Sinai J Med. 2000;  7 327-332
• 13 MacNab I. Negative disc exploration. An analysis of the causes of nerve root involvement in sixty-eight patients.  J Bone Joint Surg (Am). 1971;  53 891-903
• 14 Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy.  J Bone Joint Surg (Am). 1999;  81 958-965
• 15 Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington R, Smith MM, Fessler RG. Microendoscopic lumbar discectomy: technical note.  Neurosurgery. 2002;  51 129-136
• 16 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
• 17 Darden BV, Wade JF, Alexander R, Wood KE, Rhyne III AL, Hicks JR. Far lateral disc herniations treated by microscopic fragment excision. Techniques and results.  Spine. 1995;  20 1500-1505

Correspondence