Minimally invasive approach to extraforaminal disc herniations at the lumbosacral junction using an operating microscope: case series and review of the literature

Full access

Surgical access to extraforaminal lumbar disc herniations is complicated due to the unique anatomical constraints of the region. Minimizing complications during microdiscectomies at the level of L5–S1 in particular remains a challenge. The authors report on a small series of patients and provide a video presentation of a minimally invasive approach to L5–S1 extraforaminal lumbar disc herniations utilizing a tubular retractor with microscopic visualization.

Abbreviations used in this paper: ELDH = extraforaminal lumbar disc herniation; LSJ = lumbosacral junction.

Abstract

Surgical access to extraforaminal lumbar disc herniations is complicated due to the unique anatomical constraints of the region. Minimizing complications during microdiscectomies at the level of L5–S1 in particular remains a challenge. The authors report on a small series of patients and provide a video presentation of a minimally invasive approach to L5–S1 extraforaminal lumbar disc herniations utilizing a tubular retractor with microscopic visualization.

Extraforaminal lumbar disc herniations, otherwise known as far lateral lumbar disc herniations, are relatively rare and comprise 1–12% of all lumbar disc herniations.1,2,6,10,17,44,46,48,50,54,56,59 The approach to an ELDH is more complex than the more common posterolateral or central disc herniation due to an increased risk of postoperative instability from extensive facetectomy, inadequate decompression, or nerve root injury.5,9,13,18,20,22–24,33,34,41,49,51–53,60 The LSJ is difficult to access due to specific anatomical constraints at this level including compression of the L-5 nerve root by the sacral ala.33,44,47 In this report we describe a minimally invasive access for resection of an ELDH at L5–S1 using a muscle-splitting tubular retractor and an operating microscope. Minimally invasive access to ELDHs has been reported previously6,17,33 utilizing an endoscopy-assisted approach.44 The microscopic visualization described in the present study is more familiar to most spine surgeons and does not hinder the identification of the pertinent anatomical structures.

Methods

Four patients with symptomatic extraforaminal disc herniations at L5–S1 were included in the study. The operative technique is described below and shown in Video 1.

Windows Media (broadband): http://mfile.akamai.com/21490/wmv/digitalwbc.download.akamai.com/21492/wm.digitalsource-na-regional/foc08-74Pirris_video.asx

After the induction of general endotracheal anesthesia, patients are positioned prone on the operating table with chest bolsters. The lumbosacral region is prepared and draped in sterile fashion. Fluoroscopy is used to identify the medial border of the L-5 transverse process on anteroposterior imaging, and a 3-cm incision is made 1 cm lateral to this site, allowing the angled trajectory necessary to identify the L5–S1 extraforaminal space safely. Sequential dilators are advanced to create a muscle-splitting corridor for the tubular retractor system, which is secured in place via a table-mounted multiaxis flexible arm (Fig. 1). The operating microscope is positioned over the tube for the remainder of the procedure.

Fig. 1.
Fig. 1.

Artist's depiction of the axial plane of a tubular retractor used for access to the removal of an extraforaminal disc herniation.

The overlying muscle on the L-5 transverse process is dissected free with a monopolar cautery. Once on bone, the dissection continues inferiorly to expose the lateral pars, facet, and sacral ala. Depending on the anatomical constraints in the individual patient, it is sometimes necessary to drill the superior aspect of the sacral ala to create a functional working space. A Woodson is cautiously used to palpate the neuroforamen and overlying pedicle. A nerve stimulator is used to identify and dissect free the exiting L-5 nerve root, which is gently retracted superiorly to allow visualization of the lateral disc space in its axilla. If necessary, the lateral pars may be resected by using a long, angled drill with a small bur bit. This tool fits easily into an 18- or 22-mm working channel.

The epidural veins are cauterized and sectioned. This maneuver is facilitated by the use of long bayoneted bipolar tips on a low current setting. A down-biting curette is used to remove overlying osteophytes preventing access to the lateral disc space. The annulus is opened in cruciate fashion and traditional microdiscectomy techniques are used to decompress the nerve root. Copious irrigation is performed and meticulous hemostasis is maintained. The tubular retractors are removed allowing the split muscle to return to its native position. The fascia, deep dermis, and skin are closed in routine fashion.

Results

All 4 patients included in this case series had improvement in their preoperative symptoms and none suffered any perioperative complications. The results are summarized in Table 1.

TABLE 1

Summary of results of microscopic minimally invasive L5–S1 extraforaminal discectomies*

Prolo Score
Age (yrs), SexComplicationsEstimated Blood Loss (ml)PreopPostopFU
58, Fnone5010163
62, Mnone50121811
57, Mnone508203
73, Mnone758186

* FU = length of follow-up in weeks.

Discussion

We describe a method for minimally invasive access to resection of an ELDH at L5–S1 using a muscle-splitting tubular retractor and an operating microscope. This technique adds another option to the surgeon's armamentarium for treating this difficult problem. As noted in previous publications, access to ELDHs is more complex than the more common posterolateral or central disc herniations due to the elevated risk of postoperative instability from an extensive facetectomy, inadequate decompression, or nerve root injury.5,9,13,18,20,22–24,33,34,41,49,51–53,60 The overall incidence of ELDH is not known, but has been reported to encompass 1–12% of symptomatic lumbar disc herniations.1,2,6,10,17,44,46,48,50,54,56,59 The LSJ is difficult to access due to the specific anatomical constraints at this level including compression of the L-5 nerve root by the sacral ala (Fig. 2).33,44,47

Fig. 2.
Fig. 2.

Photograph of a fresh-frozen human cadaver specimen illustrating the anatomical constraints to the minimally invasive approach to an extraforaminal disc herniation at the LSJ. F = lateral facet of L-5; P = pars interarticularis of L-5; A = sacral ala; D = intervertebral disc at L5–S1; TP = transverse process of L-5.

Extraforaminal disc herniations and the associated symptoms due to compression of the exiting nerve root were first described by Macnab37 in 1971 in his discussion of negative disc space explorations in patients with radiculopathy. Abdullah and colleagues1 then described the clinical syndrome in 1974 which is typically more severe than that caused by the more commonly located posterolateral disc herniations. The “extreme lateral” syndrome described by Abdullah et al. is well characterized and includes marked pain due to involvement of the dorsal root ganglion, with a greater tendency for neurological deficits.11–13,44,46 The proximal lumbar levels are more typically involved in ELDHs,2,7,8,14–18,44 probably due to the narrower pedicle widths at these levels, which allow for increased disc area in the lateral zone.44,48,59 Of all ELDHs reported in the literature, L5–S1 involvement has been reported in 6.5–25% of cases since the advent of MR imaging.7,13,19–21,27,35,39,43–46,48,50

In patients in whom conservative treatment has failed, various surgical approaches have been utilized. Midline incisions with subperiosteal dissections are familiar to most spine surgeons, but often include a significant amount of facet resection, which can lead to postoperative back pain due to destabilization of the motion segment.14,17,18,20,22–24,28,29,34,55 The paramedian approach, such as that described by Wiltse and Spencer,61,62 requires the splitting of muscles with less bone resection and provides a more direct approach to the neural foramen.3,7,17,39,43 However, this approach is not as familiar to many spine surgeons.17 Some surgeons have recommended a combined approach because it permits both medial and lateral access to the neural foramen.8,13–15,28,34,36 To obtain adequate visualization of the anatomy for the combined approach, extensive stripping and lateral mobilization of the paraspinal muscles is required, which may lead to increased postoperative pain and paraspinal muscle dysfunction.26,31,32,38,42,57,58 The use of percutaneous techniques has been reported,4,30 but these are of limited value when free disc fragments and bone compression are present.17 The successful removal of free fragments and foraminal stenosis in surgically treated patients with ELDHs has been reported in 72–92% of patients.2,3,8,14–16,36,39,43

The surgical approach is best guided by the individual patient's lesion and anatomy. The paramedian approach with muscle splitting generates the least amount of osteoligamentous injury thus limiting postoperative instability.44 The anatomy of the LSJ presents unique challenges. Reulen et al.51 have described the rigid bone confines of the intertransverse operative corridor, which grows tighter caudally in the lumbar spine secondary to a wider pars interarticularis at L-5, a shorter distance from the caudal transverse process to the superior edge of the inferior articulating process, and a higher frequency of a prominent accessory process.44,51 Additionally, difficulty in achieving adequate open posterior or posterolateral access through a midline incision with subperiosteal dissection is created by a prominent iliac crest, wider disc space, oblique pedicles, and more coronally oriented facet joints.44

The goals of minimally invasive spinal approaches are to reduce postoperative pain and recovery time while maintaining proper visualization of the important anatomical structures that permit adequate neural decompression.6,16,17,44 The advantages of the minimally invasive, muscle-splitting intertransverse approach to ELDHs include a shortened operative exposure time and with less muscle destruction, preservation of the facet joint, and preservation of surrounding soft tissues, thus reducing the formation of scar tissue.33 Additionally, open paramedian approaches to resection of ELDHs require a more lateral to medial approach50 which will be limited by the position of the iliac crest for those at L5–S1.

O'Toole and colleagues44 reported that the use of progressive dilators and a tubular retractor minimizes the barrier effect of the iliac crest and recommended judicious resection of the sacral ala to allow access to the disc from a lateral approach while avoiding excessive facet resection.25,40,44,48 This retractor system is easily adaptable to performing a possible laminotomy in cases where a combined intra- and extraforaminal approach is necessary to completely decompress the nerve root.44

The microendoscopic discectomy technique for the treatment of far lateral disc herniations was initially reported by Foley et al.17 in a case series of 11 patients. These patients had herniations at L3–4 or L4–5, and all achieved excellent or good results based on Macnab criteria. Cervellini and colleagues6 reported on their experience in 17 patients with far lateral disc herniations at L3–4 and L4–5 who underwent surgical treatment with the microendoscopic discectomy technique. All patients achieved excellent or good results. Due to anatomical constraints, the authors claimed that treatment of far lateral disc herniations at the L5–S1 level with this technique is not possible.

Authors of previous reports of minimally invasive access to ELDHs at the LSJ have used endoscopic visualization through the tubular retractor44 or microscopic visualization through a self-retaining speculum.33 O'Toole et al.44 described the far lateral microendoscopic discectomy approach with a 1.8-cm incision. They then used progressive muscle-splitting dilators and placed an 18-mm tubular retractor with an endoscope attached within the tube, and fixed the apparatus in position with a flexible arm. The patient enjoyed immediate pain relief, was discharged home 3 hours postoperatively, recovered his normal gait, and returned to full work and social duties.

Kotil and colleagues33 reported on their surgical results in 14 patients with far lateral disc herniations at L5–S1 over a 4-year period. Their minimally invasive intermuscular approach involved a 3-cm transverse incision above the dorsal curvature of the ilium, followed by incision and dissection of the lumbodorsal fascia to retract them from the rim of the ilium. Further exploration was performed with the fingertip to define landmarks such as the transverse process, iliolumbar ligament, lateral edge of the L5–S1 facet, and upper rim of the sacrum with the costal process. Next, a self-retaining speculum was placed and the operating microscope brought into the field. After drilling the costal process of the sacral ala and performing any further bone resection as necessary, the exiting L-5 nerve root was identified and decompressed by discectomy. The outcomes in 13 (92%) of the 14 patients were excellent or good, and the patients were able to return to their previous occupations and activity levels. The 1 patient (8%) with a fair outcome was found to have extensive scarring around the nerve root on MR images obtained at the 2-month postoperative examination.

The approach described in this article is a truly minimally invasive approach as described by O'Toole et al.44 in that we have used muscle-splitting techniques with progressive dilators through a stab incision in the skin. The primary difference between the 2 is the use of the operating microscope. Most spine surgeons have been trained using the operating microscope and are very familiar with its nuances. The views obtained through endoscopy are undoubtedly exceptional and the purpose of this study is not to dissuade surgeons who are familiar working with the endoscope. However, the use of endoscopy entails an extensive learning curve for the surgeon and operating room staff, occupies some of the working space in the tubular retractor, and incurs a significant expense for the purchase and maintenance of the necessary equipment.

The successful early outcomes obtained in this small series reflect the probable viability of this procedure. Given the small sample size and lack of sustained follow-up, no statistical correlations were calculated. The efficacy of a microdiscectomy for the relief of painful ELDHs at the LSJ has been well documented in the literature. The goal of the present study is to present an effective and truly minimally invasive muscle–splitting approach while utilizing the familiar operating microscope at the L5–S1 level.

Conclusions

For complex extraforaminal disc herniations at the LSJ, a viable surgical option is to perform the nerve root decompression and discectomy via a minimally invasive, muscle-splitting approach with a tubular retractor and operating microscope. The patients in this limited series exhibited initial symptom relief and suffered no intraoperative complications. This approach provides excellent visualization of the pertinent anatomy while utilizing familiar tools.

Disclosure

Dr. Mummaneni is a paid consultant for DePuy Spine, Inc.

References

  • 1

    Abdullah AFDitto EW IIIByrd EBWilliams R: Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J Neurosurg 41:2292341974

  • 2

    Abdullah AFWolber PGWarfield JRGunadi IK: Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery 22:6486531988

  • 3

    An HSVaccaro ASimeone FABalderston RAO'Neill D: Herniated lumbar disc in patients over the age of fifty. J Spinal Disord 3:1431461990

  • 4

    Bonafé ATremoulet MSabatier JBoetto SDocco ARichardi G: [Foraminal and latero-foraminal hernia. Mid-term results of percutaneous techniques nucleolysis-nucleotomy.]. Neurochirurgie 39:1101151993. (Fr)

  • 5

    Briggs CAChandraraj S: Variations in the lumbosacral ligament and associated changes in the lumbosacral region resulting in compression of the fifth dorsal root ganglion and spinal nerve. Clin Anat 8:3393461995

  • 6

    Cervellini PDe Luca GPMazzetto MColombo F: Micro-endoscopic-discectomy (MED) for far lateral disc herniation in the lumbar spine. Technical note. Acta Neurochir Suppl (Wein) 92:991012005

  • 7

    Darden BV IIWade JFAlexander RWood KERhyne AL IIIHicks JR: Far lateral disc herniations treated by microscopic fragment excision. Techniques and results. Spine 20:150015051995

  • 8

    Donaldson WF IIIStar MJThorne RP: Surgical treatment for the far lateral herniated lumbar disc. Spine 18:126312671993

  • 9

    Ebeling UReichenberg WReulen HJ: Results of microsurgical lumbar discectomy. Review on 485 patients. Acta Neurochir (Wein) 81:45521986

  • 10

    Ehni BLBenzel ECBiscup RSLumbar discectomy. Benzel EC: Spine Surgery: Techniques Complication Avoidance and Management ed 2.PhiladelphiaElsevier Science2004. Vol 1:609611

  • 11

    Eichholz KMHitchon P: Far lateral lumbar disc herniation. Contemp Neurosurg 25:152003

  • 12

    Epstein NE: Different surgical approaches to far lateral lumbar disc herniations. J Spinal Disord 8:3833941995

  • 13

    Epstein NE: Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg 83:6486561995

  • 14

    Epstein NEEpstein JACarras RHyman RA: Far lateral lumbar disc herniations and associated structural abnormalities. An evaluation in 60 patients of the comparative value of CT, MRI, and myelo-CT in diagnosis and management. Spine 15:5345391990

  • 15

    Faust SEDucker TBVanHassent JA: Lateral lumbar disc herniations. J Spinal Disord 5:971031992

  • 16

    Foley KTSmith MM: Microendoscopic discectomy. Tech Neurosurg 3:3013071997

  • 17

    Foley KTSmith MMRampersaud YR: Microendoscopic approach to far-lateral lumbar disc herniation. Neurosurg Focus 7:5E51999

  • 18

    Garrido EConnaughton PN: Unilateral facetectomy approach for lateral lumbar disc herniation. J Neurosurg 74:7547561991

  • 19

    Gioia GMandelli DCapaccioni BRandelli FTessari L: Surgical treatment of far lateral lumbar disc herniation. Identification of compressed root and discectomy by lateral approach. Spine 24:195219571999

  • 20

    Godersky JCErickson DLSeljeskog EL: Extreme lateral disc herniation: diagnosis by computed tomographic scanning. Neurosurgery 14:5495521984

  • 21

    Greiner-Perth RBöhm HAllam Y: A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results. Eur Spine J 12:3203242003

  • 22

    Haher TRO'Brien MDryer JWNucci RZipnick RLeone DJ: The role of the lumbar facet joints in spinal stability. Identification of alternative paths of loading. Spine 19:266726711994

  • 23

    Howe JFLoeser JDCalvin WH: Mechanosensitivity of dorsal root ganglia and chronically injured axons: a physiological basis for the radicular pain of nerve root compression. Pain 3:25411977

  • 24

    Huber PReulen HJ: CT-observations of the intra- and extracanalicular disc herniation. Acta Neurochir (Wein) 100:3111989

  • 25

    Ichihara KTaguchi THashida TOchi YMurakami TKawai S: The treatment of far-out foraminal stenosis below a lumbosacral transitional vertebra: a report of two cases. J Spinal Disord Tech 17:1541572004

  • 26

    Jackson RK: The long-term effects of wide laminectomy for lumbar disc excision. A review of 130 patients. J Bone Joint Surg Br 53:6096161971

  • 27

    Jackson RPGlah JJ: Foraminal and extraforaminal lumbar disc herniation: diagnosis and treatment. Spine 12:5775851987

  • 28

    Jane JAHaworth CSBroaddus WCLee JHMalik J: A neurosurgical approach to far-lateral disc herniation. Technical note. J Neurosurg 72:1431441990

  • 29

    Johnsson KEWillner SJohnsson K: Postoperative instability after decompression for lumbar spinal stenosis. Spine 11:1071101986

  • 30

    Kambin PO'Brien EZhou LSchaffer JL: Arthroscopic microdiscectomy and selective fragmentectomy. Clin Orthop Relat Res 347:1501671998

  • 31

    Kawaguchi YMatsui HTsuji H: Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis. Spine 21:9419441996

  • 32

    Kawaguchi YYabuki SStyf JOlmarker KRydevik BMatsui H: Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery. Spine 21:268326881996

  • 33

    Kotil KAkcetin MBilge T: A minimally invasive transmuscular approach to far-lateral L5-S1 level disc herniations: a prospective study. J Spinal Disord Tech 20:1321382007

  • 34

    Kunogi JHasue M: Diagnosis and operative treatment of intra-foraminal and extraforaminal nerve root compression. Spine 16:131213201991

  • 35

    Kurobane YTakahashi TTajima TYamakawa HSakamoto TSawumi A: Extraforaminal disc herniation. Spine 11:2602681986

  • 36

    Lejeune JPHladky JPCotten AVinchon MChristiaens JL: Foraminal lumbar disc herniation. Experience with 83 patients. Spine 19:190519081994

  • 37

    Macnab I: Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am 53:8919031971

  • 38

    Macnab ICuthbert HGodfrey C: The incidence of denervation of the sacrospinalis muscles following spine surgery. Spine 2:2942981977

  • 39

    Maroon JCKopitnik TASchulhof LAAbla AWilberger JE: Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 72:3783821990

  • 40

    Matsumoto MChiba KIshii KWatanabe KNakamura MToyama Y: Microendoscopic partial resection of the sacral ala to relieve extraforaminal entrapment of the L-5 spinal nerve at the lumbosacral tunnel. Technical note. J Neurosurg Spine 4:3423462006

  • 41

    Melvill RLBaxter BL: The intertransverse approach to extra-foraminal disc protrusion in the lumbar spine. Spine 19:270727141994

  • 42

    Naylor A: Late results of laminectomy for lumbar disc prolapse. A review after ten to twenty-five years. J Bone Joint Surg Br 56:17291974

  • 43

    O'Hara LJMarshall RW: Far lateral lumbar disc herniation. The key to the intertransverse approach. J Bone Joint Surg Br 79:9439471997

  • 44

    O'Toole JEEichholz KMFessler RG: Minimally invasive far lateral microendoscopic discectomy for extraforaminal disc herniation at the lumbosacral junction: cadaveric dissection and technical case report. Spine J 7:4144212007

  • 45

    Osborn AGHood RSSherry RGSmoker WRHarnsberger HR: CT/MR spectrum of far lateral and anterior lumbosacral disk herniations. AJNR Am J Neuroradiol 9:7757781988

  • 46

    Ozveren MFBilge TBarut SEras M: Combined approach for far-lateral lumbar disc herniation. Neurol Med Chir 44:1181232004

  • 47

    Perves AMorvan G: [L5-S1 herniated disk migrated to the anterior part of the right sacral wing with compression of the right lumbosacral roots.]. Rev Chir Orthop Reparatrice Appar Mot 82:5575601996. (Fr)

  • 48

    Porchet FChollet-Bornand Ade Tribolet N: Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations. J Neurosurg 90:59661999

  • 49

    Prolo DJOklund SAButcher M: Toward uniformity in evaluating results of lumbar spine operations. A paradigm applied to posterior lumbar interbody fusions. Spine 11:6016061986

  • 50

    Quaglietta PCassitto DCorriero ASCorriero G: Paraspinal approach to the far lateral disc herniations: retrospective study on 42 cases. Acta Neurochir Suppl (Wein) 92:1151192005

  • 51

    Reulen HJMüller AEbeling U: Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations. Neurosurgery 39:3453511996

  • 52

    Reulen HJPfaundler SEbeling U: The lateral microsurgical approach to the “extracanalicular” lumbar disc herniation. I: a tech nical note. Acta Neurochir (Wein) 84:64671987

  • 53

    Segnarbieux FVan de Kelft ECandon EBitoun JFrèrebeau P: Disco-computed tomography in extraforaminal and foraminal lumbar disc herniation: influence on surgical approaches. Neurosurgery 34:6436481994

  • 54

    Shao KNChen SSYen YSJen SLLee LS: Far lateral lumbar disc herniation. Zhonghua Yi Xue Za Zhi (Taipei) 63:3913982000

  • 55

    Shenkin HAHash CJ: Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis. Follow-up review. J Neurosurg 50:45471979

  • 56

    Siebner HRFaulhauer K: Frequency and specific surgical management of far lateral lumbar disc herniations. Acta Neurochir (Wein) 105:1241311990

  • 57

    Sihvonen THerno APaljärvi LAiraksinen OPartanen JTapaninaho A: Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 18:5755811993

  • 58

    Styf JRWillén J: The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine 23:3543581998

  • 59

    Tessitore Ede Tribolet N: Far-lateral lumbar disc herniation: the microsurgical transmuscular approach. Neurosurgery 54:9399422004

  • 60

    Wall PDDevor M: Sensory afferent impulses originate from dorsal root ganglia as well as from the periphery in normal and nerve injured rats. Pain 17:3213391983

  • 61

    Wiltse LL: The paraspinal sacrospinalis-splitting approach to the lumbar spine. Clin Orthop Relat Res 91:48571973

  • 62

    Wiltse LLSpencer CW: New uses and refinements of the paraspinal approach to the lumbar spine. Spine 13:6967061988

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Address correspondence to: Stephen M. Pirris, M.D., UPMC-Department of Neurological Surgery, 200 Lothrop Street, Suite B-400, Pittsburgh, Pennsylvania 15213. email: pirrissm@upmc.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Artist's depiction of the axial plane of a tubular retractor used for access to the removal of an extraforaminal disc herniation.

  • View in gallery

    Photograph of a fresh-frozen human cadaver specimen illustrating the anatomical constraints to the minimally invasive approach to an extraforaminal disc herniation at the LSJ. F = lateral facet of L-5; P = pars interarticularis of L-5; A = sacral ala; D = intervertebral disc at L5–S1; TP = transverse process of L-5.

References

1

Abdullah AFDitto EW IIIByrd EBWilliams R: Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J Neurosurg 41:2292341974

2

Abdullah AFWolber PGWarfield JRGunadi IK: Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery 22:6486531988

3

An HSVaccaro ASimeone FABalderston RAO'Neill D: Herniated lumbar disc in patients over the age of fifty. J Spinal Disord 3:1431461990

4

Bonafé ATremoulet MSabatier JBoetto SDocco ARichardi G: [Foraminal and latero-foraminal hernia. Mid-term results of percutaneous techniques nucleolysis-nucleotomy.]. Neurochirurgie 39:1101151993. (Fr)

5

Briggs CAChandraraj S: Variations in the lumbosacral ligament and associated changes in the lumbosacral region resulting in compression of the fifth dorsal root ganglion and spinal nerve. Clin Anat 8:3393461995

6

Cervellini PDe Luca GPMazzetto MColombo F: Micro-endoscopic-discectomy (MED) for far lateral disc herniation in the lumbar spine. Technical note. Acta Neurochir Suppl (Wein) 92:991012005

7

Darden BV IIWade JFAlexander RWood KERhyne AL IIIHicks JR: Far lateral disc herniations treated by microscopic fragment excision. Techniques and results. Spine 20:150015051995

8

Donaldson WF IIIStar MJThorne RP: Surgical treatment for the far lateral herniated lumbar disc. Spine 18:126312671993

9

Ebeling UReichenberg WReulen HJ: Results of microsurgical lumbar discectomy. Review on 485 patients. Acta Neurochir (Wein) 81:45521986

10

Ehni BLBenzel ECBiscup RSLumbar discectomy. Benzel EC: Spine Surgery: Techniques Complication Avoidance and Management ed 2.PhiladelphiaElsevier Science2004. Vol 1:609611

11

Eichholz KMHitchon P: Far lateral lumbar disc herniation. Contemp Neurosurg 25:152003

12

Epstein NE: Different surgical approaches to far lateral lumbar disc herniations. J Spinal Disord 8:3833941995

13

Epstein NE: Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg 83:6486561995

14

Epstein NEEpstein JACarras RHyman RA: Far lateral lumbar disc herniations and associated structural abnormalities. An evaluation in 60 patients of the comparative value of CT, MRI, and myelo-CT in diagnosis and management. Spine 15:5345391990

15

Faust SEDucker TBVanHassent JA: Lateral lumbar disc herniations. J Spinal Disord 5:971031992

16

Foley KTSmith MM: Microendoscopic discectomy. Tech Neurosurg 3:3013071997

17

Foley KTSmith MMRampersaud YR: Microendoscopic approach to far-lateral lumbar disc herniation. Neurosurg Focus 7:5E51999

18

Garrido EConnaughton PN: Unilateral facetectomy approach for lateral lumbar disc herniation. J Neurosurg 74:7547561991

19

Gioia GMandelli DCapaccioni BRandelli FTessari L: Surgical treatment of far lateral lumbar disc herniation. Identification of compressed root and discectomy by lateral approach. Spine 24:195219571999

20

Godersky JCErickson DLSeljeskog EL: Extreme lateral disc herniation: diagnosis by computed tomographic scanning. Neurosurgery 14:5495521984

21

Greiner-Perth RBöhm HAllam Y: A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results. Eur Spine J 12:3203242003

22

Haher TRO'Brien MDryer JWNucci RZipnick RLeone DJ: The role of the lumbar facet joints in spinal stability. Identification of alternative paths of loading. Spine 19:266726711994

23

Howe JFLoeser JDCalvin WH: Mechanosensitivity of dorsal root ganglia and chronically injured axons: a physiological basis for the radicular pain of nerve root compression. Pain 3:25411977

24

Huber PReulen HJ: CT-observations of the intra- and extracanalicular disc herniation. Acta Neurochir (Wein) 100:3111989

25

Ichihara KTaguchi THashida TOchi YMurakami TKawai S: The treatment of far-out foraminal stenosis below a lumbosacral transitional vertebra: a report of two cases. J Spinal Disord Tech 17:1541572004

26

Jackson RK: The long-term effects of wide laminectomy for lumbar disc excision. A review of 130 patients. J Bone Joint Surg Br 53:6096161971

27

Jackson RPGlah JJ: Foraminal and extraforaminal lumbar disc herniation: diagnosis and treatment. Spine 12:5775851987

28

Jane JAHaworth CSBroaddus WCLee JHMalik J: A neurosurgical approach to far-lateral disc herniation. Technical note. J Neurosurg 72:1431441990

29

Johnsson KEWillner SJohnsson K: Postoperative instability after decompression for lumbar spinal stenosis. Spine 11:1071101986

30

Kambin PO'Brien EZhou LSchaffer JL: Arthroscopic microdiscectomy and selective fragmentectomy. Clin Orthop Relat Res 347:1501671998

31

Kawaguchi YMatsui HTsuji H: Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis. Spine 21:9419441996

32

Kawaguchi YYabuki SStyf JOlmarker KRydevik BMatsui H: Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery. Spine 21:268326881996

33

Kotil KAkcetin MBilge T: A minimally invasive transmuscular approach to far-lateral L5-S1 level disc herniations: a prospective study. J Spinal Disord Tech 20:1321382007

34

Kunogi JHasue M: Diagnosis and operative treatment of intra-foraminal and extraforaminal nerve root compression. Spine 16:131213201991

35

Kurobane YTakahashi TTajima TYamakawa HSakamoto TSawumi A: Extraforaminal disc herniation. Spine 11:2602681986

36

Lejeune JPHladky JPCotten AVinchon MChristiaens JL: Foraminal lumbar disc herniation. Experience with 83 patients. Spine 19:190519081994

37

Macnab I: Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am 53:8919031971

38

Macnab ICuthbert HGodfrey C: The incidence of denervation of the sacrospinalis muscles following spine surgery. Spine 2:2942981977

39

Maroon JCKopitnik TASchulhof LAAbla AWilberger JE: Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 72:3783821990

40

Matsumoto MChiba KIshii KWatanabe KNakamura MToyama Y: Microendoscopic partial resection of the sacral ala to relieve extraforaminal entrapment of the L-5 spinal nerve at the lumbosacral tunnel. Technical note. J Neurosurg Spine 4:3423462006

41

Melvill RLBaxter BL: The intertransverse approach to extra-foraminal disc protrusion in the lumbar spine. Spine 19:270727141994

42

Naylor A: Late results of laminectomy for lumbar disc prolapse. A review after ten to twenty-five years. J Bone Joint Surg Br 56:17291974

43

O'Hara LJMarshall RW: Far lateral lumbar disc herniation. The key to the intertransverse approach. J Bone Joint Surg Br 79:9439471997

44

O'Toole JEEichholz KMFessler RG: Minimally invasive far lateral microendoscopic discectomy for extraforaminal disc herniation at the lumbosacral junction: cadaveric dissection and technical case report. Spine J 7:4144212007

45

Osborn AGHood RSSherry RGSmoker WRHarnsberger HR: CT/MR spectrum of far lateral and anterior lumbosacral disk herniations. AJNR Am J Neuroradiol 9:7757781988

46

Ozveren MFBilge TBarut SEras M: Combined approach for far-lateral lumbar disc herniation. Neurol Med Chir 44:1181232004

47

Perves AMorvan G: [L5-S1 herniated disk migrated to the anterior part of the right sacral wing with compression of the right lumbosacral roots.]. Rev Chir Orthop Reparatrice Appar Mot 82:5575601996. (Fr)

48

Porchet FChollet-Bornand Ade Tribolet N: Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations. J Neurosurg 90:59661999

49

Prolo DJOklund SAButcher M: Toward uniformity in evaluating results of lumbar spine operations. A paradigm applied to posterior lumbar interbody fusions. Spine 11:6016061986

50

Quaglietta PCassitto DCorriero ASCorriero G: Paraspinal approach to the far lateral disc herniations: retrospective study on 42 cases. Acta Neurochir Suppl (Wein) 92:1151192005

51

Reulen HJMüller AEbeling U: Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations. Neurosurgery 39:3453511996

52

Reulen HJPfaundler SEbeling U: The lateral microsurgical approach to the “extracanalicular” lumbar disc herniation. I: a tech nical note. Acta Neurochir (Wein) 84:64671987

53

Segnarbieux FVan de Kelft ECandon EBitoun JFrèrebeau P: Disco-computed tomography in extraforaminal and foraminal lumbar disc herniation: influence on surgical approaches. Neurosurgery 34:6436481994

54

Shao KNChen SSYen YSJen SLLee LS: Far lateral lumbar disc herniation. Zhonghua Yi Xue Za Zhi (Taipei) 63:3913982000

55

Shenkin HAHash CJ: Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis. Follow-up review. J Neurosurg 50:45471979

56

Siebner HRFaulhauer K: Frequency and specific surgical management of far lateral lumbar disc herniations. Acta Neurochir (Wein) 105:1241311990

57

Sihvonen THerno APaljärvi LAiraksinen OPartanen JTapaninaho A: Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 18:5755811993

58

Styf JRWillén J: The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine 23:3543581998

59

Tessitore Ede Tribolet N: Far-lateral lumbar disc herniation: the microsurgical transmuscular approach. Neurosurgery 54:9399422004

60

Wall PDDevor M: Sensory afferent impulses originate from dorsal root ganglia as well as from the periphery in normal and nerve injured rats. Pain 17:3213391983

61

Wiltse LL: The paraspinal sacrospinalis-splitting approach to the lumbar spine. Clin Orthop Relat Res 91:48571973

62

Wiltse LLSpencer CW: New uses and refinements of the paraspinal approach to the lumbar spine. Spine 13:6967061988

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 92 92 46
PDF Downloads 46 46 13
EPUB Downloads 0 0 0

PubMed

Google Scholar