Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations

Restricted access

Object. Far-lateral (extraforaminal) and foraminal disc herniations comprise up to 11% of all herniated intervertebral discs. Operative management can be technically difficult, and the optimum surgical treatment remains controversial. Accessing these lateral disc herniations endoscopically via a percutaneous transforaminal approach offers several theoretical advantages over the more traditional procedures. The object of this study was to assess the safety and efficacy of treating patients with far-lateral and foraminal disc herniations via a percutaneous transforaminal endoscopic approach.

Methods. A retrospective analysis was performed of 47 consecutive patients who underwent surgery via this approach. All procedures were performed after induction of a local anesthetic on an outpatient basis. Outcome was measured with Macnab criteria and by determining a patient's return-to-work status. The median follow-up period was 18 months (range 4–51 months). Excellent or good outcome was obtained in 40 (85%) of 47 patients. Of the 38 patients working before the onset of symptoms, 34 (90%) returned to work. Five patients (11%) experienced poor outcomes and subsequently underwent open procedures at the same level. Of the 10 recipients of Workers' Compensation, Macnab criteria indicated a significantly worse outcome (70% excellent or good), but an excellent return-to-work status was maintained (90%). There were no complications.

Conclusions. Transforaminal percutaneous endoscopic discectomy is safe and efficacious in the treatment of far-lateral and foraminal disc herniations.

Article Information

Address reprint requests to: Sean M. Lew, M.D., Division of Neurosurgery, University of Vermont, Given Building D-319, Burlington, Vermont 05405. email: Sean.Lew@vtmednet.org.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Photograph of a model depicting the triangular working zone, which is bounded superiorly and anteriorly by the nerve root, inferiorly by the transverse process, and medially by the superior facet.

  • View in gallery

    Intraoperative photographs demonstrating the endoscopic view. a–c: The cannula (C), annulus (A), nerve root (NR), annulotomy (AN), disc fragment (DF), and pituitary forceps (PF) are visualized.

  • View in gallery

    Photograph showing a disc fragment removed using the endoscopic technique, demonstrating the size of material that can be removed through the cannula (centimeter scale).

References

1.

Abdullah AFDitto EW IIIByrd EBet al: Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J Neurosurg 41:2292341974Abdullah AF Ditto EW III Byrd EB et al: Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J Neurosurg 41:229–234 1974

2.

Abdullah AFWolber PGWarfield JRet al: Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery 22:6486531988Abdullah AF Wolber PG Warfield JR et al: Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery 22:648–653 1988

3.

Chatterjee SFoy PMFindlay GF: Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation. Spine 20:7347381995Chatterjee S Foy PM Findlay GF: Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation. Spine 20:734–738 1995

4.

Darden BV IIWade JFAlexander Ret al: Far lateral disc herniations treated by microscopic fragment excision. Techniques and results. Spine 20:150015051995Darden BV II Wade JF Alexander R et al: Far lateral disc herniations treated by microscopic fragment excision. Techniques and results. Spine 20:1500–1505 1995

5.

Ditsworth DA: Endoscopic transforaminal lumbar discectomy and reconfiguration: a postero-lateral approach into the spinal canal. Surg Neurol 49:5885981998Ditsworth DA: Endoscopic transforaminal lumbar discectomy and reconfiguration: a postero-lateral approach into the spinal canal. Surg Neurol 49:588–598 1998

6.

Donaldson WF IIIStar MJThorne RP: Surgical treatment for the far lateral herniated lumbar disc. Spine 18:126312671993Donaldson WF III Star MJ Thorne RP: Surgical treatment for the far lateral herniated lumbar disc. Spine 18:1263–1267 1993

7.

Epstein NE: Different surgical approaches to far lateral lumbar disc herniations. J Spinal Disord 8:3833941995Epstein NE: Different surgical approaches to far lateral lumbar disc herniations. J Spinal Disord 8:383–394 1995

8.

Epstein NE: Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg 83:6486561995Epstein NE: Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg 83:648–656 1995

9.

Fankhauser Hde Tribolet N: Extreme lateral lumbar disc herniation. Br J Neurosurg 1:1111291987Fankhauser H de Tribolet N: Extreme lateral lumbar disc herniation. Br J Neurosurg 1:111–129 1987

10.

Faust SEDucker TBVanHassent JA: Lateral lumbar disc herniations. J Spinal Disord 5:971031992Faust SE Ducker TB VanHassent JA: Lateral lumbar disc herniations. J Spinal Disord 5:97–103 1992

11.

Garrido EConnaughton PN: Unilateral facetectomy approach for lateral lumbar disc herniation. J Neurosurg 74:7547561991Garrido E Connaughton PN: Unilateral facetectomy approach for lateral lumbar disc herniation. J Neurosurg 74:754–756 1991

12.

Haag M: [Transforaminal endoscopic microdiscectomy. Indications and short-term to intermediate-term results.] Orthopade 28:6156211999 (Ger)Haag M: [Transforaminal endoscopic microdiscectomy. Indications and short-term to intermediate-term results.] Orthopade 28:615–621 1999 (Ger)

13.

Jackson RPGlah JJ: Foraminal and extraforaminal lumbar disc herniation: diagnosis and treatment. Spine 12:5775851987Jackson RP Glah JJ: Foraminal and extraforaminal lumbar disc herniation: diagnosis and treatment. Spine 12:577–585 1987

14.

Jane JAHaworth CSBroaddus WCet al: A neurosurgical approach to far-lateral disc herniation. Technical note. J Neurosurg 72:1431441990Jane JA Haworth CS Broaddus WC et al: A neurosurgical approach to far-lateral disc herniation. Technical note. J Neurosurg 72:143–144 1990

15.

Kahanovitz N: Percutaneous diskectomy. Clin Orthop: 75791992Kahanovitz N: Percutaneous diskectomy. Clin Orthop:75–79 1992

16.

Kambin PGellman H: Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop 174:1271321983Kambin P Gellman H: Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop 174:127–132 1983

17.

Klekamp JMcCarty ESpengler DM: Results of elective lumbar discectomy for patients involved in the workers' compensation system. J Spinal Disord 11:2772821998Klekamp J McCarty E Spengler DM: Results of elective lumbar discectomy for patients involved in the workers' compensation system. J Spinal Disord 11:277–282 1998

18.

Kunogi JHasue M: Diagnosis and operative treatment of intraforaminal and extraforaminal nerve root compression. Spine 16:131213201991Kunogi J Hasue M: Diagnosis and operative treatment of intraforaminal and extraforaminal nerve root compression. Spine 16:1312–1320 1991

19.

Lejeune JPHladky JPCotten Aet al: Foraminal lumbar disc herniation. Experience with 83 patients. Spine 19:190519081994Lejeune JP Hladky JP Cotten A et al: Foraminal lumbar disc herniation. Experience with 83 patients. Spine 19:1905–1908 1994

20.

Macnab I: Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg (Am) 53:8919031971Macnab I: Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg (Am) 53:891–903 1971

21.

Maroon JCKopitnik TASchulhof LAet al: Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 72:3783821990Maroon JC Kopitnik TA Schulhof LA et al: Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 72:378–382 1990

22.

O'Hara LJMarshall RW: Far lateral lumbar disc herniation. The key to the intertransverse approach. J Bone Joint Surg (Br) 79:9439471997O'Hara LJ Marshall RW: Far lateral lumbar disc herniation. The key to the intertransverse approach. J Bone Joint Surg (Br) 79:943–947 1997

23.

Quigley MRBost JMaroon JCet al: Outcome after microdiscectomy: results of a prospective single institutional study. Surg Neurol 49:2632681998Quigley MR Bost J Maroon JC et al: Outcome after microdiscectomy: results of a prospective single institutional study. Surg Neurol 49:263–268 1998

24.

Siebner HRFaulhauer K: Frequency and specific surgical management of far lateral lumbar disc herniations. Acta Neurochir 105:1241311990Siebner HR Faulhauer K: Frequency and specific surgical management of far lateral lumbar disc herniations. Acta Neurochir 105:124–131 1990

25.

Stucker RKrug CReichelt A: [Endoscopic treatment of intervertebral disk displacement. Percutaneous transforaminal access to the epidural space. Indications, technique and initial results.] Orthopade 26:2802871997 (Ger)Stucker R Krug C Reichelt A: [Endoscopic treatment of intervertebral disk displacement. Percutaneous transforaminal access to the epidural space. Indications technique and initial results.] Orthopade 26:280–287 1997 (Ger)

26.

Wiltse LLSpencer CW: New uses and refinements of the paraspinal approach to the lumbar spine. Spine 13:6967061988Wiltse LL Spencer CW: New uses and refinements of the paraspinal approach to the lumbar spine. Spine 13:696–706 1988

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 85 85 39
Full Text Views 53 53 23
PDF Downloads 88 88 14
EPUB Downloads 0 0 0

PubMed

Google Scholar