Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results

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✓ This study was undertaken to determine and compare indications and relative benefits of various surgical approaches in 170 patients (average age 55 years) with far-lateral herniated lumbar discs, identified by magnetic resonance (MR) imaging and computerized tomography (CT) and operated on between 1984 and 1994. Essentially three surgical procedures were performed: complete facetectomy in 73 patients, laminotomy with medial facetectomy in 39 patients, and intertransverse discectomy (also known as ITT) in 58 patients. Follow-up periods averaged 5 years (range 0.5–10 years). Outcomes were scored as excellent (no deficit), good (mild radiculopathy), fair (moderate radiculopathy), and poor (unchanged or worse).

Overall, excellent and good results were achieved in 73 and 51 patients, respectively, and fair and poor results in 26 and 20, respectively. There was little difference among the results encountered for the three major surgical groups: 79% of the intertransverse (ITT) group had good-to-excellent outcomes, as compared with 70% of the facetectomy group, and 68% of the group who underwent at minimum laminotomy, and additional hemilaminectomy or laminectomy with medial facetectomy. Results were the same for the 121 patients followed for more than 2 years and for the 49 patients studied for under 2 years.

In the management of far-lateral discs, total facetectomy provides the best exposure, but increases the risk of instability. Laminotomy and medial facetectomy uncover the lateral and subarticular recess and preserve stability, but visualization of the far-lateral compartment is often inadequate. The intertransverse approach offers extensive far-lateral but not medial intraforaminal exposure, while also preserving stability.

Full facetectomy, laminotomy with medial facetectomy, and the intertransverse approaches yielded nearly comparable outcomes in far-lateral disc surgery. Only the full facetectomy exposes the entire course of the nerve root both medially and laterally, whereas the intertransverse procedure provides direct exposure of the far-lateral compartment alone.

It is important to select the correct approach or combination of approaches to address attendant complicating factors such as spinal stenosis, spondyloarthrosis, and degenerative spondylolisthesis identified on CT and MR studies.

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Address reprint requests to: Nancy E. Epstein, M.D., Long Island Neurosurgical Associates, 410 Lakeville Road, Suite 204, New Hyde Park, New York 11042.

© AANS, except where prohibited by US copyright law.

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    Schematic drawings depicting medial facetectomy with laminotomy and focal resection of the pars interarticularis for far-lateral disc excision. The L-5 nerve root underlying the superior articular facet of L-5 (large arrow) courses around the L-5 pedicle as it extends into the L5—S1 neural foramen (small arrows) on its way to the far-lateral compartment (upper). Sequestered elements of the far-lateral disc herniation extending to and through the L5—S1 neural foramen are adequately decompressed through medial facetectomy and foraminotomy (lower, A). Focal resection of the L-5 pars interarticularis with extraspinal exposure (lower, B) is initiated through a superior L4–5 laminotomy that directly visualizes the L-5 nerve root (double arrows) as it leaves the spinal canal (lower, A) and enters the L4–5 neural foramen (lower) a. = left lateral recess; P. = pars interarticularis.

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    Drawing showing the intertransverse approach to far-lateral disc resection. This approach requires the performance of an extended L5—S1 interlaminar laminotomy or L-5 hemilaminectomy, allowing the far laterally exiting L-5 nerve root to be identified prior to its entry into the neural foramen. The pars is left alone. Laterally, the intertransverse ligament and fascia are dissected followed by the removal of the most superolateral aspect of the superior articular facet joint. An elongated retractor with a sharp bend may be introduced into the neural foramen medially to allow lateral dissection to proceed while protecting the nerve root itself in stenotic and arthrotic individuals. Far-lateral disc fragments, typically sequestered disc, and medial disc material are successfully excised (arrow).

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    Drawings illustrating hemilaminectomy and full facetectomy for excision of type III calcified far-lateral limbus vertebral fracture. A right-sided hemilaminectomy and full L5—S1 facetectomy provides completed exposure of the right L-5 root and calcified type III limbus vertebral fracture from within the canal through the foramen and into the far-lateral compartment (A). The lateral view (B) reveals fracture arising from the inferior end plate of the L-5 vertebral body intruding into the L5—S1 foramen. The transaxial view (C) illustrates the predominant foraminal location of the limbus fracture. Intraforaminal and extraforaminal lesions require a complete facetectomy.

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    Magnetic resonance (MR) images obtained in Case 1. Left: On this parasagittal T1-weighted MR image of intra- and extraforaminal far-lateral disc, the foraminal portion of a large, sequestered L5—S1 far-lateral disc herniation is well visualized (large arrow). Right: This transaxial T1-weighted MR image of the L5—S1 level shows a large, sequestered right-sided foraminal and far-lateral disc (small arrows).

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    Transaxial myelographic computerized tomography (CT) scans. Left: Case 2. Scan documenting a foraminal (small open arrow) and far-lateral (large open arrow) right-sided, L4–5 disc herniation. Because the arachnid membrane does not extend this far foraminally or laterally on the exiting L-4 nerve root, no intrathecal contrast was visualized in these areas. Center: Case 3. Scan obtained at the L5—S1 level showing a left-sided, far-lateral type III calcified limbus vertebral fracture (small arrows) accompanying a soft sequestered far-lateral disc. Multiple, calcified fragments comprising the limbus fracture obliterate the lateral-most aspect of the neural foramen and fill the far-lateral compartment. This lesion was resected through an L-5 hemilaminectomy with full facetectomy using a down-biting curette, tamp, and mallet technique. Right: Case 4. Scan showing an L5—S1 right-sided far-lateral soft sequestered disc fragment accompanied by a calcified type III limbus vertebral fracture (small straight arrows). In this 42-year-old man with a complete foot drop, a full facetectomy (large curved arrow) facilitating complete disc and limbus fracture excision resulted in a good recovery of function to the L4–5 level within the first 3 postoperative months.

References

1.

An HSVaccaro ASimeone FAet al: Herniated lumbar disc in patients over the age of fifty. J Spinal Disord 3:1431461990An HS Vaccaro A Simeone FA et al: Herniated lumbar disc in patients over the age of fifty. J Spinal Disord 3:143–146 1990

2.

Bonafe ATremoulet MSabatier Jet al: Hernies foraminales et latéroforaminales. Résultats à moyen terme des techniques percutanées nucléolyse-nucléotomie. Neurochirurgie 39:1101151993Bonafe A Tremoulet M Sabatier J et al: Hernies foraminales et latéroforaminales. Résultats à moyen terme des techniques percutanées nucléolyse-nucléotomie. Neurochirurgie 39:110–115 1993

3.

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

4.

Ebeling UReulen HJ: Are there typical localisations of lumbar disc herniations? A prospective study. Acta Neurochir 117:1431481992Ebeling U Reulen HJ: Are there typical localisations of lumbar disc herniations? A prospective study. Acta Neurochir 117:143–148 1992

5.

Epstein NEEpstein JACarras Ret al: 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 15:5345391990Epstein NE Epstein JA Carras R et al: 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 15:534–539 1990

6.

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

7.

Garrido EConnaughton PN: Lateral disc herniations. J Neurosurg 76:3423431992 (Letter)Garrido E Connaughton PN: Lateral disc herniations. J Neurosurg 76:342–343 1992 (Letter)

8.

Glickstein MFSussman SK: Time-dependent scar enhancement in magnetic resonance imaging of the postoperative lumbar spine. Skeletal Radiol 20:3333371991Glickstein MF Sussman SK: Time-dependent scar enhancement in magnetic resonance imaging of the postoperative lumbar spine. Skeletal Radiol 20:333–337 1991

9.

Hood RS: Far lateral lumbar disc herniations. Neurosurg Clin North Am 4:1171241993Hood RS: Far lateral lumbar disc herniations. Neurosurg Clin North Am 4:117–124 1993

10.

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

11.

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

12.

Maroon JCAbla AWilberger JEet al: MR imaging of lateral disc herniation. J Neurosurg 73:6426431990 (Letter)Maroon JC Abla A Wilberger JE et al: MR imaging of lateral disc herniation. J Neurosurg 73:642–643 1990 (Letter)

13.

Monteiro ALefèvre RPieters Get al: Lateral decompression of a pathological disc in the treatment of lumbar pain and sciatica. Clin Orthop 238:56631989Monteiro A Lefèvre R Pieters G et al: Lateral decompression of a pathological disc in the treatment of lumbar pain and sciatica. Clin Orthop 238:56–63 1989

14.

Oeckler RHamburger CSchmiedek Pet al: Surgical observations in extremely lateral lumbar disc herniation. Neurosurg Rev 15:2552581992Oeckler R Hamburger C Schmiedek P et al: Surgical observations in extremely lateral lumbar disc herniation. Neurosurg Rev 15:255–258 1992

15.

Perno JRRossitch E Jr: Extreme lateral lumbar disc herniation. Diagnosis and management. NC Med J 54:2242261993Perno JR Rossitch E Jr: Extreme lateral lumbar disc herniation. Diagnosis and management. NC Med J 54:224–226 1993

16.

Privat JM: Les techniques de nucléotomie-discectomie percutanée. Technique automatisée et technique manuelle. Indications et résultats. Neurochirurgie 39:1161241993Privat JM: Les techniques de nucléotomie-discectomie percutanée. Technique automatisée et technique manuelle. Indications et résultats. Neurochirurgie 39:116–124 1993

17.

Schlesinger SMFankhauser Hde Tribolet N: Microsurgical anatomy and operative technique for extreme lateral lumbar disc herniations. Acta Neurochir 118:1171291992Schlesinger SM Fankhauser H de Tribolet N: Microsurgical anatomy and operative technique for extreme lateral lumbar disc herniations. Acta Neurochir 118:117–129 1992

18.

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

19.

Spallone AGazzeri GFloris R: Extra-foraminal prolapsed lumbar disc: a possible cause of recurrent sciatica in failed low-back surgery patient. Case report. J Neurosurg Sci 6:1111151992Spallone A Gazzeri G Floris R: Extra-foraminal prolapsed lumbar disc: a possible cause of recurrent sciatica in failed low-back surgery patient. Case report. J Neurosurg Sci 6:111–115 1992

20.

Strum PFArmstrong GWO'Neil DJet al: Far lateral lumbar disc herniation treated with an anterolateral retroperitoneal approach. Report of two cases. Spine 17:3633651992Strum PF Armstrong GW O'Neil DJ et al: Far lateral lumbar disc herniation treated with an anterolateral retroperitoneal approach. Report of two cases. Spine 17:363–365 1992

21.

Wiltse LLBateman JGHutchinson RHet al: The paraspinal sacrospinalis-splitting approach to the lumbar spine. J Bone Joint Surg (Am) 50:9199261960Wiltse LL Bateman JG Hutchinson RH et al: The paraspinal sacrospinalis-splitting approach to the lumbar spine. J Bone Joint Surg (Am) 50:919–926 1960

22.

Winter DDMunk PLHelms CAet al: CT and MR of lateral disc herniation: typical appearance and pitfalls of interpretation. Can Assoc Radiol J 40:2562691989Winter DD Munk PL Helms CA et al: CT and MR of lateral disc herniation: typical appearance and pitfalls of interpretation. Can Assoc Radiol J 40:256–269 1989

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