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Management of disc herniations with bi-radicular symptoms via combined lateral and interlaminar approach

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Abstract

Large lumbosacral disc herniations causing bi-radicular symptoms are very rare clinical entities and may present a surgical challenge. This study was undertaken to evaluate the effectiveness of the simply modified combined lateral and interlaminar approach for the treatment of these unique disc herniations. Between 2000 and 2005, 18 patients with bi-radicular symptoms secondary to large disc herniations of the lumbar spine underwent surgery. There were 13 men and five women, ranging in age between 25 and 64 years (mean 54.3 years). In this three-step operation, the osseous areas that are not essential for the facet joint were removed and both upper and lower nerve roots were decompressed. There were no intraoperative or postoperative complications, except transient dysesthesia in one (5.5%) patient. The mean follow-up period was 62.6 months (range 36–96 months). At the latest follow-up examination, outcomes using the Macnab classification were excellent in 13 patients (72.2 %), good in four (22.2%) and fair in one (5.5%). Recurrent disc herniations and/or instability, either symptomatic or radiographic, have not occurred as a result of the procedure during the follow-up period. The combined approach described here is a safe and effective procedure in the surgical treatment of this subtype of disc herniations with bi-radicular involvement. It permits optimum decompression of both nerve roots, avoiding the risk of secondary spinal instability.

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Authors and Affiliations

  1. GATA Haydarpaşa Eğitim Hastanesi, Nöroşirürji Servisi, Üsküdar, 34668, İstanbul, Turkey

    Murat Kutlay, Kıvanç Topuz, Ahmet Çolak, Hakan Şimşek, Ahmet Çetinkal & Mehmet Nusret Demircan

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  1. Murat Kutlay
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  2. Kıvanç Topuz
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  3. Ahmet Çolak
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  4. Hakan Şimşek
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  5. Ahmet Çetinkal
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Correspondence to Hakan Şimşek.

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Comments

Mehmet Daneyemez, Ankara, Turkey

Present paper reported the experience in a clinic of 18 patients who underwent the combined intertransverse–interlaminar approach to large disc herniations with paramedian and lateral extensions that compressed the upper and lower nerve roots related to the disc space, as described. According to their findings, modified combined lateral and interlaminar approach was defined as ‘safe and effective procedure’ in the surgical treatment of the large disc herniations in properly selected patients.

I have been affected by the technique described in the text though it included slight differences from those which were described previously by numerous authors, because the operational technique has been described very clearly and moreover, it is clinically practical rather than just being a postulation with constricted experimental use.

Traditional techniques consisted usually of complete removal of the facet for decompression of the spinal canal and exploration of the intervertebral foramen. This inevitably frequently resulted in spinal instability. Consequently, additional posterolateral fusion is required adding morbidity and prolonged hospital stay. However, with the use of this surgical combined approach, affected nerve roots can be explored and decompressed without giving much harm to normal facet joint. Keeping the integrity of pars interarticularis sparing the lateral portion of the pars in tricortical structure will rationally enhance to decreasing the risk of spinal instability.

Approach to the L5–S1 intervertebral intertransverse pathologies seems to necessitate drilling the para-articular notch.

The goal of the aforescribed surgical technique was preservation of the pars interarticularis and the major part of the facet joint and I had the practical sense that the described approach is a successful trial and deserve appreciation as applied to properly selected group of patients.

Jack Jallo, Philadelphia, USA

The authors in this article report on their surgical experience in 18 patients over a 5-year period who underwent a combined intertransverse–interlaminar approach to large disc herniations that compressed the upper and lower nerve roots with a mean follow-up of 62.6 months.

The technique described is a simple and well-illustrated modification of previously reported surgical techniques that allows exploration of the affected roots without disruption of the facet joint. They report good outcomes in 72.2% of patients over the follow-up period and no instability or recurrent disc herniations.

In summary, the authors present an interesting and new approach to technically challenging disc herniations in a small series of patients.

Ernst Delwel, Rotterdam, the Netherlands

The authors have produced a useful article on a unique combined approach for a subgroup of patients with a bi-radicular syndrome caused by a lateral lumbar disc herniation.

This subgroup consisted of 2.1% of the total amount of patients with a symptomatic lumbar disc herniation that were operated in the period of 2000–2005. A meticulous description is given of the operative procedure and the authors have explained the indication for this technique thoroughly. They have to be complemented with their good results, even after a long follow-up period and their very low complication rate.

Before using this new and rather complex technique, a training period on anatomic specimen in the lab would be advisable to my opinion. Furthermore, I would like to emphasise to use peroperative neuronavigation or at least peroperative fluoroscopy to prevent exploring the wrong level.

Luciano Mastronardi, Rome, Italy

Disc herniations with bi-radicular involvement are rare and the optimal approach should allow the total removal of the fragments and avoid further vertebral instability.

The authors propose an interesting combined lateral and interlaminar approach, sparing the joints and, thus, preserving the stability. The good results seem to confirm that this three-step procedure is a valid proposal for this kind of procedure. Prospective studies on larger should be warranted.

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Kutlay, M., Topuz, K., Çolak, A. et al. Management of disc herniations with bi-radicular symptoms via combined lateral and interlaminar approach. Neurosurg Rev 33, 97–105 (2010). https://doi.org/10.1007/s10143-009-0218-0

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