European Spine Journal

, Volume 15, Issue 5, pp 554–558 | Cite as

Combined intra-extracanal approach to lumbosacral disc herniations with bi-radicular involvement. Technical considerations from a surgical series of 15 cases

  • Sergio Paolini
  • Pasquale Ciappetta
  • Antonino Raco
  • Paolo Missori
  • Roberto Delfini
Original Article


Large lumbosacral disc herniations effacing both the paramedian and the foraminal area often cause double radicular compression. Surgical management of these lesions may be difficult. A traditional interlaminar approach usually brings into view only the paramedian portion of the intervertebral disc, unless the lateral bone removal is considerably increased. Conversely, the numerous far-lateral approaches proposed for removing foraminal or extraforaminal disc herniations would decompress the exiting nerve root only. Overall, these approaches share the drawback of controlling the neuroforamen on one side alone. A combined intra-extraforaminal exposure is a useful yet rarely reported approach. Over a 3-year period, 15 patients with bi-radicular symptoms due to large disc herniations of the lumbar spine underwent surgery through a combined intra-extracanal approach. A standard medial exposure with an almost complete hemilaminectomy of the upper vertebra was combined with an extraforaminal exposure, achieved by minimal drilling of the inferior facet joint, the lateral border of the pars interarticularis and the inferior margin of the superior transverse process. The herniated discs were removed using key maneuvers made feasible by working simultaneously on both operative windows. In all cases the disc herniation could be completely removed, thus decompressing both nerve roots. Radicular pain was fully relieved without procedure-related morbidity. The intra-extraforaminal exposure was particularly useful in identifying the extraforaminal nerve root early. Early identification was especially advantageous when periradicular scar tissue hid the nerve root from view, as it did in patients who had undergone previous surgery at the same site or had long-standing radicular symptoms. Controlling the foramen on both sides also reduced the risk of leaving residual disc fragments. A curved probe was used to push the disc material outside the foramen. In conclusion, specific surgical maneuvers made feasible by a simultaneous extraspinal and intraspinal exposure allow quick, safe and complete removal of lumbosacral disc herniations with paramedian and foraminal extension.


Combined approach Disc herniation Foraminal Lumbar 



We are deeply indebted to Arch. Alessandra Viscione for preparing the artistic drawings.


  1. 1.
    Di Lorenzo N, Porta F, Onnis G, Cannas A, Arbau G, Maleci A (1998) Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach. Neurosurgery 42:87–89 (Discussion 89–90)Google Scholar
  2. 2.
    Donaldson WF 3rd, Star MJ, Thorne RP (1993) Surgical treatment for the far lateral herniated lumbar disc. Spine 18:1263–1267Google Scholar
  3. 3.
    Ebeling U, Kalbarcyk H, Reulen HJ (1989) Microsurgical reoperation following lumbar disc surgery. Timing, surgical findings, and outcome in 92 patients. J Neurosurg 70:397–404Google Scholar
  4. 4.
    Epstein NE (1995) Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg 83:648–656Google Scholar
  5. 5.
    Epstein NE (2002) Foraminal and far lateral lumbar disc herniations: surgical alternatives and outcome measures. Spinal Cord 40:491–500Google Scholar
  6. 6.
    Faust SE, Ducker TB, VanHassent JA (1992) Lateral lumbar disc herniations. J Spinal Disord 5:97–103Google Scholar
  7. 7.
    Garrido E, Connaughton PN (1991) Unilateral facetectomy approach for lateral lumbar disc herniation. J Neurosurg 74:754–756Google Scholar
  8. 8.
    Hassler W, Brandner S, Slansky I (1996) Microsurgical management of lateral lumbar disc herniations: combined lateral and interlaminar approach. Acta Neurochir (Wien) 138:907–910 (Discussion 910–911)Google Scholar
  9. 9.
    Hejazi N, Witzmann A, Hergan K, Hassler W (2002) Combined transarticular lateral and medial approach with partial facetectomy for lumbar foraminal stenosis. Technical note. J Neurosurg 96:118–121Google Scholar
  10. 10.
    Hood RS (1993) Far lateral lumbar disc herniations. Neurosurg Clin N Am 4:117–124Google Scholar
  11. 11.
    Macnab I (1971) Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am 53:891–903PubMedGoogle Scholar
  12. 12.
    Melvill RL, Baxter BL (1994) The intertransverse approach to extraforaminal disc protrusion in the lumbar spine. Spine 19:2707–2714Google Scholar
  13. 13.
    Monteiro A, Lefevre R, Pieters G, Wilmet E (1989) Lateral decompression of a pathological disc in the treatment of lumbar pain and sciatica. Clin Orthop 238:56–63Google Scholar
  14. 14.
    O’Brien MF, Peterson D, Crockard HA (1995) A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation. J Neurosurg 83:636–640PubMedGoogle Scholar
  15. 15.
    Reulen HJ, Pfaundler S, Ebeling U (1987) The lateral microsurgical approach to the “extracanalicular” lumbar disc herniation. I. A technical note. Acta Neurochir (Wien) 84:64–67Google Scholar
  16. 16.
    Siebner HR, Faulhauer K (1990) Frequency and specific surgical management of far lateral lumbar disc herniations. Acta Neurochir (Wien) 105:124–131Google Scholar
  17. 17.
    Weinstein PR (1998) Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach. Neurosurgery 42:89 (comment)Google Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Sergio Paolini
    • 1
  • Pasquale Ciappetta
    • 1
  • Antonino Raco
    • 2
  • Paolo Missori
    • 2
  • Roberto Delfini
    • 2
  1. 1.Cattedra di NeurochirurgiaUniversità di PerugiaTerniItaly
  2. 2.Cattedra di NeurochirurgiaUniversità di Roma “La Sapienza”Italy

Personalised recommendations