Abstract
Background
Minimally invasive surgical resection of extraforaminal disc herniation is challenging. The anatomical landmarks are varying from common interlaminar approach. The main risk is to damage the exiting nerve root as it is not yet protected by any bony structure.
Method
Here, we present the different steps of the minimally invasive approach to resect a lumbar extraforaminal disc herniation, using tubular retractor under microscopy.
Conclusion
Once the key steps of tubular placements are well known, minimally invasive approach for such extraforaminal resection affords appropriate exposure, while reducing blood loss and muscle injury.
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References
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Acknowledgements
Thanks to Thomas Graves, medical illustrator, who performed the Fig. 2.
Funding
This study was funded by Lille University hospital and New-York Presbyterian.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient gave formal consent to publication of this video.
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Summary of 10 key points
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1. MIS for extraforaminal approach is appropriate in the lumbar spine, but requires previous MIS experience with interlaminar approach.
2. A preoperative MRI with axial and sagittal planes is mandatory to assess with precision the position of the root and the potential migration of the disc herniation. In case of chronic evolution of the symptoms, an additional preoperative CT scan is useful to assess disc calcification.
3. Incision should be performed 4 cm from the midline, if too medial the foramen could not be approached conservatively.
4. Inserting the dilator, you aim at the superior part of the foramen, with a convergent and ascendant trajectory.
5. The first dilator could be used to palpate and identify the articular complex, the pars interarticularis and the inferior transverse process.
6. Dock the first dilator on bony structure in order to avoid hurting the exiting nerve root in its extraforaminal trajectory.
7. Use fluoroscopy first in lateral view, and then if necessary, in A-P view to assess tube positioning.
8. The exiting root could be identified under the superior pedicle, using Penfield dissectors.
9. Avoid unnecessary bipolar coagulation in the soft tissue surrounding the nerve root.
10. Then, the surgeon work in the Kambin’s triangle to perform the disc herniation removal.
This article is part of the Topical Collection on Spine degenerative
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Supplementary file1 This video presents the case of a 55 y/o male, harboring a right L4–L5 extraforaminal disc herniation (Fig. 3). The patient presented with a right L4 cruralgia reluctant to morphinic, associated with a motor and sensitive deficit in the same territory. Symptoms had been evolving for less than 24 h. The patient was operated on in emergency. We performed a minimally invasive extraforaminal approach, using a tubular retractor under microscopy. (MP4 222819 KB)
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Leroy, HA., Gorwood, W., Härtl, R. et al. Minimally invasive tubular approach for lumbar extraforaminal disc herniation: how I do it. Acta Neurochir 165, 761–765 (2023). https://doi.org/10.1007/s00701-023-05513-w
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DOI: https://doi.org/10.1007/s00701-023-05513-w