Lumbar microdiscectomy performed through a tubular retractor is typically the first minimally invasive operation of spine surgeons. The skin incision is placed further lateral for central the disc herniations and close to midline for foraminal herniations. With experience, the yellow ligament can be penetrated sharply. We prefer to limit the disc removal to the herniation, whenever possible, and not violate the central part of the disc. The retractor tube can be angled cranially or caudally as needed, until the entire disc herniation is removed. Confirmation by fluoroscopy after disc herniation removal is recommended.
This full-length video illustrates the typical case of a patient with a large central disc herniation, slightly eccentric to the right. The skin incision is placed relatively far from the midline in order to provide better access to the central part of the canal. The yellow ligament is opened with the 11-blade. The disc herniation is removed in several large fragments. The final inspection is documented by fluoroscopy (MP4 750131 kb)
This full-length video illustrates the difficult case of a patient with a large calcified disc herniation. The disc could not be penetrated with the 11-blade, despite multiple attempts, and had to be removed with the high-speed drill, while gently retracting the spinal sac medially. This maneuver required more extensive exposure both laterally, drilling of the medial facet, and medially, drilling off the underside of the spinous process and exposing both sides of the spinal sac (MP4 396036 kb)
This short video illustrates the inspection of the epidural space with a Helen instrument. We prefer to start cranial to the disc and move the Helen over the disc space and under the dural sac until reaching the caudal vertebral body, without any obstacles. The inspection is also carried out medially until reaching the midline. We confirm the completeness of decompression by placing a Penfield 4 above and below the disc space and taking a lateral fluoroscopic image, and then placing the down-biting curette on top of the decompressed posterior longitudinal ligament and take a lateral and then an AP fluoroscopic image (MP4 9866 kb)
This short video illustrates another case of a patient with a large soft disc herniation. A small lateral annulotomy allowed for expression of the disc fragments upon pressure on the posterior longitudinal ligament with the suction tip (MP4 157665 kb)
This short video illustrates the case of a patient with an accidental durotomy upon removal of the nerve root retractor. The durotomy is covered with a dural substitute followed by dural sealant (MP4 206873 kb)
This video illustrates the closure of minimally invasive incisions in anatomical layers (MP4 938267 kb)
- 7.Kogias E, et al. Incidental durotomy in open vs. tubular revision microdiscectomy: a retrospective controlled study on incidence, management and outcome. Clin Spine Surg. 2016. https://doi.org/10.1097/bsd.0000000000000279.
- 8.Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev. 2014:CD010328. https://doi.org/10.1002/14651858.CD010328.pub2.