Clinical Results and Surgical Technique for the Treatment of Extreme Lateral Lumbar Disc Herniations: The Minimally Invasive Microscopically Assisted Percutaneous Approach

Abstract

Objective: Operative techniques for the treatment of extreme lateral lumbar disc herniations (ELLDH) have ranged from an interlaminar approach with subtotal or total facetectomy to an enlarged midline approach and various paraspinal lateral, as well as endoscopic approaches. In contrast to purely endoscopic techniques, use of a working tube together with an operative microscope (“minimally invasive microscopically assisted percutaneous approach”) combines the advantages of three-dimensional visual control with the minimal surgical trauma of an endoscopic approach. We present this technique and the clinical results in patients with extreme lateral lumbar disc herniation (ELLDH).

Methods: In a retrospective case series we analyzed the data of 73 consecutive patients with a disc herniation within or lateral to the intervertebral foramen. All of them were operated on using the surgical microscope after blunt dilatation of the paraspinal muscles and insertion of a tubular retractor system (METRx, Medtronic Sofamor Danek). Fifty-nine patients were included in the follow-up study. Follow-up ranged from 10 to 47 months (mean 30.4) and was evaluated after telephone inquiry by the co-author using the modified MacNab criteria [28].

Results: The results with respect to improvement of preoperative symptoms were excellent in 23 patients (39%), good in 25 patients (42.4%), fair in 8 patients (13.5%) and poor in 3 patients (5.1%). Twenty-four patients had still been working prior to surgery, and 20 returned to work after 4-8 weeks.

Conclusion: The paraspinal approach for extreme lateral lumbar disc herniations using the minimally invasive microscopically assisted percutaneous technique is reasonable and safe and thus a good alternative to open surgical procedures.

Zusammenfassung

Hintergrund: Operative Techniken für die Behandlung extrem lateraler lumbaler Bandscheibenvorfälle reichen vom interlaminaren Zugang mit subtotaler oder totaler Facettektomie, über einen erweiterten mittelliniennahen Zugang, diverse paraspinale Zugänge bis hin zu endoskopischen Techniken. Im Gegensatz zur rein endoskopischen Operation verbindet die Kombination eines endoskopischen Arbeitskanals mit dem Operationsmikrosokop die Vorteile des dreidimensionalen Sehens mit denen des minimal invasiven Zuganges (“minimally invasive microscopically asssited percutaneous approach”). Wir präsentieren diese Operationstechnik und die klinischen Ergebnisse bei der Behandlung extrem lateraler lumbaler Bandscheibenvorfälle.

Methoden: Anhand einer retrospektiven Studie analysierten wir die Daten von 73 konsekutiven Patienten mit lumbalen intra- oder extraforaminalen Bandscheibenvorfällen. All diese Patienten wurden mikroskopisch nach stumpfer Dilatation der paravertebralen Muskulatur und Insertion eines tubulären Retraktors (METRx, Medtronic Sofamor Danek) operiert. 59 Patienten konnten in das follow-up eingeschlossen werden. Dieses reichte von 10 bis 47 Monaten (mittel 30,4 Monate) und wurde mit den modifizierten Mc Nab-Kriterien via Telefon-Erhebung durch den Co-Autor evaluiert.

Ergebnisse: Bezüglich der Besserung präoperativer Symptome waren die Ergebnisse exzellent in 39%, gut in 25%, mäßig in 13,5% und schlecht in 5,1% der Fälle. 20 der 24 Patienten, welche präoperativ arbeiteten, kehrten in ihren Beruf zurück.

Schlussfolgerung: Der paraspinale Zugang zu extrem lateralen lumbalen Bandscheibenvorfällen mittels tubulärem Retraktor in Verbindung mit dem Operationsmikroskop ist sinnvoll und sicher und somit eine gute Alternative zum offenen chirugischen Vorgehen.

Key words

lumbar disc surgery - minimally invasive - lateral disc herniation - percutaneous approach - surgical techniques - disc surgery outcomes

Schlüsselwörter

minimal invasiv - lateraler Bandscheibenvorfall - perkutaner Zugang

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