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had 1.1% mortality, while DDF had 0.39% mortality and PSF 0.56% mortality [12].
Over the period of this analysis, the preferred treatment shifted substantially from
DDE (performed in 30% of the patients in 2000) to PSF (performed in almost 50%
of all patients by 2010) [12].
References
1. Court C, Mansour E, Bouthors C. Thoracic disc herniation: surgical treatment. Orthop
Traumatol Surg Res. 2018 Feb;104(1S):S31–40.
2. Simpson JM, Silveri CP, Simeone FA, Balderston RA, An HS.Thoracic disc herniation. Spine
(Phila Pa 1976). 1993;18(13):1872–7.
3. El-Kalliny M, Tew JM, van Loveren H, Dunsker S.Surgical approaches to thoracic disk her-
niations. Acta Neurochir. 1991;111:22–32.
4. Yoshihara H.Surgical treatment for thoracic disc herniation: an update. Spine (Phila Pa 1976).
2014;39(6):E406–12.
5. Uribe JS, Smith WD, Pimenta L, Härtl R, Dakwar E, Modhia UM, Pollock GA, Nagineni V,
Smith R, Christian G, Oliveira L, Marchi L, Deviren V.Minimally invasive lateral approach
for symptomatic thoracic disc herniation: initial multicentral clinical experience. J Neurosurg
Spine. 2012;16:264–79.
6. Yoshihara H, Yoneoka D.Comparison of in-hospital morbidity and mortality rates between
anterior and nonanterior approach procedures for thoracic disc herniation. Spine (Phila Pa
1976). 2014;39(12):E728–33.
7. Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH. Experience in the surgi-
cal management of 82 symptomatic herniated thoracic discs and review of the literature. J
Neurosurg. 1998;88:623–33.
8. Quint U, Bordon G, Preissl I, Sanner C, Rosenthal D.Thoracoscopic treatment for single level
symptomatic thoracic disc herniation: a prospective followed cohort study in a group of 167
consecutive cases. Eur Spine J. 2012 Apr;21(4):637–45.
9. Shirzadi A, Drazin D, Jeswani S, Lovely L, Liu J.Atypical presentation of thoracic disc her-
niation: case series and review of the literature. Case Rep Orthop. 2013;2013:621476.
10. Arce CA, Dohrmann GJ.Herniated thoracic disks. Neurol Clin. 1985;3(2):383–92.
11. Elhadi AM, Zehri AH, Zaidi HA, Almefty KK, Preul MC, Theodore N, Dickman C.Surgical
efcacy of minimally invasive thoracic discectomy. J Clin Neurosci. 2015;22:1708–13.
12. Jain A, Menga EN, Hassanzadeh H, Jain P, Lemma MA, Mesn A.Thoracic disc disorders
with myelopathy: treatment trends, patient characteristics, and complications. Spine (Phila Pa
1976). 2014;39(20):E1233–8.
13. McCormick WE, Will SF, Benzel EC.Surgery for thoracic disc disease. Complication avoid-
ance: overview and management. Neurosurg Focus. 2000;9(4):e13.
14. Dietze DD Jr, Fessler RG.Thoracic disc herniations. Neurosurg Clin North Am. 1993;4:75–90.
15. Stillerman CB, Chen TC, Couldwell WT, etal. Experience in the surgical management of 82
symptomatic herniated thoracic discs and review of the literature. J Neurosurg. 1998;88:623–33.
16. Maiman DJ, Larson SJ, Luck E, etal. Lateral extracavitary approach to the spine for thoracic
disc herniation: report of 23 cases. Neurosurgery. 1984;14:178–82.
17. Willson MC, Ross JS. Postoperative spine complications. Neuroimaging Clin N Am.
2014;24(2):305–26.
18. Mody MG, Nourbakhsh A, Stahl DL, etal. The prevalence of wrong level surgery among spine
surgeons. Spine. 2008;33:194–8.
19. Upadhyaya CD, Wu JC, Chin CT, etal. Avoidance of wrong-level thoracic spine surgery: intra-
operative localization with preoperative percutaneous ducial screw placement. J Neurosurg
Spine. 2012;16:280–4.
J. E. McGowan et al.
123© Springer Nature Switzerland AG 2020
J. R. O’Brien et al. (eds.), The Resident’s Guide to Spine Surgery,
https://doi.org/10.1007/978-3-030-20847-9_14
Chapter 14
Lumbar Microdiscectomy
RaviS.Nunna, JoshuaT.Wewel, andJohnE.O’Toole
Introduction
Low back pain (LBP) is one of the most common conditions, affecting up to 70% of
the population [1]. A large portion of patients with LBP have sciatica correlating to a
lumbar herniated disc [1, 2]. Lumbar microdiscectomy is offered to those who fail
non-operative measures or have a progressive neurologic decit or cauda equina syn-
drome. Conventional open microdiscectomy and minimally invasive (MIS) tubular
microdiscectomy are the most common techniques employed to treat this condition.
Pathophysiology
The intervertebral lumbar disc is composed of (1) the nucleus pulposus (a centrally
located gelatinous structure rich in proteoglycans), (2) the annulus brosus (con-
centric layers of collagen surrounding the nucleus and restricting its egress espe-
cially during axial loading) [3, 4], and (3) the cartilaginous end plates that abut the
vertebral bodies. The adult disc is largely avascular and relies on passive diffusion
for the uptake of necessary nutrients [3].
Age-related dehydration of the nucleus and subsequent weakening of the annu-
lus brosus due to cumulative biomechanical axial load may lead to a defect in the
annulus resulting in disc extrusion [4, 5]. The posterolateral herniation occurs more
frequently because the posterior longitudinal ligament (PLL) is thickest at the mid-
line and becomes thinner laterally. While the pathophysiology of radiculopathy is
poorly understood, it is generally accepted to be compressive in nature [3, 6, 7].
R. S. Nunna (*) · J. T. Wewel · J. E. O’Toole
Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
124
Clinical Presentation
Symptoms
Radicular symptoms correlate with the level and laterality of lumbar disc hernia-
tions. Central, paracentral, and posterolateral disc herniations cause mass effect and
irritation on the traversing nerve root. Foraminal and extraforaminal disc hernia-
tions compress the exiting nerve root and are considered to be more painful if com-
pression on the dorsal root ganglion exists.
Patients often present after an acute onset of lower extremity radiculopathy and
less commonly have a temporal correlation to an inciting event. Pain, paresthesia,
and/or numbness often occurs in the respective nerve root dermatomes with or with-
out correlative myotomal decits.
Physical Examination
A complete neurological exam should be performed paying particular attention to
lower extremity individual motor group testing, dermatomal sensory changes, nerve
root tension signs, and reexes.
Imaging
Magnetic resonance imaging (MRI) is the diagnostic imaging study of choice for
herniated discs. For patients who cannot obtain an MRI, non-contrasted computed
tomography (CT) can be obtained. CT imaging can be the rst-line imaging for
those with the inability to lay supine, claustrophobia, or implanted metallic hard-
ware. However, a CT myelogram study is typically necessary for those unable to
undergo MRI.
Treatment
Non-operative Management
Initial management of lumbar disc herniation typically entails a spectrum of medi-
cations and non-surgical interventions. Radiculopathy of short duration is frequently
managed initially by NSAIDs, muscle relaxants, short course corticosteroids, and if
necessary, opioids. Activity modication is typically required. Mechanical interven-
tions including physical therapy, core stabilization, and other exercises may be
R. S. Nunna et al.
125
benecial if pain levels are not too high [3, 6, 7]. For persistent pain, epidural steroid
injections can be offered. Interventions such as chiropractic manipulations, acu-
puncture, and trigger point injections have also been used with variable success [8].
Non-operative treatment strategies are aimed at reducing disability and pain and
returning patients to activities of daily living since the majority of lumbar disc her-
niation cases will resolve without surgery.
Surgical Indications
Most data support a trial of non-operative management for at least 4weeks, if not
longer [3, 6, 7]. While early surgery may lead to earlier resolution of symptoms,
long-term outcomes have been shown to be similar in both surgical and non-surgical
groups [6, 7]. Persistent and/or worsening pain is the primary non-urgent indication
for surgical intervention, and some patients undergo early decompression as they are
unable to tolerate the severity of pain. More urgent surgical intervention is indicated
in those with cauda equina syndrome or acute and disabling motor weakness [7].
Surgical Techniques
Positioning
Most commonly patients are positioned prone using gel rolls or the Wilson frame on
a radiolucent table. The patient’s arms are externally rotated and abducted to less
than or equal to 90 degrees at the shoulder, raised above the head, and padded at the
pressure points to avoid a brachial plexus injury. The head rests on foam padding,
making sure the eyes are free of compression. Other positioning techniques includ-
ing knee-chest and lateral decubitus are available but much less commonly used.
Central andPosterolateral Disc Herniation
Following standard, sterile skin preparation and draping, a conventional open
microdiscectomy begins by localizing the correct level on uoroscopy, and a mid-
line skin incision is made. Monopolar cautery is used to dissect the subcutaneous
tissue and fascia and perform a subperiosteal dissection along the spinous process
to expose the facet capsule laterally, the laminar edge inferiorly, and the lamina and
pars interarticularis superiorly.
Alternatively, MIS tubular approach may be performed. The entry site is planned
as previously described, but the incision is made approximately 1.5cm off midline
14 Lumbar Microdiscectomy
126
to the affected side. A guide wire is used to pierce the fascia and, using uoroscopy,
is docked on the laminofacet junction. Sequential tubular dilation is then used with
intermittent uoroscopy to dock the tube at the level of the index disc space. For
MIS microdiscectomy, we prefer to use tubes 18mm in diameter. A microscope is
then brought in for visualization.
For conventional open as well as MIS discectomies, a laminotomy is performed
using a high-speed drill. The lamintomy begins inferiorly and medially and is car-
ried superiorly to the insertion of the ligametum avum and laterally to the medial
facet. A medial facetectomy is often necessary for visualization taking care to main-
tain 50% of the facet if possible. The ligamentum avum is dissected away from and
resected using a combination of curettes and Kerrison rongeurs. The dura and tra-
versing nerve root are identied and retracted medially. The disc is localized, its
capsule incised and the herniation removed using a combination of rongeurs, nerve
hooks and ball-tipped probes.
Decompression of the neural structures is conrmed with angled dissectors.
Hemostasis is achieved and the retractor is removed slowly, obtaining hemostasis
through the various soft tissue layers. The fascia and subcutaneous layer are closed
with absorbable suture and the skin sealed with topical adhesive.
Foraminal/Extraforaminal Disc Herniations
True foraminal disc herniations can be approached by a “cross-canal” technique that
involves either a full laminectomy or a unilateral approach (from the contralateral
side) for bilateral decompression. The former can be performed open, the latter,
MIS.Either will allow observation of the foramen from the contralateral side, and
the disc herniation can be removed easily. True extraforaminal disc herniations
often require the far lateral approach. The target for a tubular or open conventional
dissection is the lateral facet-transverse process junction. The inferolateral facet and
pars interarticularis are identied and the intertransverse membrane dissected off
the bone. The pedicle of the level below is palpated and the disc herniation encoun-
tered in Kambin’s triangle. The inferolateral facet can be shaved back if necessary
to visualize the exiting nerve root. The disc fragment is removed and the nerve root
inspected to ensure adequate decompression.
Postoperative Care andPain Management
Most patients can be discharged on the day of surgery. Postoperative care focuses on
pain management and a rapid return to activity and daily routines [9]. Early ambula-
tion and other low-impact activities are strongly recommended. Multimodal pharma-
cologic management of postoperative pain can reduce the overall need for opioids that
can lead to urinary retention, ileus, cognitive changes, and medication dependence.
R. S. Nunna et al.
127
Complications
Incidental durotomy is the most common complication during lumbar discectomy,
ranging from 0.5% to 18% with risk factors including recurrent disc herniation or
concomitant pathology (stenosis, spondylolisthesis, juxtafacet cysts) [10, 11].
Postoperative vision loss occurs at an exceedingly low rate with an incidence of
0.017–0.92% in non-cardiac patients undergoing spine surgery [12, 13]. Risk fac-
tors include male sex, obesity, longer anesthesia time, use of a Wilson frame, larger
estimated blood loss, hypotension, and direct ocular compression [12]. Great vessel
injury occurs with a range of 0.1–0.17% [14]. Postoperative wound infection occurs
in less than 1% of patients [15].
Outcomes
The natural history of lumbar disc herniation is generally favorable. Weinstein
etal. published the largest randomized control trial (SPORT trial) comparing sur-
gery to conservative management. An intention to treat (ITT) analysis found no
signicant difference between groups. However, high rates of crossover patients
confounded the ITT analysis, such that an as-treated analysis revealed a superiority
of surgery over non-operative care [7]. The most common postoperative complica-
tion after lumbar discectomy is reherniation, with estimates ranging from 5% to
15% [16].
Conclusions
Lumbar disc herniation is one of the most frequently encountered entities in spinal
surgical practice. Surgical treatment of patients who have failed an initial trial of
non-operative care results in excellent results and is superior to non-operative care.
Both open and MIS surgical techniques produce similar long-term outcomes, and
surgeons should be familiar with both approaches.
References
1. Konstantinou K, Dunn KM.Sciatica: review of epidemiological studies and prevalence esti-
mates. Spine. 33:2464.
2. Koes BW, van Tulder MW, Ostelo R, Kim Burton A, Waddell G.Clinical guidelines for the
management of low back pain in primary care: an international comparison. Spine. 26:2504–
13; discussion 2513-2514, 2001.
14 Lumbar Microdiscectomy
128
3. Raj PP. Intervertebral disc: anatomy-physiology-pathophysiology-treatment. Pain Pract.
2008;8(1):18–44.
4. Roberts S, Evans H, Trivedi J, Menage J.Histology and pathology of the human intervertebral
disc. J Bone Joint Surg Am. 2006;88(Suppl 2):10–4.
5. Buckwalter JA. Aging and degeneration of the human intervertebral disc. Spine.
1995;20(11):1307–14.
6. Saal JA. Natural history and nonoperative treatment of lumbar disc herniation. Spine.
1996;21(24 Suppl):2S–9S.
7. Weinstein JN, Lurie JD, Tosteson TD, etal. Surgical versus nonoperative treatment for lumbar
disc herniation: four-year results for the spine patient outcomes research trial (SPORT). Spine.
2008;33(25):2789–800.
8. Cohen SP, Argoff CE, Carragee EJ.Management of low back pain. BMJ. 2008;337:a2718.
9. Buvanendran A, Thillainathan V.Preoperative and postoperative anesthetic and analgesic tech-
niques for minimally invasive surgery of the spine. Spine. 2010;35(26 Suppl):S274–80.
10. Albayrak S, Ozturk S, Ayden O, Ucler N.Dural tear: a feared complication of lumbar discec-
tomy. Turk Neurosurg. 26:918.
11. Takahashi Y, Sato T, Hyodo H, Kawamata T, Takahashi E, Miyatake N, et al. Incidental
durotomy during lumbar spine surgery: risk factors and anatomic locations: clinical article. J
Neurosurg Spine. 18:165.
12. Gabel BC, Lam A, Chapman JR, Oskouian RJ, Nassr A, Currier BL, etal. Perioperative vision
loss in cervical spinal surgery. Glob Spine J. 7:91S.
13. Lee LA. Perioperative visual loss and anesthetic management. Curr Opin Anaesthesiol.
26:375. Opin Anae.
14. Altun G, Hemsinli D, Kutanis D, Gazioglu G.Silent killer: a scalpel in the aortic wall after
spinal surgery. Neurol Neurochir Pol. 50:294.
15. Shousha M, Cirovic D, Boehm H.Infection rate after minimally invasive noninstrumented
spinal surgery based on 4350 procedures. Spine. 40:201.
16. Swartz KR, Trost GR.Recurrent lumbar disc herniation. Neurosurg Focus. 2003;15(3):E10.
R. S. Nunna et al.
129© Springer Nature Switzerland AG 2020
J. R. O’Brien et al. (eds.), The Resident’s Guide to Spine Surgery,
https://doi.org/10.1007/978-3-030-20847-9_15
Chapter 15
Approaching Far Lateral Disc Herniations:
TheMIS Perspective
KyleMueller andAmjadAnaizi
Introduction
Lumbar disc disease is a common condition that is treated by spine surgeons. The
degenerative process can result in disc herniations causing severe pain and disabil-
ity. Disc herniations can be central, paracentral, or far lateral depending on which
compartment the herniation occurs. Far lateral disc herniations (FLDHs) occur in
about 1–12% of all symptomatic lumbar disc herniation syndromes [1–3]. Various
conservative and surgical management strategies exist for treatment [4–8].
Minimally invasive surgical techniques have become more prevalent over the last
decade. Using these techniques often leads to shorter hospital stays, reduced blood
loss, and reduced narcotic usage [9]. This chapter aims to review FLDH with an
emphasis on the minimally invasive surgical approach to treatment.
Presentation/Work-Up
Patients with FLDH can present with pain and motor or sensory disturbances
depending on which nerve root is being compressed. Pain is often a more signicant
component of the presentation owing to compression of the dorsal root ganglion
(DRG) [10, 11]. As compared with herniated discs in other compartments, FLDHs
compress the exiting nerve root. Physical exam may be signicant for pain with
lateral bending and the absence of pain with straight leg raise; however, no maneu-
ver is very sensitive or specic. The diagnosis often is made radiographically with
clinical correlation.
K. Mueller · A. Anaizi (*)
Department of Neurosurgery, MedStar Georgetown University Hospital,
Washington, DC, USA
130
The imaging work-up entails a non-contrast lumbar magnetic resonance image
(MRI) as well as full set of lumbar x-rays that include dynamic views. MRI is the
imaging modality of choice that shows the soft tissue structures including the neural
elements the best. X-rays are used to assess alignment and to make sure there is no
underlying instability present.
Treatment
There are a variety of treatment options that are available to patients with FLDHs
[12–19]. Similar to treatments for other lumbar disc diseases, there are conservative
and surgical options. Conservative treatment typically involves some combination
of physical therapy, steroid injections, or pain medication. Consultation with a pain
management specialist can assist in optimizing these therapies. Surgery is usually
considered after failure of conservative pain management strategies or if there is
progressive neurological decit.
Surgical Technique: Minimally Invasive Far Lateral
Discectomy
A minimally invasive tubular technique is the preferred approach to far lateral disc
herniations. The patient is induced under general anesthesia and placed in the prone
position on a Jackson table with a Wilson frame. All pressure points are padded. The
midline is marked and AP and lateral radiographs are obtained. AP radiographs
must show the pedicles clearly with the spinous process in the midline. The endplate
borders should be crisp and without parallax. Failing to obtain quality images prior
to starting the procedure can lead to a poorly positioned incision and suboptimal
trajectory raising the likelihood of complications. Patients undergo a unilateral
approach using a tubular retractor system. A 2cm incision is made approximately
4cm lateral to the midline on the ipsilateral side of pathology centered over the disc
space of interest. This will allow medial angulation of the tubular retractor. A
Steinman pin or initial dilator is docked on the junction of the transverse process
(TP) and the facet joint of the level of interest under uoroscopic guidance. A series
of progressively larger muscle splitting dilators are then inserted with a twisting
motion to create the surgical corridor. A 20mm working channel is xed to the
table-mounted exible arm and directed to the disease disc space. Prior to locking
the exible arm, uoroscopic imaging is used to conrm location and trajectory
(Fig.15.1). The remainder of the procedure is performed with a microscope. The TP
and lateral aspect of the pars interarticularis are carefully dened by removing the
overlying soft tissue with a straight curette and bovie electrocautery. Brisk arterial
bleeding can sometimes be encountered from the spinal or dorsal branch of the
lumbar segmental artery. This can often be cauterized with bipolar forceps without
K. Mueller and A. Anaizi
131
difculty. The intertransverse ligament is identied and divided often using a ker-
rison rongeur. Great care is taken to expose and protect the exiting nerve root and
ganglion. It is crucial to limit manipulation of the DRG to prevent postoperative
dysthetic pain. The herniated disc is then identied and a discectomy is performed
in a routine manner (Fig.15.2). The sacral ala often can obstruct the path to a far
lateral L5-S1 disc herniation. This can be addressed by removal of the sacral ala
using a high-speed drill. The remainder of the procedure is similar as other levels.
Hemostasis is then achieved in standard fashion. Epidural steroids can be used to
reduce the likelihood of any potential dysthetic pain. The incision is then closed in
a multilayer fashion.
A list of the key steps is listed below.
Summary of Key Steps:
1. Position the patient.
2. AP and lateral radiographs.
3. Docking on the TP/facet junction of the level of interest.
a
de f
bc
Fig. 15.1 (a) AP view that shows crisp endplate borders and symmetric pedicles with the spinous
process midline. Establishing good imaging prior to proceeding with the procedure is key. (b)
Lateral view that shows the nal docking position of the retractor. The insert shows the dilator
prior to placing the tubular retractor. It is important to be parallel with the disc space. (c) The inci-
sion is usually 3.5–4cm off of midline and spans 2cm. (d–f) Anatomical models with the retractor
in various views that demonstrate how the tubular retractor should be positioned in relation to the
TP and disc space
15 Approaching Far Lateral Disc Herniations: TheMIS Perspective