Microdiskectomy and translaminar approach: minimal invasiveness and flavum ligament preservation

A transfacet approach to the lumbar nerve root canal: technical note

BACKGROUND

Intraforaminal and extraforaminal nerve root compressions caused by disk herniation or stenosis are relatively common causes of lumbar radiculopathy. Currently, the two available surgical treatment methods are decompression from the spinal canal or lateral decompression via the Wiltse approach.

OBJECTIVE

To describe a novel transosseous approach to the lumbar nerve root canal.

METHODS

Transfacet foraminotomy was performed in 11 patients with intraforaminal or extraforaminal disk herniation. The outcome was measured using the Patient Satisfaction Index (PSI), need for reoperation, radiographic criteria, and finite element analysis.

RESULTS

We noted that at the time of dismissal, PSI scores of 1 and 3 were reported by 10 and one patients, respectively. At the last follow-up, 10 patients reported a PSI score of 1 or 2. Two patients required reoperation because of recurrent disk herniation. Two patients underwent computed tomography (CT) postoperatively, which showed the transfacet approach. Intriguingly, a second postoperative CT after one month showed that the hole through the facet joint had shrunk significantly.

CONCLUSION

A posterior-anterior transfacet approach for intraforaminal or extraforaminal disk herniations using an ellipsoid facetectomy is safe and allows for fast and comfortable decompression of the nerve root without compromising the long-term strength of the facet joint.

Unilateral Biportal Endoscopic Discectomy via the Contralateral Sublaminar Approach for Lumbar Disc Herniation with Very High-Grade Migration: A Technical Note and Case Series

BACKGROUND

Lumbar disc herniation (LDH) with very high-grade migration is difficult to manage surgically because of its anatomic complexity and the risk of incomplete decompression. The unilateral biportal endoscopic (UBE) contralateral sublaminar approach is a minimally invasive technique that may be an alternative option for managing these cases.

METHODS

In this multicenter retrospective study, we analyzed the clinical data of 15 patients with lumbar disc herniation with very high-grade upward or downward migration of ruptured disc fragments removed via the UBE contralateral sublaminar approach between June 2022 and June 2024. Clinical outcomes were assessed using the visual analog scale for back and leg pain, Oswestry Disability Index, and modified MacNab criteria. Radiologic outcomes were evaluated on postoperative magnetic resonance images and serial plain radiographs.

RESULTS

The mean operation time was 45.3 minutes, and the average length of hospital stay was 4.1 days. The visual analog scale scores for back and leg pain improved significantly, and the Oswestry Disability Index was notably lower at the final follow-up. Postoperative magnetic resonance imaging confirmed the complete removal of migrated disc fragments in all patients, with no segmental instability observed during the follow-up. The technique allows for effective decompression with minimal bone removal, thereby preserving adjacent structures.

CONCLUSIONS

This study showed the feasibility and potential benefits of the UBE contralateral sublaminar approach for lumbar disc herniation with very high-grade migration of ruptured disc fragments. Although initial outcomes are promising, further comparative studies with more patients are needed to validate its efficacy and safety.

Unilateral BIPORTAL endoscopic translaminar approach to treat up-migrated lumbar disc herniation: 12 cases report

OBJECTIVE

There are difficulties on removing migrated disc herniation (MDH) using a microscope. The purpose of this study was to introduce a unilateral biportal endoscopic (UBE) translaminar approach to treat up-migrated lumbar disc herniation (LDH).

PATIENTS AND METHODS

A total of 12 patients from March 2021 to February 2022 with up-migrated LDH were treated with a UBE translaminar approach. Clinical outcomes such as a visual analog scale (VAS) (back and leg pain) and MacNab criteria were assessed preoperative, postoperative, and 1 month after surgery.

RESULTS

Seven patients were diagnosed with high-grade up-migrated LDH, while five patients presented very-high grade up-migrated LDH. In all cases, the migrated LDH were removed completely and were confirmed by postoperative magnetic resonance imaging. The VAS for back pain were improved from 4.5 (SD = 3.1) to 2.0 (SD = 1.0) and 1.0 (SD = 1.0) for immediately postoperative and in 1-month follow-up, respectively, showing a statistically significant difference (p < 0.001). VAS for leg pain was 6.5 (SD = 2.5) preoperatively to 2.3 (SD = 1.1) and 0.8 (SD = 0.4) immediately postoperative and 1-month follow-up, respectively, also showing a significant difference (p < 0.001). According to the MacNab criteria, we observed excellent outcomes in 66.6% and good outcomes in 33.3%.

CONCLUSION

The UBE translaminar approach showed a high success rate with high patient satisfaction for the management of up-migrated LDH. It could be considered a feasible alternative surgical option to treat up-migrated LDH.

Trans-Tubular Translaminar Microscopic-Assisted Nucleotomy for Lumbar Disc Herniations in the Hidden Zone

STUDY DESIGN

A prospective cohort study in a high-flow spine center in Germany.

OBJECTIVES

This study aimed to evaluate clinical outcomes and complications of the trans-tubular translaminar microscopic-assisted percutaneous nucleotomy in cases of cranially migrated lumbar disc herniations (LDH).

METHODS

Between January 2013 and January 2018, 66 consecutive patients with cranio-laterally migrated LDH were operated upon. The following outcome measures were evaluated: (1) Visual Analog Scale (VAS) for leg and back pain; (2) Oswestry Disability Index (ODI) and Macnab´s criteria. All patients were operated upon with trans-tubular Translaminar Microscopic-assisted Percutaneous Nucleotomy (TL-MAPN). Perioperative radiographic and clinical evaluations were reported. The mean follow-up period was 32 months.

RESULTS

The mean age was 59 years. L4/L5 was the commonest affected level (27 patients). The mean preoperative VAS for leg pain was 6.44 (±2.06), improved to 0,35 (±0.59) postoperatively. Dural injury occurred in 1 patient, treated with dural patch. Improved neurological function was reported in 41/44 Patients (neurological improvement rate of 93%) at the final follow up. There was a significant improvement in the mean ODI values, from 50.19 ± 4.92 preoperatively to 10.14 ± 2.22 postoperatively (P < 0.001). Sixty four out of 66 patients (96%) showed an excellent or good functional outcome according to Macnab´s criteria. No recurrent herniations were observed.

CONCLUSION

The translaminar approach is a viable minimal invasive technique for cranially migrated LDH. The preservation of the flavum ligament is one of the main advantages of this technique. It is an effective, safe and reproducible minimally invasive surgical alternative in treatment of cranially migrated LDHs.

Efficacy of an ethyl alcohol gel in symptomatic disc herniation

PURPOSE

To evaluate the clinical outcome of DiscoGel® chemonucleolysis for symptomatic disc herniation in patients who fail conservative treatment.

MATERIAL AND METHODS

Consecutive patients with symptomatic disc herniation confirmed on MRI who failed conservative management for at least 6 months were included. Visual analogue scale (VAS), Oswestry Disability Index (ODI) scores, and analgesic use were recorded at baseline, and 12 months after treatment. Multidetector CT (MDCT) was performed at baseline, and 12 months after treatment to assess for DiscoGel® extravasation and alteration in treated disc volume. In a unique long-term subgroup analysis of 31 patients, telephonic follow-up was performed utilizing VAS and ODI parameters 7 years after the procedure.

RESULTS

A total of 87 disc herniations were treated in 71 patients; majority (54%) were treated at L4/5 and L5/S1. VAS score of 8 before treatment was reduced to 3 at 12 months after treatment (p = 0.0001); ODI score of 51 before treatment was reduced to 15 at 12 months after treatment (p = 0.0001). Analgesic use of 70.4% was reduced to 29.6% after treatment. There were no symptomatic procedural complications; MDCT revealed 1 asymptomatic peri-neural DiscoGel® extravasation. In the 31 subjects that underwent telephonic follow-up the VAS and ODI parameters maintained their values without statistically significant differences when compared with the 12-month follow-up.

CONCLUSION

Patients with symptomatic disc herniation who failed conservative treatment and were treated with DiscoGel® chemonucleolysis achieved significant gains in pain relief and reduced disability without symptomatic complication. DiscoGel® chemonucleolysis is a feasible, minimally invasive technique for treatment of symptomatic disc herniation.

The Use of Tubular Retractors for Translaminar Discectomy for Cranially and Caudally Extruded Discs

BACKGROUND

The conventional interlaminar approach is adequate for access to most disc herniations in lumbar spine surgery. The access to cranially and caudally migrated disc fragments, by conventional interlaminar fenestration, requires an extension of the fenestration with the potential destruction of the facet joint complex and consequent postsurgical instability. To describe the technique and results of the translaminar technique of targeted discectomy using tubular retractors for the surgical treatment of cranially and caudally extruded discs.

MATERIALS AND METHODS

The study period extended from January 2008 to December 2014. All patients with lumbar herniated discs who failed conservative management were selected for surgery and underwent routine erect radiographs and magnetic resonance imaging (MRI) of the lumbar spine. The patients with cranially or caudally migrated discs were included in this study. The technique involves approaching migrated disc through an oval window (sculpted through an 18 mm tubular retractor using a burr) in the lamina precisely over the location of the migrated disc as predicted by the preoperative MRI (inferior lamina for inferior migration and superior lamina for superior migration). The perioperative parameters studied were operative time, blood loss, complications, Oswestry Disability Index (ODI), and visual analog scale (VAS) for leg pain before surgery and at last followup. In the study, 4 patients underwent a postoperative computed tomography-scan with a three-dimensional reconstruction to visualize the oval window and to rule out any pars fracture. All technical difficulties and complications were analyzed.

RESULTS

17 patients in the age group of 41-58 years underwent the translaminar technique of targeted discectomy. The migration of disc was cranial in 12 patients and caudal in 5 patients. Fourteen of the affected discs were at the L4-L5 level and three were at the L5-S1 level. The mean VAS (leg pain) scale improved from 8 to 1 and the mean ODI changed from 59.8 to 23.6. There were no intraoperative or postoperative complications encountered in this study. Furthermore, no patient in the present study required a conventional laminotomy or medial facetectomy. There was no evidence of iatrogenic pars injury or instability at the last followup. There were no recurrences till the last followup.

CONCLUSIONS

The targeted translaminar approach preserves structures important for segmental spinal stability thus causing minimal anatomical disruption. This approach allows access to the extruded disc fragment and intervertebral disc space comparable to classical approaches.

Technical note: microdiscectomy and translaminar approach

Lumbar disk herniation (LDH) is a degenerative pathology. Although LDH generally occurs without migration of the fragment to the levels above or below, in 10% of the cases, this circumstance might happen. In these cases, the standard interlaminar approach, described by Caspar cannot be performed without laminotomies, interlaminectomies, or partial or total facetectomies. The translaminar approach is the only "tissue-sparing" technique viable in cases of cranially migrated LDH encroaching on the exiting nerve root in the preforaminal zones, for the levels above L2-L3, and in the preforaminal and foraminal zones, for the levels below L3-L4 (L5-S1 included, if a total microdiscectomy is unnecessary). This approach is more effective than the standard one, because it resolves the symptoms; it is associated with less postoperative pain and faster recovery times without the risk of iatrogenic instability, and it can also be used in cases with previous signs of radiographic instability. The possibility to spare the flavum ligament is one of the main advantages of this technique. For these reasons, the translaminar approach is a valid technique in terms of safety and efficacy. In this article the surgical technique will be extensively analyzed and the tips and tricks will be highlighted.