Transmuscular trocar technique - minimal access spine surgery for far lateral lumbar disc herniations

Minimally Invasive Far-Lateral Microdiscectomy: A New Retractor for Far-Lateral Lumbar Disc Surgery

Background

To date, a number of approaches have been described for far-lateral disc surgery, including midline, paramedian, and intertransverse approaches. These approaches pose challenges for surgeons due to the difficulty in retraction caused by the anatomy of the foramen. We designed a retractor suitable for the three-dimensional anatomical structure of the foramen. In this study, we aimed to evaluate the surgical outcomes of the patients who were operated on using this retractor in our clinic.

Methods 

The retrospective study included patients who were operated on due to far-lateral disc herniation using the retractor designed in our clinic between February 2013 and December 2018.

Results 

The study included 11 (64.7%) women and 6 (35.3%) men, with a mean age of 56 years (range: 42-70 years). The mean operative time was 49 minutes (range: 40-70 minutes), the mean estimated blood loss was 42 mL (range: 25-60 mL), and the mean follow-up period was 22.6 months (range: 13-48 months). No complication occurred in any patient. A minimally invasive discectomy was performed via the paramedian approach in each patient. The patients were evaluated using the visual analog scale (VAS) for radicular pain, Oswestry Disability Index (ODI), 36-Item Short Form Survey (SF-36), and the modified MacNab criteria.

Conclusion 

The retractor developed in our study provided numerous benefits during the surgical procedure as it led to minimal blood loss and reduced operative times by avoiding bone resection in extraforaminal discs and requiring minimal bone resection in foraminal discs.

Extraforaminal microscopic assisted percutaneous nucleotomy for foraminal and extraforaminal lumbar disc herniations

BACKGROUND

Foraminal and extraforaminal lumbar disc herniations are uncommon. The main presentation is radicular pain related to the exiting nerve root at the affected level. Different approaches for surgical intervention have been described.

PURPOSE

This study aimed to evaluate the clinical outcome, complications recurrence, and reoperation rate of extraforaminal microscopic-assisted percutaneous nucleotomy, with literature review focusing on complications and recurrence rate.

STUDY DESIGN

This is a prospective cohort study done in a high-flow spine center in Germany.

PATIENT SAMPLE

Between October 2012 and October 2015, 76 patients (35 women and 41 men) with foraminal or extraforaminal lumbar disc prolapse were operated on.

OUTCOME MEASURES

The following were the outcome measures: (1) self-report measures: Visual Analogue Scale (VAS) for leg pain and back pain; (2) physiological measures: standing plain X-rays (anterioposterior, lateral, and dynamic views); and (3) functional measures: Oswestry Disability Index (ODI) (validated German version) and Odom's criteria.

METHODS

All patients were operated upon with trans-tubular extraforaminal microscopic-assisted percutaneous nucleotomy (EF-MAPN) technique. Preoperative clinical and neurologic evaluations were done. The mean follow-up period was 38 months (range 12-54). The study has not received funding for research from any organization. All authors do not have any conflict of interest.

RESULTS

The mean age was 54 years. The most commonly affected level was L4/L5 (34 patients). The mean preoperative VAS for leg pain was 7.6 (3-10), which improved to 1.4 (0-4) postoperatively. The average operative time was 57.5 minutes. There were no intraoperative complications. One patient had temporary postoperative quadriceps weakness (L4 radiculopathy) that was completely improved at 3 months' follow-up. Another patient had deep venous thrombosis after discharge. Two patients had recurrences that necessitated another operation within the first 6 months postoperatively. Both were followed up for 1 year without a second recurrence.

CONCLUSION

Trans-tubular percutaneous extraforaminal microscopic-assisted nucleotomy is effective for foraminal and extraforaminal disc herniations. It is a muscle-splitting minimally invasive approach with minimal morbidity. Complications, recurrence, and reoperation rate are not different compared with microsurgical open or endoscopic techniques.

Ozone injection with or without percutaneous microdiscectomy for treatment of cervical disc herniation

OBJECTIVE

This retrospective study compared the efficacy of combined percutaneous ozone injection and percutaneous discectomyto percutaneous ozone injection alone for the treatment of cervical disc herniation.

METHODS

Patients with cervical disc herniation who were enrolled in our hospital from October 2010 to June 2015 were divided into two groups: 1) treated with percutaneous ozone injection alone (control; n= 19); and 2) those treated with combined ozone injection and percutaneous microdiscectomy (combined treatment; n= 28). The efficacy of the combined treatment was evaluated relative to the control by visual analogue scale (VAS) and the modified Macnab standard. Effective treatment was defined as excellent or good, and ineffective as fair or poor.

RESULTS

No major complications occurred in either group. For the control group, the VAS scores dropped from 6.75 ± 2.34 before surgery to 2.78 ± 1.85 immediately after surgery, and to 4.18 ± 1.46 during the follow-ups. For patients who received the combined treatment, the VAS scores were 7.12 ± 2.03 before surgery, 3.86 ± 2.87 immediately after surgery, and 3.27 ± 1.53 during the follow-ups. At the 6-month follow-up, 73.7% (14 from 19 patients) in the control group and 89.2% (25 from 28 patients) in the treatment group were judged to have received effective treatment. Difference in efficacy between two groups of treatment was statistically significant (P= 0.033).

CONCLUSION

The rate of effective treatment in patients who received combined percutaneous microdiscectomy and ozone injection was higher than that of patients who received ozone injection alone. Combination of percutaneous microdiscectomy and ozone injection might be an effective method to treat patients with cervical disk hernia.

COMPARISON OF ENDOSCOPIC AND MICROSURGICAL METHODS IN THE TREATMENT OF LUMBAR DISC HERNIATIONS

ABSTRACT Objective: The development of minimally invasive spine surgery leads us to reflect on the efficiency of new methods compared with older ones. In the case of endoscopic spine surgery, we always seek to compare our results using new techniques with the results of older and trusted microsurgical techniques. Unfortunately, there are few reliable studies measuring endoscopic and microsurgical approaches. We therefore decided to compare our treatment results with those of what are, in our opinion, the best and most thorough studies found. Furthermore, we found no illustrated experience in the usability of endoscopic methods. We therefore analyzed each step of the technique used, according to the practical experience with microsurgical discectomy. Methods: We compared our two-year experience of treatment of 183 patients with lumbar disc herniations using the endoscopic technique, with data reported in the literature on microsurgical minimally invasive methods. Results: Our group achieved good to excellent results in 92.9% of cases (170 patients) compared to 90% reported in the literature. We compared the capabilities of endoscopic discectomy with microsurgical methods, and concluded that the endoscopic method is sufficient to perform any movement inside the surgical field that is microscopically possible. It is also possible to perform any type of spinal cord decompression, with better visualization provided by the endoscope. Conclusions: We conclude that endoscopic microdiscectomy is a good and reliable alternative, with better outcomes and more efficient usage of the approach space.

Direct Tubular Lumbar Microdiscectomy for Far Lateral Disc Herniation: A Modified Approach

OBJECTIVE

The concept of minimally invasive tubular discectomy is based on precise placement of the retractor over the surgical target to minimize collateral tissue trauma. For far lateral disc herniation, the junction between the pars and the transverse process has generally been adopted as the target for facilitating early nerve root exposure; however, this may limit access to the disc space and increase the risks of iatrogenic neuralgia. An alternative approach to help address these issues involving docking the retractor caudally directly over the disc space with the aid of a microscope is here proposed. The purpose of this study was to evaluate the safety and efficacy of such an approach.

METHODS

Nineteen patients in whom the modified approach was performed over a 35-month period were identified. Direct access to the disc space was attained by directing the retractor against the lateral margin of the facet joint and following the inferior transverse process medially towards the foramen with minimal exposure of the nerve root. Clinical outcomes were assessed by the Oswestry Disability Index, visual analogue scale scores for leg and back pain, Short Form 36 physical functioning (SF36-PF) and bodily pain (SF36-BP) scores and sciatica bothersomeness and frequency indexes (SBI & SFI) and obtained from a prospective patient database. Follow-up data in the first 6 months were compared with preoperative baseline data.

RESULTS

All procedures were successfully completed with the modified approach. Contained disc herniation without sequestrated fragments was found in all but four cases. No perioperative complications or reoperation were recorded and no postoperative dysesthesia was noted. Clinically significant reductions in mean Oswestry Disability Index (32; 95% CI, 21-43) and visual analogue scale scores for leg pain (38 mm; 95% CI, 23-54 mm) and back pain (35 mm; 95% CI, 21-48 mm) scores were noted in the first 6 months. Significant improvements in SF36-PF (40; 95% CI, 30-51) and SF36-BP (35; 95% CI, 26-43), SBI (9; 95% CI, 6-11) and SFI (11; 95% CI, 8-13) were also recorded.

CONCLUSIONS

A modified direct tubular approach is safe and effective for treating far lateral lumbar disc herniation. Our early results suggest that this approach helps safeguard adequate decompression and reduce the risk of postoperative dysesthesia.

Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral lumbar disc herniations in children

PURPOSE

The use of transforaminal percutaneous endoscopic discectomy for the treatment of far-lateral lumbar disc herniations has been applied mostly in adults. However, transforaminal percutaneous endoscopic discectomy in children has probably been rarely documented. The aim of this study was to assess the efficacy of transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral lumbar disc herniations in children.

METHODS

Overall, 12 cases of far-lateral lumbar disc herniations were treated with the procedure of transforaminal percutaneous endoscopic discectomy between January 2010 and December 2014. There were seven male and five female children included, with an average age of 12.6 years (11-16 years). Pre-operative and post-operative (6 weeks, 6 months and 12 months) clinical outcome data (back and leg visual analog scale [VAS] and Macnab criteria) were collected along with clinical assessments of motor strength (graded 0-5).

RESULTS

All patients were discharged to home on the same day of surgery. The average leg VAS score improved from 8.6 ± 1.6 to 2.1 ± 0.4 (p < 0.005). Six patients had excellent outcomes, five had good outcomes, one had fair outcomes, and none had poor outcomes, according to the Macnab criteria. Eleven of 12 patients had excellent or good outcomes, for an overall success rate of 91.6 %. No patients required re-operation. There were no incidental durotomies, infections, vascular or visceral injuries. There was one complication, a case of leg numbness caused by ganglion injury. The numbness improved after two weeks. After three months, it was obvious that the total area of numbness in the legs had become smaller. At last follow-up, the patient had no pain, and only a few areas with numbness remained and did not affect the patient's activities of daily living.

CONCLUSIONS

Transforaminal percutaneous endoscopic discectomy achieved satisfactory results for children with far-lateral lumbar disc herniations.

[A comparative analysis of the effectiveness and potential of endoscopic and microsurgical resection of disc herniations in the lumbosacral spine]

The issue of advantage of endoscopic treatment of spinal disc herniations is debatable. Throughout the development, endoscopic technologies have been compared to microsurgical methods. The two-year experience of applying endoscopic methods was analyzed. The study included 183 patients. The effectiveness of the performed treatment was evaluated according to the MacNab scale of surgical treatment outcomes. Good and excellent results were obtained in 170 cases, which amounted to 92.9%. This cure rate was compared to the similar rate for good and excellent results of the microsurgical treatment method derived from the literature data. The article by American authors who conducted a multicenter study (Lumbar microdiscectomy: a historical perspective and current technical considerations. Koebbe C.J., Maroon J.C., Abla A., El-Kadi H., Bost J. Neurosurg Focus 2002 Aug 15; 13(2): E3) was used. On the basis of this study, the data on higher effectiveness of endoscopic discectomy compared to the microsurgical technique were obtained. The technical capabilities of the endoscopic method for removing spinal disc herniations in comparison to minimally invasive microsurgical techniques were carefully analyzed. It was noted that there were no significant instrumental limitations for using endoscopic techniques, while angled optics and excellent color rendition enable better visualization of the surgical wound structures and more efficient use of the approach space. Given that the technical characteristics and capabilities of this method are not inferior to those of the microsurgical technique, the former technology can be used instead of the standard technique for removing intervertebral disc herniations. Furthermore, the technical capabilities of the method allow performing wide decompression of the neural structures during surgery, which can be used to treat spinal stenoses.

The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials

OBJECT

Advocates of minimally invasive discectomy (MID) have promoted this operation as an alternative to open discectomy (OD), arguing that there may be less injury to the paraspinal muscles, decreased postoperative pain, and a faster recovery time. However, a recently published large randomized controlled trial (RCT) comparing these approaches reported inferior relief of leg pain in patients undergoing MID. The authors conducted a meta-analysis to evaluate complications and improvement in leg pain in patients with radiculopathy enrolled in RCTs comparing OD to MID.

METHODS

The authors performed a literature search using Medline and EMBASE of studies indexed between January 1990 and January 2011. Predetermined RCT eligibility included the usage of tubular retractors during MID, a minimum follow-up duration of 1 year, and quantification of pain with the visual analog scale (VAS). Trials that only evaluated patients with recurrent disc herniation were excluded. Data on operative parameters, complications, and VAS scores of leg pain were extracted by 2 investigators. A meta-analysis was performed assuming random effects to determine the difference in mean change for continuous outcomes and the risk ratio for binary outcomes.

RESULTS

Six trials comprising 837 patients (of whom 388 were randomized to MID and 449 were randomized to OD) were included. The mean operative time was 49 minutes during MID and 44 minutes during OD; this difference was not statistically significant. Incidental durotomies occurred significantly more frequently during MID (5.67% compared with 2.90% for OD; RR 2.05, 95% CI 1.05-3.98). Intraoperative complications (incidental durotomies and nerve root injuries) were also significantly more common in patients undergoing MID (RR 2.01, 95% CI 1.07-3.77). The mean preoperative VAS score for leg pain was 6.9 in patients randomized to MID and 7.2 in those randomized to OD. With long-term follow-up (1-2 years postoperatively), the mean VAS score improved to 1.6 in both the MID and OD cohorts. There was no significant difference in relief of leg pain between the 2 approaches with either short-term follow-up (2-3 months postoperatively, 0.81 points on the VAS, 95% CI -4.71 to 6.32) or long-term follow-up (2.64 on the VAS, 95% CI -2.15 to 7.43). Reoperation for recurrent herniation was more common in patients randomized to the MID group (8.50% compared with 5.35% in patients randomized to the OD group), but this difference was not statistically significant (RR 1.56, 95% CI 0.92-2.66). Total complications did not differ significantly between the operations (RR 1.50, 95% CI 0.97-2.33).

CONCLUSIONS

The current evidence suggests that both OD and MID lead to a substantial and equivalent long-term improvement in leg pain. Adequate decompression, regardless of the operative approach used, may be the primary determinant of pain relief-the major complaint of many patients with radiculopathy. Incidental durotomies occurred significantly more frequently during MID, but total complications did not differ between the techniques.

Extreme-lateral, minimally invasive, transpsoas approach for the treatment of far-lateral lumbar disc herniation

The authors present 2 cases of far-lateral lumbar disc herniations treated surgically via an extreme-lateral transpsoas approach. The procedure was performed using the MaXcess minimally invasive retractor system to access and successfully remove the disc fragments without complication. To the authors' knowledge, these are the first reported cases of using a minimally invasive retroperitoneal approach for the treatment of far-lateral disc herniations.

A new endoscopic spine system: the first results with "Easy GO"

PURPOSE

Endoscopy meets increasing interest by spine surgeons. However, endoscopic results are diverging and many spinal endoscopic systems are difficult to apply and handle.

METHODS

A system for endoscopic spinal surgery was developed where the main goals were: (1) easy intraoperative handling with standard microsurgical techniques, and (2) avoidance of a prolonged learning curve. The system consists of various dilators, two different work sheaths, two different 30 degrees endoscopes, and an endoscope holder.

RESULTS

Between August 2006 and April 2008, 80 spinal surgeries were performed in degenerative lumbar spine cases (mean age 52 years, range 22-85 years). Intraoperatively, the system was easy to handle. Standard microsurgical techniques were used. Mean surgical time scored 75 min (range 28-168 min). There was no intraoperative complication, no new postoperative deficit and no infection. In four cases, the endoscope was abandoned and the procedure microsurgically continued (5%). At the last follow-up (mean FU 10 months, range 2 weeks up to 21 months), 89% of the patient were pain free (71/80). Four patients suffered from recurrent disc prolapses (5%). Another five patients (6%) were not satisfied without evidence of re-prolaps. Of those who answered the questionnaire of patient satisfaction, 83% (45/54) considered their postoperative status as excellent, 13% as good (7/54), 4% were not satisfied (2/54).

CONCLUSIONS

The Easy GO system was easy and safe to handle with the standard bimanual microsurgical technique and good postoperative results. Further studies are needed to show a significant advantage of the technique in comparison to the microsurgical standard procedure.