An oblique paraspinal approach for intracanalicular disc herniations of the upper lumbar spine: technical case report

The Results of Using a Transforaminal Lumbar Interbody Fusion Cage at the Upper Lumbar Level

Aim

The aim of this study is to apply surgical treatments to upper lumbar disc hernias in order to provide lumbar stability and lumbar lordosis using a transforaminal lumbar interbody fusion (TLIF) cage and to preserve the success rate of surgical results by protecting neural structures without excessive subject tension.

Material and methods

Between 2012 and 2017, 32 patients who had undergone an operation for upper lumbar disc herniation and who had received a transforaminal lumbar interbody fusion cage using a posterior technique were evaluated retrospectively.

Results

The radiological and clinical findings, surgical methods, and results of the patients were evaluated. In our study, 25 (78.1%) of the patients with upper lumbar disc hernias who were evaluated retrospectively were female and seven (21.9%) were male. Their average age was 55.43 years. The average follow-up was 21.75 months. The most common complaints were lower back pain, leg pain, and claudication. In the findings from neurological examinations, a positive result on the femoral stretching test occurred in 30 (93.7%) patients. In the degenerative spinal structure of patients at the L1-2 and L2-3 levels, a transforaminal lumbar interbody fusion was performed via a wide laminectomy with posterior stabilization due to a wide-bottomed disc hernia and stenosis. Only one of the patients with a neurological deficit still had a motor deficit after surgery.

Conclusion

While planning a surgery for upper lumbar disc hernias, the anatomical features of this region and the patients' radiological and neurological findings should be carefully evaluated. If TLIF is performed during upper lumbar region surgery, it may be preferable to perform it using a posterior technique.

Surgical Outcomes for Upper Lumbar Disc Herniations: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To conduct a literature review on outcomes of discectomy for upper lumbar disc herniations (ULDH), estimate pooled rates of satisfactory outcomes, compare open laminectomy/microdiscectomy (OLM) versus minimally invasive surgical (MIS) techniques, and compare results of disc herniations at L1-3 versus L3-4.

METHODS

A systematic review of articles reporting outcomes of nonfusion surgical treatment of L1-2, L2-3, and/or L3-4 disc herniations was performed. The inclusion and exclusion of studies was performed according to the latest version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

A total of 20 articles were included in the quantitative meta-analysis. Pooled proportion of satisfactory outcome (95% CI) was 0.77 (0.70, 0.83) for MIS and 0.82 (0.78, 0.84) for OLM. There was no significant improvement with MIS techniques compared with standard OLM, odds ratio (OR) = 0.86, 95% CI (0.42, 1.74), P = .66. Separating results by levels revealed a trend of higher satisfaction with L3-4 versus L1-3 with OLM surgery, OR = 0.46, 95% CI (0.19, 1.12), P = .08.

CONCLUSION

Our analysis reveals that discectomy for ULDH has an overall success rate of approximately 80% and has not improved with MIS. Discectomy for herniations at L3-4 trends toward better outcomes compared with L1-2 and L2-3, but was not significant.

Surgical Outcomes for Upper Lumbar Disc Herniation: Decompression Alone versus Fusion Surgery

Upper lumbar herniated intervertebral disc (HIVD), defined as L1-2 and L2-3 levels, presents with a lower incidence and more unfavorable surgical outcomes than lower lumbar levels. There are very few reports onthe appropriate surgical interventions for treating upper lumbar HIVD. This study aimed to evaluate the surgical outcome of decompression alone, when compared with spinal fusion surgery. A retrospective study involving a total of 7592 patients who underwent surgery due to HIVD in our institution was conducted. A total of 49 patients were included in this study: 33 patients who underwent decompression-only surgery and 16 patients who underwent fusion surgery. Demographic data, perioperative information, and functional outcomes were recorded. The visual analog scale (VAS) scores showed improvement in both groups postoperatively. The three-month postoperative Oswestry Disability Index score was significantly better in the fusion group. Additionally, 10 patients (76.9%) in the decompression group and 5 patients (83.3%) in the fusion group reported improvement in preoperative motor weakness. The final “satisfactory” rate was 66.7% in the decompression group and 93.8% in the fusion group (p = 0.034). The overall surgical outcomes of patients with upper lumbar HIVD were satisfactory in this study without any major complications. More reliable satisfactory rates and better functional scores at the three-month postoperative follow-up were reported in the fusion group.

Recurrent upper lumbar disc herniation treated via the transforaminal approach using microendoscopy-assisted lumbar discectomy: a case report

BACKGROUND

Although microendoscopy-assisted lumbar discectomy for lateral or extraforaminal lumbar disc herniations via the lateral approach has previously been reported, microendoscopy-assisted lumbar discectomy for central or paramedian disc herniations via the lateral approach has not been reported. We report the first case of recurrent upper lumbar disc herniation (L2-L3) treated with microendoscopy-assisted lumbar discectomy via the transforaminal approach. No microendoscopy-assisted lumbar discectomy for recurrent upper lumbar disc herniation via the transforaminal approach has previously been reported. Percutaneous endoscopic lumbar discectomy via the transforaminal approach is very useful as a minimally invasive surgery for disc herniations. We applied percutaneous endoscopic lumbar discectomy via the transforaminal approach, and invented a new microendoscopy-assisted lumbar discectomy via the transforaminal approach.

CASE PRESENTATION

A 79-year-old Japanese man was operatively managed for recurrent L2-L3 herniation. An 18 mm skin incision was made approximately 70 mm from the midline to the lateral side to allow a sufficiently angled trajectory to the extraforaminal space. The transforaminal approach was used. The exiting nerve root was identified along its course inferior to the pedicle. The lateral portion of the pars interarticularis and the facet joint was removed using a high-speed drill under the guidance of an endoscope. The tip of the endoscope was set at the lateral side of the dura mater. The dura mater was retracted medially and gently, and the herniated disc fragments were removed safely. All symptoms were relieved postoperatively. Postoperative magnetic resonance imaging demonstrated disappearance of all herniated disc fragments. A postoperative three-dimensional computed tomographic scan demonstrated the complete preservation of the facet joint.

CONCLUSIONS

This is the first report of a case of recurrent upper lumbar disc herniation treated with microendoscopy-assisted lumbar discectomy via the transforaminal approach. This procedure allows for the use of a nerve retractor and other instruments to detach adhesions from the dura mater. This procedure has the advantages of clear visualization of the dura mater, exiting nerve root, and traversing nerve root, and diminished risk of nerve injury, and complete preservation of the articular surface of the facet joint.

Significance and pitfalls of percutaneous endoscopic lumbar discectomy for large central lumbar disc herniation

Background

Percutaneous endoscopic lumbar discectomy (PELD) is a relatively less invasive treatment for lumbar disc herniation (LDH). The present study focused on the transforaminal approach (TFA) and investigated the significance of PELD via this approach for large central LDH.

Methods

LDH that did not show cerebrospinal fluid (CSF) on axial T2-weighted magnetic resonance images was defined as large central LDH. PELD via the TFA was performed in 11 patients with large central LDH. Pre- and post-operative statuses were evaluated using the modified Japanese Orthopedic Association (mJOA) and Numerical Rating Scale (NRS) scores.

Results

The patients' mean age was 44.1 years; there was single-level involvement, mostly at L4/5 (seven cases). The mean recovery rate of the mJOA score was 48.7%, and mean pre- and post-operative NRS scores were 7.1 and 1.5, respectively. The mean operative time was 38.1 min. Although there were no major complications, the dura was accidentally punctured at the initial operative step for discography in one case. LDH recurred in one case at 5 months after the operation, and the patient was treated by PELD via the TFA on the contralateral side.

Conclusions

The TFA for PELD is a safe, minimally invasive, effective treatment for large central LDH. However, the operator should pay attention to malpositioning of the flat and laterally expanded dural sac.

Iatrogenic injury to the erector spinae during posterior lumbar spine surgery: underlying anatomical considerations, preventable root causes, and surgical tips and tricks

The approach-related morbidity resulting from iatrogenic erector spinae injury in posterior lumbar surgery has become an increasing concern for spine surgeons. Many studies have explained the injury mechanisms and reported new surgical approaches to prevent this iatrogenic injury from their own point of views, but there is still no systemic information for a thorough understanding of this iatrogenic erector spinae injury that may give spine surgeons practical advices in their individual operations. We consequently reviewed the literature on the anatomy of erector spinae, causes of injury, and relative minimally invasive approaches. We found that the local anatomic structures make the erector spinae vulnerable to injury during posterior lumbar surgery, especially the medial multifidus which is innervated only by the medial branch of the dorsal ramus, with no intersegmental nerve supply as in the other paraspinal muscles, and the injury factors mainly include dissection, retraction, denervation, and immobility. Studies suggest that the goal of prevention is to preserve the physiological structure of erector spinae and to avoid or limit the injury causes: approaches through spatium intermusculare and approaches with endoscope and tubular retractor system can prevent the erector spinae from injury by less dissection and retraction; non-fusion techniques may prevent the erector spinae from disuse atrophy by preserving the segmental motion and the adjacent erector spinae activity.

Oblique paraspinal approach for thoracic disc herniations using tubular retractor with robotic holder: a technical note

INTRODUCTION

Symptomatic thoracic disc herniations (TDHs) are uncommon and can be surgically treated. Although transthoracic decompression is considered the gold standard, it is associated with significant comorbidities. In particular, approach via a posterior laminectomy has been associated with poor results. Several strategies have been developed for the resection of TDHs without manipulating the spinal cord. We describe a minimally invasive technique by using 3-D navigation and tubular retractors with the aid of a robotic holder via an oblique paraspinal approach.

MATERIALS AND METHODS

The 20-mm working tube via an oblique trajectory through the fascia provides a good surgical field for thoracic discectomy through a microscope. We present our first five patients with TDHs operated using this minimally invasive approach.

RESULTS

Neurological symptoms were improved postoperatively, and there were no surgical complications. There was no instability or recurrence during the follow-up period.

CONCLUSION

The oblique paraspinal approach may offer an alternative surgical option for treating TDHs.