Elsevier

The Spine Journal

Volume 18, Issue 4, April 2018, Pages 620-625
The Spine Journal

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

https://doi.org/10.1016/j.spinee.2017.08.258Get rights and content

Abstract

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.

Introduction

Extraforaminal disc herniations (EFDHs) defined as disc herniations in the area lateral to the pedicles, represent 7%–12% of all lumbar disc herniations [1], [2], [3]. With availability of modern imaging facilities such as high-resolution computed tomography and magnetic resonance imaging (MRI) scans, the frequency of diagnosis for EFDH is on the rise. Despite increased awareness about its existence, the optimal treatment is still a matter of controversy [4].

A considerable number of varying approach techniques to the neuroforamen and the extraforaminal space have been published. Classically these herniations have been treated via a variety of posterior surgical approaches, including a medial facetectomy, intertransverse technique, full facetectomy, trans pars technique, and extraforaminal technique [5]. The far lateral paraspinal muscle splitting approach previously described by Wiltse et al. [6] resembles a true minimally invasive approach. More recently, minimally invasive options have arisen, including percutaneous endoscopic techniques and transmuscular techniques through tubular retractors [2], [4], [7], [8], [9]. The goals of minimally invasive techniques are to maintain biomechanical stability by avoiding extensive facet joint resection and to reduce postoperative morbidity by minimizing the access-related soft tissue trauma [10].

Combining the advantages of the often used paramedian muscle-splitting approach and the endoscopic far-lateral approach, Greiner-Perth et al. described a minimally invasive paraspinal muscle-splitting approach through a tubular working channel [11]. The use of a tubular working canal reduces surgical trauma, especially in obese patients, and prevents instability [12].

This study presents the results of operative treatment of foraminal and EFDH using extraforaminal microscopic-assisted percutaneous nucleotomy (EF-MAPN) with a literature review focusing on complications and recurrence rate.

Section snippets

Patients and methods

This is a prospective cohort study of a single surgeon (first author) in a single institution (Spine Center, Helios Hospitals Erfurt). Between October 2012 and October 2015, a total of 76 patients (41 men and 35 women, with a mean age of 54 years [±12 years]) have been treated because of foraminal or EFDH using the EF-MAPN technique. The total number of trans-tubular MAPN procedures done in that period was 1,146.

Inclusion criteria:

  • 1.

    unilateral radicular symptoms including pain, paraesthesia, or

Results

Sixty-three patients (82.9%) presented with pure extraforaminal disc herniation, 13 patients (17.1%) had intraforaminal disc fragments that led to obturation of the neural foramen. The mean body mass index of the entire patient group was 26.6 (range 17–40). The mean duration of symptoms was 12.5 weeks (range 1–13 weeks). Intraoperatively, no dural injury had been encountered. Over the course of the study, the operating time was an average of 57.5 minutes with a range of 25–114 minutes. Blood

Discussion

Since its first description by Greiner-Perth et al. in 2003 [11], few studies have reported on the results of trans-tubular EF-MAPN technique. Many studies described different surgical approaches and varying techniques for treatment of EFDH [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]. However, few studies focused on complications and recurrence rate.

One advantage of the EF-MAPN over the midline approaches is the safe lateral exposure of the nerve and adequate extraforaminal

Conclusion

Extraforaminal microscopic-assisted percutaneous nucleotomy represent a valuable reproducible alternative in treatment of EFDH. It is a minimal invasive technique with minimal morbidity. Clinical outcome, complications, recurrence, and re-operation rate are comparable with other techniques.

References (23)

  • A.F. Abdullah et al.

    Surgical management of extreme lateral lumbar disc herniations: review of 138 cases

    Neurosurgery

    (1988)
  • K.T. Foley et al.

    Microendoscopic approach to far-lateral lumbar disc herniation

    Neurosurg Focus

    (1999)
  • S.M. Pirris et al.

    Minimally invasive approach to extraforaminal disc herniations at the lumbosacral junction using an operating microscope: case series and review of the literature

    Neurosurg Focus

    (2008)
  • G. Choi et al.

    Percutaneous endoscopic discectomy for extraforaminal lumbar disc herniations extraforaminal targeted fragmentectomy technique using working channel endoscope

    Spine

    (2007)
  • N.E. Epstein

    Foraminal and far lateral lumbar disc herniations: surgical alternatives and outcome measures

    Spinal Cord

    (2002)
  • L.L. Wiltse et al.

    The paraspinal sacrospinalis-splitting approach to the lumbar spine

    J Bone Joint Surg Am

    (1968)
  • H.J. Reulen et al.

    The lateral microsurgical approach to the “extracanalicular” lumbar disc herniation. I: a technical note

    Acta Neurochir (Wien)

    (1987)
  • Y.M. Ryang et al.

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

    Minim Invasive Neurosurg

    (2007)
  • M. Sasani et al.

    Percutaneous endoscopic discectomy for far lateral lumbar disc herniations: prospective study and outcome of 66 patients

    Minim Invasive Neurosurg

    (2007)
  • C. Mehren et al.

    Neuroforaminal decompression and intra-/extraforaminal discectomy via a paraspinal muscle-splitting approach

    Eur Spine J

    (2016)
  • R. Greiner-Perth et al.

    A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results

    Eur Spine J

    (2003)
  • Cited by (12)

    • Comparison of Two Minimally Invasive Techniques with Endoscopy and Microscopy for Extraforaminal Disc Herniations

      2020, World Neurosurgery
      Citation Excerpt :

      Before the invention of magnetic resonance imaging (MRI), EFDHs were believed to account for approximately 4% of lumbar disc herniations.5 After the invention of contemporary radiologic diagnostic techniques such as high-resolution computed tomography and MRI, EFDHs were found to account for 7%–12% of all lumbar disc herniations.4,6-8 For median disc herniations, the classic median approach was first described by Mixter and Barr in 19349,10; however, this traditional technique is insufficient for EFDHs.

    • Delayed Infected Pseudomeningocele After Percutaneous Endoscopic Lumbar Diskectomy

      2018, World Neurosurgery
      Citation Excerpt :

      The risk of neural or dural injury is minimal when the foraminotomy is done through a far lateral paraspinal muscle splitting approach previously described by Wiltse et al.,33 and modified by Greiner-Perth et al.,34 in 2003, who reported the technique through a tubular retractor providing less iatrogenic damage to the paravertebral muscles. In general, the paraspinal approach offers adequate lateral nerve exposure and allows safer extraforaminal decompression with access to the foraminal and extraforaminal portion of the disk, with minimal disruption of the facet joint.35 However, the main concerns of percutaneous endoscopic foraminotomy are dural and neural injury.

    View all citing articles on Scopus

    FDA device/drug status: Not applicable.

    Author disclosures: ASA: Nothing to disclose. DB: Nothing to disclose. AES: Nothing to disclose. AE: Nothing to disclose.

    There are no disclosures related to the subject of the paper.

    We have not received funding from any organization for research on which our article is based.

    View full text