Clinical StudyExtraforaminal microscopic assisted percutaneous nucleotomy for foraminal and extraforaminal lumbar disc herniations
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.
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Cited by (12)
Comparison of Two Minimally Invasive Techniques with Endoscopy and Microscopy for Extraforaminal Disc Herniations
2020, World NeurosurgeryCitation 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 NeurosurgeryCitation 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.
Percutaneous endoscopic lumbar discectomy and research progress of endoscopic treatment of complex migrated lumbar disc herniation
2023, Fudan University Journal of Medical SciencesA Retrospective Study of Far Lateral Midline Microlumbar Discectomy in 20 Patients at a Single Center in Turkey
2023, Medical Science MonitorLong-term follow-up results of surgically treated patients with foraminal and far lateral disc herniations
2023, British Journal of Neurosurgery
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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.