Posterior Far Lateral Disk Herniation

Operative Techniques: Spine Surgery

Volumn , Issue , 2007, Pages 325-333

  Tannoury, Chadi ^a   Anderson, D Greg ^a   Vaccaro, Alexander R ^b,c,d   Albert, Todd J ^a,e  

^a THOMAS JEFFERSON UNIVERSITY HOSPITAL   (United States)

^b Thomas Jefferson University Hospital and The Rothman Institute ^*  (United States)

^c Delaware Valley Regional Spinal Cord Injury Service   (United States)

^d THOMAS JEFFERSON UNIVERSITY   (United States)

^e THOMAS JEFFERSON UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 77949818582     PISSN: None     EISSN: None     Source Type: Book    
DOI: 10.1016/B978-1-4160-3279-3.50030-0     Document Type: Chapter

References (8)

1. BV Darden 2nd, JF Wade, R Alexander, KE Wood, AL Rhyne 3rd and JR Hicks (1995) Far lateral disc herniations treated by microscopic fragment excision: techniques and results. Spine 20 1500-1505. A series of patients who had been treated with microscopic facet-sparing paraspinal muscle-splitting approach for far lateral disk herniation were evaluated retrospectively using parameters such as history, physical examination, pain questionnaires, visual analog scales, and plain radiographs. The overall clinical results were encouraging, and no radiographic signs of instability were noted. In addition, the paraspinal muscle-splitting approach is thought to minimize manipulation of the dorsal root ganglion, which is responsible for postoperative dysesthesia.
2. H Fankhauser and N de Tribolet (1991) Extraforaminal approach for extreme lateral lumbar disc herniation. MJ Torrens, RA Dickinson (Eds) Operative Spinal Sugery (Practice of Surgery Series) Edinburgh: Churchill Livingstone 145-160. Using the transmuscular approach for far lateral disk herniation, the authors observed the posterior primary ramus of the spinal nerve during operative dissection. However, its usefulness as an anatomic landmark has been argued because of difficult identification of its branches and time consumption.
3. RP Jackson and JJ Glah (1987) Foraminal and extraforaminal lumbar disc herniation: diagnosis and treatment. Spine 12 577-585. In this study, 10% of patients undergoing lumbar diskectomy for herniated nucleus pulposus were found to have far lateral foraminal or extraforaminal disk herniation. Different diagnostic radiographic evaluations have been proposed; however, diskography-enhanced computed tomgraphy proved accuracy in more than 90% of cases. In terms of surgical approach, the authors opted for bilateral hemilaminectomy with partial medial facetectomy and partial internal foraminotomy as most effective for diskectomy and nerve root decompression.
4. MF O'Brien, D Peterson and HA Crockard (1995) A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation. J Neurosurg 83 636-640. O'Brien et al. have adopted the posterolateral approach of Watkins for patients with a far lateral disk herniation. The authors recommend the use of the lateral branch of the posterior primary ramus as a key anatomic landmark to direct them to the spinal nerve and the intervertebral foramen.
5. LJ O'Hara and RW Marshall (1997) Far lateral lumbar disc herniation: the key to the intertransverse approach. J Bone Joint Surg Br 79 943-947. In a series of patients with far lateral lumbar disk herniation, an intertransverse muscle-splitting approach has been adopted with encouraging outcomes. A cadaver study describing the anatomic course of the posterior primary ramus within the intertransverse membrane has also been reported. The authors recommend the use of a muscle-splitting intertransverse approach to far lateral herniation, refering to the posterior primary ramus as the anatomic key to safe dissection.
6. AG Osborn, RS Hood, RG Sherry, WRK Smoker and HR Harnsberger (1988) CT/MRI spectrum of far lateral and anterior lumbosacral disc herniations. AJNR Am J Neuroradiol 9 775-778. A radiologic assessment of patients with extraforaminal disk herniations (EFDHs) using CT and/or MRI reported that the most commonly affected level was L4-5; however, 46% of EFDHs were overlooked and located at L2-3 or L3-4 levels. EFDHs can be readily diagnosed on both CT and MRI if appropriate scans are obtained from L2 through S1 and if the neural foramina and paravertebral spaces are carefully examined. Overlooked EFDHs are an important preventable cause of failed intraspinal diskectomy.
7. L Papavero and W Caspar (1993) The lumbar microdiscectomy. Acta Orthop Scand Suppl 64 34-37.
8. HJ Reulen, A Muller and U Ebeling (1996) Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations. Neurosurgery 39 345-350. In lumbar spine specimens taken from human cadavers, the relevant distances and proportions of the operative window were measured at the levels L1-2 to L5-S1. The anatomic findings led to important conclusions regarding the microsurgical approach to extraforaminal lumbar disk herniations; at levels L1-2 to L3-4, the midline approach with lateral retraction of the paraspinal muscles allows for efficient exposure of the lateral neural foramen and avoidance of trauma to the facet joint. Often at level L4-5, and nearly always at level L5-S1, a tangential route through a paramedian transmuscular approach offers many advantages. discussion 350-1