J Neurosurg 72:143-144, 1990
A neurosurgical approach to far-lateral disc herniation Technical note JOHN A. JANE, M.D., PH.D., CHARLES S. HAWORTH, M.D., WILLIAM C. BROADDUS, M.D., PH.D., JOUNG H. LEE, M.D., AND JACEK MALIK, M.D.
Department of Neurological Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia t,- A technique for exposing far-lateral intervertebral disc herniations without disrupting the facet is described. This technique is a simple modification of the standard neurosurgical approach. KEY WORDS lumbar spine 9 herniated nucleus pulposis intervertebral disc herniation 9 operative approach 9
9
T
HE existence of lumbar disc herniations lateral to the facet has long been known, but the consistent demonstration o f these lesions has depended upon the development of computerized tomography scanning. These lesions can be removed through the usual laminectomy, but then it is often necessary to remove the inferior facet o f the superior lamina, as well as the more medial portion o f the superior facet of the inferior lamina. Although this is probably acceptable when performed on only one side, it nonetheless disrupts a normal articulation. Abdullah, et al., ~ have advocated an extensive intraspinal approach which also saves the facet, and muscle-splitting approaches to these lesions have been described by others; 2-5 however, these latter techniques are somewhat foreign to the neurosurgical mind. The following m e t h o d is easier, a more natural outgrowth of the usual approach, and does not disrupt the facet.
Operative Technique After infiltration with 1% Marcaine (bupivacaine), a skin incision is made and carried down to the lumbodorsal fascia. The lumbodorsal fascia is opened in a gentle arc away from the insertion upon the spinous processes (Fig. 1A). Then, with scissors and forceps, the muscles are cut away from the spinous processes and lamina and are retracted further laterally over the facet, but not beyond it (Fig. 1A and B). It is convenient to use the Gelpi retractors to maintain retraction. The
J. Neurosurg. / Volume 72/January, 1990
FIG. 1. Operative drawings. A: The curved incision is made in the fascia and the paraspinal musculature is retracted. B: Representation of the normal anatomy. C: An opening has been made in the ligamentum flavum, and a small hemilaminectomy is made in the lamina of L-3. D: Removal of the lateral and inferior portions of the superior facet of the inferior lamina. The dotted line shows how much was actually removed. In addition, the intertransversarius muscle is seen. 143
Approach to far-lateral disc herniation the laminectomy can be enlarged (Fig. 2B) and both fragments removed through the extraforaminal route, combined with the usual intraspinal technique. At the end of the procedure, the foramen can be explored both inside and out to make sure that all disc fragments have been removed (Fig. 2C). Finally, a fat graft is placed in the extraforaminal and intraspinal defects (Fig. 2D). Comment
FIG. 2. Operative drawings. A: On removal of the intertransversarius muscle, the L-3 nerve root overlying the disc laterally is exposed. B: The muscle is removed, the enlargement of the hemilamineetomy and the disc herniation are removed from the outside, the inside, or both. C: A dissector is placed into the foramen in order to verify that it is open. D: A fat graft is placed laterally. Another fat graft can also be placed medially if the dissection has been carried out there as well.
ligamentum is opened and a small partial hemilaminectomy is performed in the superior lamina (L-3, in the case illustrated, Fig. 1C). An x-ray film is taken to verify the correct position of the dissection, which is then carried further laterally over the facet in order to remove the lateral portion o f the superior facet of the inferior vertebral body (Fig. I D). At this point, the intertransversarius lateralis muscle comes into view and is removed from the transverse process of the superior vertebral body (Fig. 2A). This exposes the L-3 nerve root, and the ruptured disc is usually seen superior to the nerve root. If the disc rupture is also intraspinal,
144
This technique is easy to learn, requiring little modification from the traditional neurosurgical approach. The paraspinal musculature must be brought to the edge of the facet, although not beyond. Then, after identification of the proper space, the lateral and inferior portions o f the superior facet of the inferior vertebral body can be removed. This exposes the intertransversarius muscle which, when removed, reveals the nerve root and herniated disc. If the operator is not confident that the disc has been entirely removed, an intraspinal approach can easily be made and the foramen probed both inside and out. This simple technique has proved successful for approaching far-lateral discs without rupturing the articulation. References 1. Abdullah AF, Wolber PGH, Warfield JR, et al: Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery 22:648-653, 1988 2. Fankhauser H, de Tribolet N: Extreme lateral lumbar disc herniation. Br J Neurosurg 1:111-129, 1987 3. Recoules-Arche D: La chirurgie de la bernie discale du canal de conjugaison lombaire. Neurochirurgie 31: 61-64, 1985 4. Wiltse LL, Spencer CW: New uses and refinements of the paraspinal approach to the lumbar spine. Spine 13" 696-706, 1988 5. Zindrick MR, Wiltse LL, Rauschning W: Disc herniations lateral to the intervertebral foramen, in White AH, Rothman RH, Ray CD (eds): Lumbar Spine Surgery. London: CV Mosby, 1987, pp 195-207 Manuscript received March 27, 1989. Address reprint requests to: John A. Jane, M.D., Ph.D., Department of Neurological Surgery, Box 212, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908.
3". Neurosurg. / Volume 7 2 / J a n u a r y , 1990
A neurosurgical approach to far-lateral disc herniation Technical note JOHN A. JANE, M.D., PH.D., CHARLES S. HAWORTH, M.D., WILLIAM C. BROADDUS, M.D., PH.D., JOUNG H. LEE, M.D., AND JACEK MALIK, M.D.
Department of Neurological Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia t,- A technique for exposing far-lateral intervertebral disc herniations without disrupting the facet is described. This technique is a simple modification of the standard neurosurgical approach. KEY WORDS lumbar spine 9 herniated nucleus pulposis intervertebral disc herniation 9 operative approach 9
9
T
HE existence of lumbar disc herniations lateral to the facet has long been known, but the consistent demonstration o f these lesions has depended upon the development of computerized tomography scanning. These lesions can be removed through the usual laminectomy, but then it is often necessary to remove the inferior facet o f the superior lamina, as well as the more medial portion o f the superior facet of the inferior lamina. Although this is probably acceptable when performed on only one side, it nonetheless disrupts a normal articulation. Abdullah, et al., ~ have advocated an extensive intraspinal approach which also saves the facet, and muscle-splitting approaches to these lesions have been described by others; 2-5 however, these latter techniques are somewhat foreign to the neurosurgical mind. The following m e t h o d is easier, a more natural outgrowth of the usual approach, and does not disrupt the facet.
Operative Technique After infiltration with 1% Marcaine (bupivacaine), a skin incision is made and carried down to the lumbodorsal fascia. The lumbodorsal fascia is opened in a gentle arc away from the insertion upon the spinous processes (Fig. 1A). Then, with scissors and forceps, the muscles are cut away from the spinous processes and lamina and are retracted further laterally over the facet, but not beyond it (Fig. 1A and B). It is convenient to use the Gelpi retractors to maintain retraction. The
J. Neurosurg. / Volume 72/January, 1990
FIG. 1. Operative drawings. A: The curved incision is made in the fascia and the paraspinal musculature is retracted. B: Representation of the normal anatomy. C: An opening has been made in the ligamentum flavum, and a small hemilaminectomy is made in the lamina of L-3. D: Removal of the lateral and inferior portions of the superior facet of the inferior lamina. The dotted line shows how much was actually removed. In addition, the intertransversarius muscle is seen. 143
Approach to far-lateral disc herniation the laminectomy can be enlarged (Fig. 2B) and both fragments removed through the extraforaminal route, combined with the usual intraspinal technique. At the end of the procedure, the foramen can be explored both inside and out to make sure that all disc fragments have been removed (Fig. 2C). Finally, a fat graft is placed in the extraforaminal and intraspinal defects (Fig. 2D). Comment
FIG. 2. Operative drawings. A: On removal of the intertransversarius muscle, the L-3 nerve root overlying the disc laterally is exposed. B: The muscle is removed, the enlargement of the hemilamineetomy and the disc herniation are removed from the outside, the inside, or both. C: A dissector is placed into the foramen in order to verify that it is open. D: A fat graft is placed laterally. Another fat graft can also be placed medially if the dissection has been carried out there as well.
ligamentum is opened and a small partial hemilaminectomy is performed in the superior lamina (L-3, in the case illustrated, Fig. 1C). An x-ray film is taken to verify the correct position of the dissection, which is then carried further laterally over the facet in order to remove the lateral portion o f the superior facet of the inferior vertebral body (Fig. I D). At this point, the intertransversarius lateralis muscle comes into view and is removed from the transverse process of the superior vertebral body (Fig. 2A). This exposes the L-3 nerve root, and the ruptured disc is usually seen superior to the nerve root. If the disc rupture is also intraspinal,
144
This technique is easy to learn, requiring little modification from the traditional neurosurgical approach. The paraspinal musculature must be brought to the edge of the facet, although not beyond. Then, after identification of the proper space, the lateral and inferior portions o f the superior facet of the inferior vertebral body can be removed. This exposes the intertransversarius muscle which, when removed, reveals the nerve root and herniated disc. If the operator is not confident that the disc has been entirely removed, an intraspinal approach can easily be made and the foramen probed both inside and out. This simple technique has proved successful for approaching far-lateral discs without rupturing the articulation. References 1. Abdullah AF, Wolber PGH, Warfield JR, et al: Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery 22:648-653, 1988 2. Fankhauser H, de Tribolet N: Extreme lateral lumbar disc herniation. Br J Neurosurg 1:111-129, 1987 3. Recoules-Arche D: La chirurgie de la bernie discale du canal de conjugaison lombaire. Neurochirurgie 31: 61-64, 1985 4. Wiltse LL, Spencer CW: New uses and refinements of the paraspinal approach to the lumbar spine. Spine 13" 696-706, 1988 5. Zindrick MR, Wiltse LL, Rauschning W: Disc herniations lateral to the intervertebral foramen, in White AH, Rothman RH, Ray CD (eds): Lumbar Spine Surgery. London: CV Mosby, 1987, pp 195-207 Manuscript received March 27, 1989. Address reprint requests to: John A. Jane, M.D., Ph.D., Department of Neurological Surgery, Box 212, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908.
3". Neurosurg. / Volume 7 2 / J a n u a r y , 1990
