168 © 2014 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd
VIDEO OF ORTHOPAEDIC TECHNIQUE
Lumbar Discectomy for Lumbar Disc Herniation Hua-jiang Chen, MD, Lei Liang, MD, Jian-xi Wang, MD, Peng Cao, MD, Chang-gui Shi, MD, Wen Yuan, MD Department of Orthopaedics, Changzheng Hospital, Shanghai, China
Introduction ow back pain is one of the commonest chronic pain disorders affecting human health. Approximately 60%–95% of all people experience low back pain at some point during their lifetime1,2. Lumbar disc herniation, a very prevalent disease of the spinal column, is responsible for most low back pain. In addition, lumbar disc herniation can also result in defecation dysfunction and even paralysis if accompanied by cauda equina injury3. Lumbar discectomy by techniques such as interlaminar fenestration involve removal of the vertebral plate on the symptomatic side, and excision of the protrusion of the intervertebral disc, thus relieving nerve root compression4.
L
Case Presentation and Surgical Technique 23-year-old man presented with a six-month history of right lower extremity radicular pain which had progressively become more severe in the previous 2 months. Careful physical examination showed diminished muscle strength in the right lower extremity. Ptosis of the right foot was present and hallux dorsiflexion strength was weaker in his right foot than in his left. He had a positive Lasègue sign and straight leg raising test in the right leg; these were negative on his left. X-ray films revealed disappearance of the physiological curvature of the lumbar spine. Magnetic resonance imaging revealed disc herniation on the right side at the L4–5 level. The preoperative diagnosis was therefore disc herniation at L4–5. Lumbar discectomy was recommended. Informed consent was obtained after the explanation of the purpose and risks of the operation to the patient. Preoperatively, the patient was instructed to do some requisite preparation (e.g., prone position exercise or getting used to defecation in bed) and the doctors examined and marked the proposed operation region carefully. After tracheal intubation and induction of general anesthesia, the patient was positioned prone on a padded spinal operating frame. Radiography was used to locate the involved lumbar segment. A midline skin incision was made centered over the involved lumbar segment. Dissection was then performed in the midline through the skin, subcutaneous tissue, and lumbodorsal fascia to the tips of the spinous processes. The posterior elements (the laminae of the vertebra and
A
articular processes) were subperiosteally exposed from distal to proximal using electrocautery and periosteal elevators to detach the muscles from them. Part of the lamina was then removed using a rongeur and bone wax was applied to stop bleeding. The ligamentum flavum was separated from the underlying tissue and then incised to explore the distribution of the nerve root and confirm the preoperative diagnosis of prolapsed disc. The protrusion the disc was exposed thoroughly after which an adequate discectomy was performed and the nerve root was carefully decompressed. The intervertebral space was packed with a taped sponge to decrease bleeding. After completion of the spinal procedure, the wound was closed in layers over a drain. The operation time was 60 min with an estimated blood loss of 30 mL. The patient was able to walk the day after surgery with the protection of a lumbar support belt. Three days after surgery, the patient was discharged and expected to return to work 2 weeks later. Significant improvement was noted at the patients postoperative visit 6 months later. Discussion umbar discectomy is indicated primarily for treating lumbar disc herniation5. The procedure has several advantages over posterior fusion techniques. These include shorter operation time, simpler surgical procedure, faster postoperative recovery, markedly lower surgery cost and preservation of mobility of the operation segments. The indications for this procedure include: (i) definite diagnosis of disc herniation, 3 months of conservative treatment ineffective and severe and recurrent symptoms; (ii) lumbar disc herniation combined with dysfunction of nerve root(s) or cauda equine and (iii) lumbar disc herniation combined with spinal stenosis and/or lateral crypt stenosis. The contraindications are as follows: (i) diagnosis not confirmed and absence of typical manifestations of lumbar disc herniation on radiological examination; (ii) mild low back pain, symptoms alleviated by non-surgical treatment and daily life not affected; (iii) presence of comorbidities that contraindicate surgery; and (iv) severe instability of the lumbar vertebrae.
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Address for correspondence Hua-jiang Chen, MD, Department of Orthopaedics, Changzheng Hospital, Shanghai, China 200003 Tel: 0086013818559892; Email: [email protected]
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Orthopaedic Surgery 2014;6:168–169 • DOI: 10.1111/os.12111
169 Orthopaedic Surgery Volume 6 · Number 2 · May, 2014
Video Image dditional video images may be found in the online version of this article.
A
Lumbar Discectomy for Disc Herniation
Visit http://onlinelibrary.wiley.com/doi/10.1111/ os.12111/suppinfo
References 1. Krismer M, van, Tulder M, Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol, 2007, 21: 77–91. 2. Luoma K, Riihimäki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminen A. Low back pain in relation to lumbar disc degeneration. Spine, 2000, 25: 487–492. 3. Mauffrey C, Randhawa K, Lewis C, Brewster M, Dabke H. Cauda equina syndrome: an anatomically driven review. Br J Hosp Med (Lond), 2008, 69: 344–347.
4. Majeed SA, Vikraman CS, Mathew V, S AT. Comparison of outcomes between conventional lumbar fenestration discectomy and minimally invasive lumbar discectomy: an observational study with a minimum 2-year follow-up. J Orthop Surg Res, 2013, 8: 34. 5. Guterl CC, See EY, Blanquer SB, et al. Challenges and strategies in the repair of ruptured annulus fibrosu. Eur Cell Mater, 2013, 25: 1–21.
VIDEO OF ORTHOPAEDIC TECHNIQUE
Lumbar Discectomy for Lumbar Disc Herniation Hua-jiang Chen, MD, Lei Liang, MD, Jian-xi Wang, MD, Peng Cao, MD, Chang-gui Shi, MD, Wen Yuan, MD Department of Orthopaedics, Changzheng Hospital, Shanghai, China
Introduction ow back pain is one of the commonest chronic pain disorders affecting human health. Approximately 60%–95% of all people experience low back pain at some point during their lifetime1,2. Lumbar disc herniation, a very prevalent disease of the spinal column, is responsible for most low back pain. In addition, lumbar disc herniation can also result in defecation dysfunction and even paralysis if accompanied by cauda equina injury3. Lumbar discectomy by techniques such as interlaminar fenestration involve removal of the vertebral plate on the symptomatic side, and excision of the protrusion of the intervertebral disc, thus relieving nerve root compression4.
L
Case Presentation and Surgical Technique 23-year-old man presented with a six-month history of right lower extremity radicular pain which had progressively become more severe in the previous 2 months. Careful physical examination showed diminished muscle strength in the right lower extremity. Ptosis of the right foot was present and hallux dorsiflexion strength was weaker in his right foot than in his left. He had a positive Lasègue sign and straight leg raising test in the right leg; these were negative on his left. X-ray films revealed disappearance of the physiological curvature of the lumbar spine. Magnetic resonance imaging revealed disc herniation on the right side at the L4–5 level. The preoperative diagnosis was therefore disc herniation at L4–5. Lumbar discectomy was recommended. Informed consent was obtained after the explanation of the purpose and risks of the operation to the patient. Preoperatively, the patient was instructed to do some requisite preparation (e.g., prone position exercise or getting used to defecation in bed) and the doctors examined and marked the proposed operation region carefully. After tracheal intubation and induction of general anesthesia, the patient was positioned prone on a padded spinal operating frame. Radiography was used to locate the involved lumbar segment. A midline skin incision was made centered over the involved lumbar segment. Dissection was then performed in the midline through the skin, subcutaneous tissue, and lumbodorsal fascia to the tips of the spinous processes. The posterior elements (the laminae of the vertebra and
A
articular processes) were subperiosteally exposed from distal to proximal using electrocautery and periosteal elevators to detach the muscles from them. Part of the lamina was then removed using a rongeur and bone wax was applied to stop bleeding. The ligamentum flavum was separated from the underlying tissue and then incised to explore the distribution of the nerve root and confirm the preoperative diagnosis of prolapsed disc. The protrusion the disc was exposed thoroughly after which an adequate discectomy was performed and the nerve root was carefully decompressed. The intervertebral space was packed with a taped sponge to decrease bleeding. After completion of the spinal procedure, the wound was closed in layers over a drain. The operation time was 60 min with an estimated blood loss of 30 mL. The patient was able to walk the day after surgery with the protection of a lumbar support belt. Three days after surgery, the patient was discharged and expected to return to work 2 weeks later. Significant improvement was noted at the patients postoperative visit 6 months later. Discussion umbar discectomy is indicated primarily for treating lumbar disc herniation5. The procedure has several advantages over posterior fusion techniques. These include shorter operation time, simpler surgical procedure, faster postoperative recovery, markedly lower surgery cost and preservation of mobility of the operation segments. The indications for this procedure include: (i) definite diagnosis of disc herniation, 3 months of conservative treatment ineffective and severe and recurrent symptoms; (ii) lumbar disc herniation combined with dysfunction of nerve root(s) or cauda equine and (iii) lumbar disc herniation combined with spinal stenosis and/or lateral crypt stenosis. The contraindications are as follows: (i) diagnosis not confirmed and absence of typical manifestations of lumbar disc herniation on radiological examination; (ii) mild low back pain, symptoms alleviated by non-surgical treatment and daily life not affected; (iii) presence of comorbidities that contraindicate surgery; and (iv) severe instability of the lumbar vertebrae.
L
Address for correspondence Hua-jiang Chen, MD, Department of Orthopaedics, Changzheng Hospital, Shanghai, China 200003 Tel: 0086013818559892; Email: [email protected]
bs_bs_banner
Orthopaedic Surgery 2014;6:168–169 • DOI: 10.1111/os.12111
169 Orthopaedic Surgery Volume 6 · Number 2 · May, 2014
Video Image dditional video images may be found in the online version of this article.
A
Lumbar Discectomy for Disc Herniation
Visit http://onlinelibrary.wiley.com/doi/10.1111/ os.12111/suppinfo
References 1. Krismer M, van, Tulder M, Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol, 2007, 21: 77–91. 2. Luoma K, Riihimäki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminen A. Low back pain in relation to lumbar disc degeneration. Spine, 2000, 25: 487–492. 3. Mauffrey C, Randhawa K, Lewis C, Brewster M, Dabke H. Cauda equina syndrome: an anatomically driven review. Br J Hosp Med (Lond), 2008, 69: 344–347.
4. Majeed SA, Vikraman CS, Mathew V, S AT. Comparison of outcomes between conventional lumbar fenestration discectomy and minimally invasive lumbar discectomy: an observational study with a minimum 2-year follow-up. J Orthop Surg Res, 2013, 8: 34. 5. Guterl CC, See EY, Blanquer SB, et al. Challenges and strategies in the repair of ruptured annulus fibrosu. Eur Cell Mater, 2013, 25: 1–21.
