Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation

Abstract

Objective: Removal of a sequestered lumbar disk; in instances of foraminal stenosis a decompression (foraminoplasty) can also be performed. The objective is to restore the best possible pain-free function of the spinal column.

Indications: Prolapsed lumbar vertebral disk, sequestered caudally or cranially, that is no longer responding to nonoperative treatment. Cauda equina syndrome.

Contraindications: Sequestered herniated lumbar disk posterior to the dura mater.

Surgical technique: Lateral decubitus on a radiolucent table allowing the use of an image intensifier. The usual access to a sequester at segments L5/S1 and L4/5 is approximately 12-14 cm lateral to the midline, at segments L3/4 and L2/3 approximately 10 cm lateral to the midline. In the case of sequestration in a cranial direction a somewhat smaller angle of access should be chosen, for caudal displacement the angle should be greater. Reaming of a lateral transforaminal approach to the spinal canal. The sequester is removed endoscopically through a working cannula.

Postoperative management: The patient remains in the recovery room for approximately 2 h, is fitted with a brace and transferred to the ward. No medicinal thrombosis prophylaxis. Follow-up examination the next morning. Physiotherapy after 1 week. The brace is worn for approximately 2-6 weeks. MRI checkup and after 3 months evaluation of the development of strength and the state of the back musculature.

Results: Between January 1999 and January 2002, 611 patients underwent surgery, 32% women and 68% men, age between 18 and 65 years (average age 43.8 years). Clinical follow-up examinations were carried out after 3 months, follow-ups with questionnaire after 1 and 2 years. The evaluation criteria were based on an own questionnaire, and also on MacNab's score and the visual analog scale (VAS). After 2 years 558 patients (91.2%) responded to the questionnaires. Excellent or good results were achieved in 95.3% of the patients. 74.7% were very satisfied, 20.6% satisfied. The result was judged unsatisfactory by 4.7% of patients (less satisfied 3.9%, unsatisfied 0.8%). The numbness of the leg, present in 448 patients preoperatively, was either no longer present (63.9%) or had improved (30.3%). There were no serious complications, in particular no infections. The recurrence rate was 3.6%.