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. 2014 Dec 1:8:16.
doi: 10.14444/1016. eCollection 2014.

The surgical treatment of single level multi-focal subarticular and paracentral and/or far-lateral lumbar disc herniations: the single incision full endoscopic approach

James J Yue  1 , David L Scott  1 , Xiao Han  1 , Alem Yacob  1
Affiliations

The surgical treatment of single level multi-focal subarticular and paracentral and/or far-lateral lumbar disc herniations: the single incision full endoscopic approach

James J Yue et al. Int J Spine Surg. .

Abstract

Background: Surgery for same level multi-focal extruded lumbar disc herniations is technically challenging and the optimal method controversial. The subarticular disc herniation may pose the most challenging subtype requiring partial or complete facetectomy with or without fusion. The far-lateral disc herniation, often treated using a Wiltse approach, can also be difficult to access especially in the obese patient. When both the subarticular and far-lateral subtypes are simultaneously present at the same level with or without a paracentral disc herniation, a total facetectomy and interbody fusion (TLIF) or a total disc replacement (TDR) may be necessary. Endoscopic surgical techniques may reduce the need for these more invasive methods.

Methods: Fifteen patients (6 male and 9 female) who had same level multi-focal (subarticular as well as far-lateral and/or paracentral) extruded disc herniations underwent single incision unilateral endoscopic disc excision by the same surgeon at a single institution. Patients were prospectively followed for an average of 15.3 months (range 14-18 months) and outcomes were evaluated radiographically and clinically (Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI).

Results: The mean operative time was 52 minutes with minimal blood loss in all cases. Fourteen of the 15 patients were discharged to home on the day of their surgery. The mean ODI and leg VAS scores improved from 22.9 ± 3.2 to 12.9 ± 2.7 (p < 0.005), and from 8.6 ± 1.6 to 2.1 + 0.4 (p < 0.005), respectively.

Conclusions: After an average of 15.3 months of follow-up, the clinical and radiographic results of full endoscopic surgical treatment of single level multi-focal (subarticular as well as far-lateral and/or paracentral) disc herniations are excellent. This study is a case series with mid-term follow-up (Level IV).

Clinical relevance: Foraminal and extra-foraminal full endoscopic decompression appears to offer a safe minimally invasive solution to a complex pathologic problem.

Keywords: Disc Herniation; Endoscopic Spine Surgery; Far-lateral; Lumbar; Paracentral; Subarticular.

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Figures

Fig. 1
Fig. 1
Intra-foraminal needle starting point just anterior to the posterior facet line.
Fig. 2
Fig. 2
A: Sagittal MRI (the red arrow identifies the foraminal herniated nucleus pulposus (HNP)). B: Sub-articular (SA) and far-lateral (FL) disc herniations.
Fig. 3
Fig. 3
A: Left L3 nerve root (NR) with far lateral herniated nucleus pulposus (HNP) medial to the nerve. B: L3 nerve root (NR) partially decompressed. HNP (herniated nucleus pulposus). C: L3 nerve root decompressed. Kambin (K) triangle visualized. D: Normal full left hip extension 10 days post-operative.
Fig. 4
Fig. 4
A, B: Subarticular (SA) and paracentral (PC) herniated nucleus pulposus (HNP). C: Extruded disc (HNP) surrounding nerve root (NR). D: Post-discectomy, decompressed nerve root (NR) surrounded by epidural fat.
Fig. 5
Fig. 5
A, B: Post-operative MRI 5 months after discectomy.
Fig. 6
Fig. 6
A, B: Preoperative MRI demonstrating L4-5 foraminal/subarticular herniated nucleus pulposus (HNP) and far-lateral HNP. Nerve root (NR) compression demonstrated.
Fig. 7
Fig. 7
Pre-operative back showing two previous surgical incisions.
Fig. 8
Fig. 8
Intradiscal starting (INTRA) line more medial and extra discal / intra foraminal (EXTRA) starting line more lateral. Dark line is posterior facet line (PFL).
Fig. 9
Fig. 9
A: Subarticular herniated nucleus pulposus (HNP).B: L3 nerve root.
Fig. 10
Fig. 10
Postoperative incision (9 mm).
Fig. 11
Fig. 11
A, B: MRI of uni-focal herniated nucleus pulposus (HNP).
See this image and copyright information in PMC

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