LATERAL MICROSURGICAL APPROACH PERFORMED WITH MEDIAN INCISION WITHOUT OPENING INTERTRANSVERSE FASCIA FOR PATIENTS WITH L5-S1 FAR LATERAL DISC HERNIATION: A RETROSPECTIVE EVALUATION OF 12 PATIENTS

Öz

Objective: HL5-S1 far lateral lumbar disc herniations (FLLDH) are extremely rare disc pathologies and herniated disc is located on the lateral side of the pedicle. The aim of this study is to evaluate 12 patients suffering from L5-S1 FLLDH who were operated on using/via the lateral interpedicular microsurgical approach and to discuss in the context of the current literature. Material and Methods: 12 patients (5 male and 7 females) with L5-S1 FLLDH partcicpated/participated in this study. All patients were operated on between the year 2015 and 2017 at the same medical center using the lateral interpedicular microsurgical approach. After the midline skin incision, thoracolumbar fascia was opened at the side of the herniation, a subperiosteal dissection of paravertebral muscles was carried out and Taylor retractors were placed. Subsequently, minimal amounts of bone were removed from the fascet joints and pars interarticularis, the exiting nerve root was explored at the lateral of the pars interarticularis and a microsurgical removal of herniation was performed. Results: The mean visual analog scores (VAS) decreased from 9.25±0.75 to 0.76±0.75 postoperatively and the difference between the preoperative and postoperative VAS scores was statistically significant (p=0.0001). 6 months after surgery 5 patients were graded as excellent (41.7%), 6 patients were good (50%) and 1 patient was fair (8.3%) according to the MacNab classification. Conclusion: The lateral interpedicular microsurgical approach with median incision without opening intertransverse fascia is a safe, easy and minimally invasive technique for the surgical treatment of L5-S1 FLLDH. 

Anahtar Kelimeler

• L5-S1 far lateral,Microsurgical approach,Minimally invasive

L5-S1 FAR LATERAL DİSK HERNİASYONLU HASTALAR İÇİN İNTERTRANSVERS FASYA AÇILMADAN MEDİAN İNSİZYON İLE GERÇEKLEŞTİRİLEN LATERAL MİKROŞİRÜRJİKAL YAKLAŞIM: 12 HASTANIN RETROSPEKTİF DEĞERLENDİRİLMESİ

Öz

Amaç: L5-S1 far lateral lumbar disk herniasyonları (FLLDH) nadir görülen disk patolojileridir. FLLDH’nda disk materyali pedikülün lateralindedir. Bu çalışmanın amacı; lateral interpediküler mikroşirürjikal yaklaşımla opere edilen L5-S1 FLLDH’lu 12 hastanın retrospektif olarak değerlendirilip güncel literatür eşliğinde tartışılmasıdır. Gereç ve Yöntem: Çalışmamıza L5-S1 far lateral alana ve foramene uzanım gösteren, radikülopatiye neden olan ekstrüde veya sekestre disk herniasyonları dahil edilmiştir. Orta hat cilt insizyonu ile torakolomber fasyanın orta hattan açılması, paravertebral adelelerin subperiostal sıyrılarak pars lateralinde exiting kökün açığa konulması, far lateral kompartımanda sekestre veya ekstrüde disk fragmanlarının alınması hedeflenmiştir. Bulgular: Ameliyat öncesi VAS değeri 9,25±0,75’lerden 0,76±0,75 değerlerine geriledi. Ameliyat öncesi ve sonrası VAS skor ortalamaları birbirinden anlamlı derecede farklıydı (p=0,0001). MacNab sınıflamasına göre 6 ay sonraki postoperatif sonuçlar; 5 hasta mükemmel (%41,7), 6 hasta iyi (%50) ve 1 hasta orta derecede memnun (%8,3) şeklindeydi. Sonuç: İntertransvers fasya açılmadan median insizyon ile yapılan lateral interpediküler mikroşirürjikal yaklaşım, L5-S1 FLLDH’nın cerrahi tedavisi için uygulanabilirliği kolay, operasyon süresi kısa, komplikasyon oranı düşük, güvenli minimal invazif bir yöntemdir.

Anahtar Kelimeler

• L5-S1 far lateral,Lateral mikroşirürjikal yaklaşım,Lomber disk herniasyonu

Kaynakça

1. 1. Abdullah A, Ditto III EW, Byrd EB, Williams R. Extremelateral lumbar disc herniations: clinical syndrome and special problems of diagnosis. Journal of Neurosurgery 1974;41:229-34.
2. 2. Kotil K, Akcetin M, Bilge T. A minimally invasive transmuscular approach to far-lateral L5-S1 level disc herniations: a prospective study. J Spinal Disord Tech 2007;20:132-8.
3. 3. MacNab I. Negative disc exploration: an analysis of the cause of nerve root involvement in sixty-eight patients. J Bone Jt Surg (Am) 1971;53:891-3.
4. 4. Epstein NE. Foraminal and far lateral lumbar disc herniations: surgical alternatives and outcome measures. Spinal Cord 2002;40:491-500.
5. 5. Tessitore E, de Tribolet N. Far-lateral lumbar disc herniation: the microsurgical transmuscular approach. Neurosurgery 2004;54:939-42.
6. 6. O’Toole JE, Eichholz KM, Fessler RG. Minimally invasive far lateral microendoscopic discectomy for extraforaminal disc herniation at the lumbosacral junction: cadaveric dissection and technical case report. Spine J 2007;7:414-21.
7. 7. Haher TR, O’brien M, Dryer JW, Nucci R, Zipnick R, and Leone DJ. The role of the lumbar facet joints in spinal stability: identifcation of alternative paths of loading. Spine 1994;19: 2667-71.
8. 8. Marquardt G, Bruder M, Theuss S, Setzer M, Seifert V. Ultralong-term outcome of surgically treated far-lateral, extraforaminal lumbar disc herniations: a single-center series. Eur Spine J 2012;21:660-5.

9. 9. Epstein NE. Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg 1995;83:648-56.
10. 10. Reulen HJ, Müller A, Ebeling U. Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations. Neurosurgery 1996;39:345-51.
11. 11. Melvill RL, Baxter BL. The intertransverse approach to extraforaminal disc protrusion in the lumbar spine. Spine 1994;19:2707-14.
12. 12. Jang JS, An SH, Lee SH. Clinical analysis of extraforaminalentrapment of L5 in the lumbosacral spine. J Korean Neurosurg Soc 2004;36:383-7.
13. 13. Nathan H, Weizenbluth M, Halperin N. The lumbosacral ligament (LSL), with special emphasis on the “lumbosacral tunnel” and the entrapment of the 5th lumbar nerve. Int Orthop 1982;6:197-202.
14. 14. Pirris SM, Dhall S, Mummaneni PV, and Kanter AS. Minimally invasive approach to extraforaminal disc herniations at the lumbosacral junction using an operating microscope: case series and review of the literatüre. Neurosurgical Focus 2008;25(2):E10.
15. 15. Lee S, Kang JH, SriKantha U, Jang İT, and Oh SH. Extraforaminal compression of the L-5 nerve root at the lumbosacral junction: clinical analysis, decompression technique, and outcome. J Neurosurg Spine 2014;20:371-9.
16. 16. Foley KT, Smith MM, Rampersaud YR. Microendoscopic approach to far-lateral lumbar disc herniation. Neurosurg Focus 1999;7(5):E5.
17. 17. Cervellini P, De Luca GP, Mazzetto M, Colombo F. Microendoscopic-discectomy (MED) for far lateral disc herniation in the lumbar spine. Technical note. Acta Neurochir Suppl 2005;92:99-10.
18. 18. Greiner-Perth R, Böhm H, Allam Y. A new technique fort he treatment of lumbar far lateral disc herniation: technical note and preliminary results. Eur Spine J 2003;12(3):320-4.
19. 19. Tun K, Cemil B, Göker T, Eylen O, Korkmaz M, Kaptanoğlu E. Uzak Lateral Disk Hernilerinde Ekstraforaminal Yaklaşım. Türk Nöroşirürji Dergisi 2010;20(3):111-6.
20. 20. Fairbanks JE, Couper JC, Davies JB, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980; 66:271-3.
21. 21. Yeom JS, Kim KH, Hong SW, Park KW, Chang BS, Lee CK, Buchowski JM. A minimally invasive technique for L5-S1 intraforaminal disc herniations: microdiscectomy with a tubular retractor via a contralateral approach. J Neurosurg Spine 2008;8(2):193-8.
22. 22. Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976) 200;27(7):722-31.
23. 23. Müller A, Reulen HJ. A paramedian tangential approach to lumbosacral extraforaminal disc herniations. Neurosurgery. 1998;43(4):854-61.
24. 24. Kambin P, O’Brien E, Zhou L, Schaffer JL. Arthroscopic microdiscectomy and selective fragmentectomy. Clin Orthop Relat Res 1998;(347):150-67.
25. 25. Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine. Spine (Phila Pa 1976). 1988;13(6):696-706.
26. 26. Kunogi J, Hasue M. Diagnosis and operative treatment of intraforaminal and extraforaminal nerve root compression. Spine (Phila Pa 1976) 1991;16(11):1312-20.
27. 27. Macnab I, Cuthbertc H, Godfrey CM. The Incidence of Denervation of the Sacrospinales Muscles Following Spinal Surgery. Spine 1977;2(4):294-8.
28. 28. O’Hara LJ, Marshall RW. Far lateral lumbar disc herniation. The key to the intertransverse approach. J Bone Joint Surg Br 1997;79:943-7.
29. 29. Schlesinger SM, Fankhauser H, de Tribolet N. Microsurgical anatomy and operative technique for extreme lateral lumbar disc herniations. Acta Neurochir (Wien) 1992;118:117-29.
30. 30. Ryang YM, Rohde I, Ince A, Oertel MF, Gilsbach JM, Rohde V. Lateral transmuscular or combined interlaminar/ paraisthmic approach to lateral lumbar disc herniation? A comparative clinical series of 48 patients. J Neurol Neurosurg Pyschiatry 2005;76:971-6.