A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results

Direct Tubular Lumbar Microdiscectomy for Far Lateral Disc Herniation: A Modified Approach

“…The results of our study confirm previous data that microscopic tubular discectomy is highly effective in improving sciatic pain secondary to far lateral lumbar disc herniation. Our caudal approach offers a safe alternative to the standard pars–transverse process approach.…”

“…However, one important trade off of such a minimally invasive approach is that it is not possible to achieve the panoramic survey of the entire intertransverse region that is generally afforded by an open approach. Thus, various authors have advocated a strategy for facilitating early exposure of the exiting nerve root by targeting the transverse process–pars junction where the exiting nerve root courses just lateral and deep to the lateral margin of the pars. Our study has shown that modifying this approach by targeting the facet joint and inferior transverse process is technically feasible and effective.…”

“…Pioneered by Foley and colleagues in the 1990s, the approach is based on the tenet of highly selective targeting and minimization of collateral tissue trauma by using tubular retractors, generally less than 20 mm in diameter, together with specialized long, tapered instruments to facilitate operating through a long narrow channel. These techniques were originally designed for endoscopic surgery; however, the added infrastructure cost, disadvantages of monoscopic vision, wide availability of operating microscopes and their familiarity to most surgeons have prompted modifications in favor of microscopes. In particular, the tubular approach offers clear advantages in treatment of far lateral disc herniation through the paraspinal corridor, enabling minimization of soft tissue trauma compared with a conventional open approach.…”

“…The techniques for performing minimally invasive tubular surgery for far lateral disc herniation have been described by several authors. Despite variations in their techniques, one principle that underscores all of them is early identification of the nerve root by adopting a cranial trajectory to expose the superior aspect of the intertransverse space rather than targeting the disc space caudally (Fig.…”

“…A). Tissue dissection is advanced to define the pars, superior transverse process and exiting nerve root at the pars–transverse process junction ventral to the intertransverse ligament. The herniated disc or osteophytes caudal to the exposed nerve root is then identified at the edge of the surgical field by mobilizing and retracting the nerve root cephalad (Fig.…”