Trans-Tubular Translaminar Microscopic-Assisted Nucleotomy for Lumbar Disc Herniations in the Hidden Zone

Abstract

Study Design: A prospective cohort study in a high-flow spine center in Germany. Objectives: This study aimed to evaluate clinical outcomes and complications of the trans-tubular translaminar microscopic-assisted percutaneous nucleotomy in cases of cranially migrated lumbar disc herniations (LDH). Methods: Between January 2013 and January 2018, 66 consecutive patients with cranio-laterally migrated LDH were operated upon. The following outcome measures were evaluated: (1) Visual Analog Scale (VAS) for leg and back pain; (2) Oswestry Disability Index (ODI) and Macnab´s criteria. All patients were operated upon with trans-tubular Translaminar Microscopic-assisted Percutaneous Nucleotomy (TL-MAPN). Perioperative radiographic and clinical evaluations were reported. The mean follow-up period was 32 months. Results: The mean age was 59 years. L4/L5 was the commonest affected level (27 patients). The mean preoperative VAS for leg pain was 6.44 (±2.06), improved to 0,35 (±0.59) postoperatively. Dural injury occurred in 1 patient, treated with dural patch. Improved neurological function was reported in 41/44 Patients (neurological improvement rate of 93%) at the final follow up. There was a significant improvement in the mean ODI values, from 50.19 ± 4.92 preoperatively to 10.14 ± 2.22 postoperatively (P < 0.001). Sixty four out of 66 patients (96%) showed an excellent or good functional outcome according to Macnab´s criteria. No recurrent herniations were observed. Conclusion: The translaminar approach is a viable minimal invasive technique for cranially migrated LDH. The preservation of the flavum ligament is one of the main advantages of this technique. It is an effective, safe and reproducible minimally invasive surgical alternative in treatment of cranially migrated LDHs.

Translaminar Fully Endoscopic Discectomy for Lumbar Foraminal Disc Herniation: A Technical Note

“…The TLA was developed to approach the hidden zone directly from above by creating a window in the isthmus part of the lamina. Many reports exist using the transpars approach using the open technique by Di Lorenzo et al [4] in 1998, as well as reports utilizing the caspase retractor, tubular retractor under the microscope, and endoscopic techniques [5,11]. Currently, an 8-mm full-endoscopic surgery is considered the least invasive technique [12][13][14][15][16].…”

“…Foraminal LDH are located ventral to the facet joints, making them difficult to approach using a normal posterior approach while preserving the facet joints, possibly resulting in postoperative instability. Although various modifications of standard open and microsurgical techniques have been described for foraminal LDH [1,2,4,5], endoscopically approaching the fo-foraminal stenosis, is particularly effective for foraminal LDH protruding from the medial part of the foramen at the L5/S1 level [6][7][8]. Because the transverse diameter of the L5/S1 foramen is anatomically long, it is relatively difficult.…”