Dott. Nicola Zullo

UF Neurochirurgia

Clinica Eporediese Policlinico di Monza

Responsabile: Dott. C. Musso

Extreme lateral disc herniation causing lumbar and radicular

pain: surgical management

IV Italian XLIF Consensus Meeting13-14 September 2013

Santa Vittoria (Cn)

• Herniated disc lateral to a line drawn between two adiacent pedicles

• Herniation located at the outer upper corner of the intervertebral disk

• Usually extends from the foramen laterally

• Completely free or contained within a minimal covering of the anulus

• Unusual: 10-12% of disk herniations

• Most common in L4-L5 and in L3-L4

• Usually compress the root exiting around the pedicle, causing painful ganglion irritation

Far Lateral disc herniation: definition

• Midline with medial facetectomy

• Midline with total facetectomy

• Paramedian/intertransverse process

• Endoscopic diskectomy

• Retroperitoneal diskectomy

• Controlateral approach to intraforaminal disk herniation (Berra et al. Spine Volume 25, Number 6, pp 709-713, 2010)

Far Lateral disc herniation: surgical approaches

Surgical approaches to far lateral HNP

Controlateral approache

Extra-articular intertransverse

Median approache

• In most articles far lateral and extreme lateral disc herniation are synonymous

• Clinical presentation, diagnosis, surgical treatments are the same previously reported

• Only one article by Madhok and Kanter describes a minimally invasive extreme lateral trans psoas approach in two cases of far lateral LDH

• Dezawa et al. described a retroperitoneal laparoscopic lateral approach for far lateral disc herniation at L5-S1 or L1-L2 levels

Extreme lateral disc herniation: review of the Literature

M.P. female, 43 YO, no previous history of back or radicular pain

In November 2012 the patient lifted a load; one month later sudden onset of mild lumbar back pain and severe radicular pain descending on the antero-medial aspect of left thigh and leg, not responsive to drugs and physical therapy

MRI: no intracanalicular, intra or extra-foraminal DH at L1-S1 levels; L2-L3 right lateral disc prolapse; no evidence of lesions of lumbar nerve roots

TC: confirmed the L2-L3 right disc prolapse extending between the muscular fibers of psoas muscle

Case Report

• Disc herniation removed via extreme lateral trans psoas approach

• Minimal blo0d loss

• Short operative time (about an hour)

• Interbody fusion with Co-Roent XL 22x50x10 mm minimize the risk of recurrency

• No disruption or removal of bone structures

• For a pure lateral disc herniation, traditional postero-lateral approaches to intra-extraforaminal disc prolapses are not helpful

Surgical Management

• Clinical evaluation + LS X-Ray one month later, VAS Back/Leg and ODI questionnaire + Lumbo-Sacral X-Ray at three months

• Clinical evaluation one month later: improvement of the left inferior limb pain, no back pain

• LS X-Ray at three months: no subsidence, no evidence of fusion.

Follow Up

ODI VAS B VAS L0

10

20

30

40

50

60

70

80

PrePost

• X-Lif approach can be an option for the treatment of far lateral and extreme lateral disc herniations

• In far lateral disc herniation help to avoid bone removal and articular disruption (Madhok and Kanter)

• In extreme lateral disc herniation retroperitoneal access is mandatory, because the lateral aspect of the disc lie below the transverse processes; minimally invasive trans psoas approach with MaXcess retractor is a good option: fast, safe, minimal blood loss, well known by Orthopedic and Neurosurgeons

CONCLUSION

Thank You