The Far Lateral Approach to Lumbar Disc Herniations
The diagnosis of extreme lateral lumbar disc herniation (ELLDH) as a cause of lumbar radiculopathy was first described by Abdullah in 1974 [1 ]. This discal pathology has been recognized for many years as an occasional cause of negative disc exploration a
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Contents Introduction Clinical Presentation Anatomical Review Paravertebral Muscles and Fasciae The Lumbar Arteries and Veins Lumbar Spinal Nerves and Their Relationship to the LIPC Indication for Operative Treatment Preoperative Evaluation Surgical Technique Selection of Approach Positioning Prophylaxis of Infection Operative Technique of Transmuscular Approach Operative Technique of Paramuscular Approach Ten Steps of the Transmuscular Approach Discussion Outcome Acknowledgement References
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Introduction The diagnosis of extreme lateral lumbar disc herniation (ELLDH) as a cause oflumbar radiculopathy was first described by Abdullah in 1974 [1]. This discal pathology has been recognized for many years as an occasional cause of negative disc exploration and immediate failure of classical disc surgery in sciatica [I, 18, 24, 25, 29, 31, 30, 31, 33, 35,41]. Only since the introduction of computed tomography (CT) for the diagnosis of lumbar disc disease have the characteristics of ELLDH become fully appreciated F. Cohadon et al. (eds .), Advances and Technical Standards in Neurosurgery [3,6, 13, 17,23,30,32,47]. Myelography alone was an insufficient diagnos© Springer-Verlag/Wien 1997
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tic tool to detect this specific pathology. With the rapid development of neuroradiologic diagnostic imaging, including magnetic resonance imaging (MRI) [13, 32], recognition of this particular type of lumbar disc disease has increased its incidence, ranging from 0.7% to 11.7% of the total operated herniated discs [1, 22, 24, 45]. In a recent review of our series of patients with lumbar disc disease we found an overall incidence of ELLDH of 5.8% over a period of 8 years [38]. 78% of all ELLDH occured at the L4-L5 and L5-S1 levels, with an almost equal frequency, but the overall incidence of ELLDH per level varied relative to the level of the pathological disc. Parallel with the improvement in neuroradiological imaging, the surgical techniques were modified with a particular interest in microsurgery [10, 28, 42, 46, 50]. The advantage of microdissection is brilliant coaxial illumination, together with the high magnification it affords, allowing meticulous preparation in the depth with minimal retraction. Using the microscope, the approach to ELLDH was restudied [11, 12, 14, 16,21,27,43]. In the past, ELLDH were usually reached in the course of an extended interlaminar approach, including total removal of the facet joint [1, 2, 22, 24, 29, 35, 39, 41]. There is justified concern about the removal of a potentially important structure, although single facetectomy does not necessarily lead to gmss radiological instability. The enlarged interlaminar approach with medial removal and undermining of the facet joint remains a satisfactory technique to handle some of the far lateral lumbar disc herniations. ELLDH however protrude or extrude in a lateral and cranial direction and come to lie underneath the dorsal root ganglion or even between the up
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