Extreme Lateral Disc Herniation Causing Lumbar And Radicular Pain

1. 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 Meeting
13-14 September 2013
SantaVittoria (Cn)

2. • 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

3. • Midline with medial facetectomy
• Midline with total facetectomy
• Paramedian/intertransverse process
• Endoscopic diskectomy
• Retroperitoneal diskectomy
• Controlateral approach to intraforaminal disk herniation (Berra et
al. SpineVolume 25, Number 6, pp 709-713, 2010)
Far Lateral disc herniation: surgical
approaches

4. Surgical approaches to far lateral HNP
Controlateral approache Extra-articular
intertransverse
Median approache

5. • 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

6. M.P. female, 43YO, 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

7. • 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

8. • 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
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ODI VAS B VAS L
Pre
Post

9. • 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