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Dott. Nicola Zullo
UF Neurochirurgia
Clinica Eporediese Policlinico di Monza
Responsabile: Dott. C. Musso
Extreme lateral ...
• Herniated disc lateral to a line drawn between two adiacent
pedicles
• Herniation located at the outer upper corner of t...
• Midline with medial facetectomy
• Midline with total facetectomy
• Paramedian/intertransverse process
• Endoscopic diske...
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, surg...
M.P. female, 43YO, no previous history of back or radicular pain
In November 2012 the patient lifted a load; one month lat...
• Disc herniation removed via extreme lateral trans psoas approach
• Minimal blo0d loss
• Short operative time (about an h...
• Clinical evaluation + LS X-Ray one month later, VAS Back/Leg and ODI
questionnaire + Lumbo-Sacral X-Ray at three months
...
• X-Lif approach can be an option for the treatment of far lateral and
extreme lateral disc herniations
• In far lateral d...
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Extreme Lateral Disc Herniation Causing Lumbar And Radicular Pain

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Extreme Lateral Disc Herniation Causing Lumbar And Radicular Pain

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Extreme Lateral Disc Herniation Causing Lumbar And Radicular Pain

  1. 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. 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. 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. 4. Surgical approaches to far lateral HNP Controlateral approache Extra-articular intertransverse Median approache
  5. 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. 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. 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. 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 0 10 20 30 40 50 60 70 80 ODI VAS B VAS L Pre Post
  9. 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

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