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| Procedures: Lumbar Spine Microsurgery |
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| In addition, surgeons discovered
that precision was tied to magnification and illumination. A magnified structure
could be appreciated with a different perspective than the image on the
naked eye. The gross movements supervised by distant vision (naked eye)
succumbed to the accuracy of micro-instruments rolled by finger tips. As
recovery times quickened under the influence of greater preservation of
normal anatomy, and smaller surgical windows, the concept of rehabilitation
beginning with the operation rather than some distant concept which surgeons
expressed but did not understand, established a principle: the first step
in rehabilitation is surgery. Indications Lumbar microsurgery is indicated for the herniated lumbar disc and in selected cases of spinal stenosis. The common symptoms forming a criteria for microsurgery in association with a disc herniation are: leg pain, leg numbness, leg weakness and bowel and bladder symptoms. Technical Considerations The key technical consideration is adequate exposure to identify the area of spinal nerve compression. Literature Review Featured Review Findlay and his associates reviewed a group of patients who had lumbar microsurgery for herniated disc 10 years after the original operation. Was the original successful outcome of surgery maintained over the ten year period of time. In this series, the initial outcome at 6 months after surgery was 91% successful. At 10 years, the results were 83% successful, although this minimal decline was not consdiered statistically significant. There was a high patient satisfaction rate with lumbar microdiscectomy. (reference #4)Kotilainen and his associates reviewed 237 patients who had a micosurgical lumbar discectomy for lumbar disc herniation. The median follow-up time was 2 years for this group of patients. Results were tied to the intra-operative anatomy of the herniation and duration of preoperative leg pain. |
| Intra-Operative Anatomy | Return to Work | |
| protrusion | 68% | |
| sequestrum | 76% | |
| prolapse | 85% | |
| Duration of Preoperative Leg Pain | Return to Work | |
| mean duration = 3.8 months | Yes | |
| mean duration = 6.3 months | No |
| Overall, 92% sciatic pain was
relieved or "markedly diminished" and 79% had returned to work.
"Surgical complications were infreuent in this study." (reference
#21) Nygaard and his associates reviewed 132 consecutive patients undergoing surgery for lumbar disc herniation to analyze the factors separating those patients with relief of leg pain and those patients who had residual leg pain. The patients were analyzed at 1 year after their surgery. Patients having surgery who have had leg pain for 8 months or greater had poorer results than those patients with leg pain for less than 8 months prior to surgery. (reference #1) Complications Complications of lumbar microsurgery for herniated lumbar disc include the following: death, paralysis, nerve root injury, spinal fluid leak, spinal instability, recurrence of herniation, wound problems, infection, failure to improve. Author’s Comment I have chosen these featured references to illustrate the following points: the results of surgery are tied to the duration of mechanical pressure on the spinal nerve and the type of biology of the herniation. The space available for the spinal nerve and the degree of compression of the spinal nerve are the biological factors influencing results. Surgery performed for spinal nerve compression due to lumbar herniated disc around the three month range is most successful. There are exceptions to every principle so careful review of individual circumstances is warranted. The degree of herniation and pressure determined in surgery correlates with results. An MRI scan measurement of herniation is not a predictor of results compared to the intra-opertive findings. Large disc herniations (extruded or sequestered) do better than marginal disc protursions in general. There are exceptions to this concept because a small disc protrusion in conjunction with narrowing of the bony space (spinal stenosis) for the spinal nerve may exert the same degree of pressure on the spinal nerve as the larger herniation. References 1: Nygaard OP, Kloster R, Solberg T. Duration of leg pain as a predictor of outcome after surgery for lumbar disc herniation: a prospective cohort study with 1-year follow up. J Neurosurg. 2000 Apr;92(2 Suppl):131-4. 2: Kotilainen E. Long-term outcome of patients suffering from clinical instability aftermicrosurgical treatment of lumbar disc herniation. Acta Neurochir (Wien). 1998;140(2):120-5. 3: Lavyne MH. Pars interarticularis fenestration in the treatment of foraminal disc herniation: a further surgical approach. Neurosurgery. 1999 Jan;44(1):234. 4: Findlay GF, Hall BI, Musa BS, Oliveira MD, Fear SC. A 10-year follow-up of the outcome of lumbar microdiscectomy. Spine. 1998 May 15;23(10):1168-71. 5: Postacchini F, Cinotti G, Gumina S.Microsurgical excision of lateral lumbar disc herniation through an interlaminar approach. J Bone Joint Surg Br. 1998 Mar;80(2):201-7. 6: Floris R, Spallone A, Aref TY, Rizzo A, Apruzzese A, Mulas M, Castriota Scanderbeg A, Simonetti G. Early postoperative MRI findings following surgery for herniated lumbar disc. Part II: A gadolinium-enhanced study. Acta Neurochir (Wien). 1997;139(12):1101-7. 7: Nygaard OP, Kloster R, Dullerud R, Jacobsen EA, Mellgren SI. No association between peridural scar and outcome after lumbar microdiscectomy. Acta Neurochir (Wien). 1997;139(12):1095-100. 8: Floris R, Spallone A, Aref TY, Rizzo A, Apruzzese A, Mulas M, Simonetti G. Early postoperative MRI findings following surgery for herniated lumbar disc. Acta Neurochir (Wien). 1997;139(3):169-75. 9: McCulloch JA.Focus issue on lumbar disc herniation: macro- and microdiscectomy. Spine. 1996 Dec 15;21(24 Suppl):45S-56S. Review. 10: Reulen HJ, Muller A, Ebeling U. Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations. Neurosurgery. 1996 Aug;39(2):345-50; discussion 350-1. 11: O'Brien MF, Peterson D, Crockard HA. A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation. J Neurosurg. 1995 Oct;83(4):636-40. 12: Kraemer J. Natural course and prognosis of intervertebral disc diseases. International Society for the Study of the Lumbar Spine Seattle, Washington, June 1994. Spine. 1995 Mar 15;20(6):635-9. Review. 13: Kramer J. A new classification of lumbar motion segments for microdiscotomy. Eur Spine J. 1995;4(6):327-34. 14: Faulhauer K, Manicke C. Fragment excision versus conventional disc removal in the microsurgical treatment of herniated lumbar disc. Acta Neurochir (Wien). 1995;133(3-4):107-11. 15: Kulali A, von Wild K. Microsurgical management of the lumbar intervertebral disc-disease. Neurosurg Rev. 1995;18(3):183-8. 16: Kramer J. Micro- or macrodiscotomy for open lumbar disc surgery? Eur Spine J. 1995;4(2):69-70. 17: Goffin J. Microdiscectomy for lumbar disc herniation. Clin Neurol Neurosurg. 1994 May;96(2):130-4. 18: Kotilainen E. Microinvasive lumbar disc surgery. A study on patients treated with microdiscectomy or percutaneous nucleotomy for disc herniation. Ann Chir Gynaecol Suppl. 1994;209:1-50. Review. 19: Wilkinson HA. Outcome analysis in 654 surgically treated lumbar disc herniations. Neurosurgery. 1993 May;32(5):879. No abstract available. 20: Baccarani G, Brunetti E, Meringolo R. Microsurgery in the treatment of crural and sciatic pain due to disc and bone compression: considerations on the first 100 cases. Chir Organi Mov. 1993 Apr-Jun;78(2):77-80. 21: Kotilainen E, Valtonen S, Carlson CA. Microsurgical treatment of lumbar disc herniation: follow-up of 237 patients. Acta Neurochir (Wien). 1993;120(3-4):143-9. 22: Tullberg T, Isacson J, Weidenhielm L. Does microscopic removal of lumbar disc herniation lead to better results than the standard procedure? Results of a one-year randomized study. Spine. 1993 Jan;18(1):24-7. 23: Frizzell RT, Hadley MN. Lumbar microdiscectomy with medial facetectomy. Techniques and analysis of results. Neurosurg Clin N Am. 1993 Jan;4(1):109-15. Review. 24: Williams RW. Lumbar disc disease. Microdiscectomy. Neurosurg Clin N Am. 1993 Jan;4(1):101-8. Review. 25: Kotilainen E, Valtonen S. Clinical instability of the lumbar spine after microdiscectomy. Acta Neurochir (Wien). 1993;125(1-4):120-6. 26: Pappas CT, Harrington T, Sonntag VK. Outcome analysis in 654 surgically treated lumbar disc herniations. Neurosurgery. 1992 Jun;30(6):862-6. 27: Schlesinger SM, Fankhauser H, de Tribolet N. Microsurgical anatomy and operative technique for extreme lateral lumbar disc herniations. Acta Neurochir (Wien). 1992;118(3-4):117-29. 28: Findlay GF. Minimally invasive lumbar disc surgery. Br J Neurosurg. 1992;6(5):405-8. No abstract available. 29: Postacchini F, Cinotti G, Perugia D. Microdiscectomy in treatment of herniated lumbar disc. Ital J Orthop Traumatol. 1992;18(1):5-16. 30: Caspar W, Campbell B, Barbier DD, Kretschmmer R, Gotfried Y. The Caspar microsurgical discectomy and comparison with a conventional standard lumbar disc procedure. Neurosurgery. 1991 Jan;28(1):78-86; discussion 86-7. 31: Striffeler H, Groger U, Reulen HJ. "Standard" microsurgical lumbar discectomy vs. "conservative" microsurgical discectomy. A preliminary study. Acta Neurochir (Wien). 1991;112(1-2):62-4. 32: Griffith HB, Mathew BG.Microdiscectomy. Br J Hosp Med. 1990 Dec;44(6):410-2. 33: Barrios C, Ahmed M, Arrotegui J, Bjornsson A, Gillstrom P. Microsurgery versus standard removal of the herniated lumbar disc. A 3-yearcomparison in 150 cases. Acta Orthop Scand. 1990 Oct;61(5):399-403. 34: Andrews DW, Lavyne MH. Retrospective analysis of microsurgical and standard lumbar discectomy. Spine. 1990 Apr;15(4):329-35. 35: Maroon JC, Kopitnik TA, Schulhof LA, Abla A, Wilberger JE. Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg. 1990 Mar;72(3):378-82. 36: Evans G, Jackson RK. Microdiscectomy for treating lumbar disc protrusion. BMJ. 1988 Jul 2;297(6640):5. No abstract available. 37: Silvers HR. Microsurgical versus standard lumbar discectomy. Neurosurgery. 1988 May;22(5):837-41. 38: Watters WC 3rd, Mirkovic S, Boss J. Treatment of the isolated lumbar intervertebral disc herniation: microdiscectomy versus chemonucleolysis. Spine. 1988 Mar;13(3):360-2. 39: Rogers LA. Experience with limited versus extensive disc removal in patients undergoing microsurgical operations for ruptured lumbar discs. Neurosurgery. 1988 Jan;22(1 Pt 1):82-5. 40: Ferrer E, Garcia-Bach M, Lopez L, Isamat F. Lumbar microdiscectomy: analysis of 100 consecutive cases. Its pitfalls and final results. Acta Neurochir Suppl (Wien). 1988;43:39-43. 41: Leung PC. Complications in the first 40 cases of microdiscectomy. J Spinal Disord. 1988;1(4):306-10. 42: Thomas AM, Afshar F. The microsurgical treatment of lumbar disc protrusion. Follow-up of 60 cases. J Bone Joint Surg Br. 1987 Nov;69(5):696-8. 43: Zeiger HE Jr. Comparison of chemonucleolysis and microsurgical discectomy for the treatment of herniated lumbar disc. Spine. 1987 Oct;12(8):796-9. 44: Nystrom B. Experience of microsurgical compared with conventional technique in lumbar disc operations. Acta Neurol Scand. 1987 Aug;76(2):129-41. 45: Ebeling U, Reichenberg W, Reulen HJ. Results of microsurgical lumbar discectomy. Review on 485 patients. Acta Neurochir (Wien). 1986;81(1-2):45-52. 46: Sachdev VP. Microsurgical lumbar discectomy: a personal series of 300 patients with at least 1 year of follow-up. Microsurgery. 1986;7(2):55-62. 47: Merli GA, Angiari P, Tonelli L. Three years experience with microsurgical technique in treatment of protruded lumbar disc. J Neurosurg Sci. 1984 Jan-Mar;28(1):25-31. 48: Wilson DH, Harbaugh R. Microsurgical and standard removal of the protruded lumbar disc: a comparative study. Neurosurgery. 1981 Apr;8(4):422-7. |
