Current and Future Approaches to Lumbar Disc Surgery (A Literature Review)

, and , Emory University School of Medicine, Atlanta, Ga.

Disclosures

Medscape General Medicine. 1997;1(2) 

In This Article

Laparoscopic Discectomy

Indications. Obenchain and Cloyd[27] reported on the relatively new technique of laparoscopic discectomy first performed on a patient in 1991.[28] Indications for this procedure include leg pain more severe than back pain, radicular signs and symptoms, and 6 weeks of failed conservative therapy. Pathology consistent with the patient's symptoms should be confirmed with MRI. Unlike the other approaches to lumbar disc surgery, extruded, and even some migrated fragments can be treated with this approach. This technique is contraindicated for fragments migrated completely below the level of the disc space.

Surgical techniques. There are two approaches to laparoscopic discectomy: transperitoneal and retroperitoneal.

A. Transperitoneal laparoscopy. The patient is placed in the supine position under general anesthesia and the abdomen is insufflated to 16 mm via an umbilical port. Three to four additional ports are positioned and the patient placed in Trendelenburg to minimize the need for retraction of the small bowel. For herniations at L5-S1, the working port is placed just above the pubic symphysis in the midline. The parietal peritoneum is opened to 1 cm between the common iliac vessels. Autonomic nerves traversing the annulus can be visualized and avoided. The working port for disc levels above the L5-S1 interspace is 4 to 5 cm below and to the left of the umbilicus. The disc is approached left of the iliac vessels (or aorta) and medial to the inner aspect of the psoas, for both left- and right-sided herniations.

B. Retroperitoneal laparoscopy. This approach to laparoscopic discectomy can be performed in a lateral decubitus position with either local anesthesia with sedation or general anesthesia. Entry into the retroperitoneal space is accomplished with the use of a trocar or by incising the individual muscle layers. With endoscopy, the "receding line of the peritoneum can be observed moving medially across the psoas muscle and into the adventitial tissue surrounding the great vessels," while a balloon is inflated.[27] The balloon is deflated and replaced with a trocar. Insufflation is continued and two more ports for dissecting tools are inserted into the flank. The annulus medial to the psoas muscle is exposed and impaled (under fluoroscopy and endoscopy) with a trephine placed through the initial abdominal entry site.

The instruments (curettes, rongeurs, automatic shavers) are inserted and the disc removed under endoscopic visualization in both approaches until the defect in the PLL is seen. Extruded disc material is retrieved through the PLL defect. At the end of the procedure the abdomen is desufflated, fascial sutures are placed at the site of the working port, and the patient awakened from anesthesia. The patient is discharged home three hours later.

Results. Obenchain and Cloyd[27] performed laparoscopic discectomy in 29 patients, 7 of whom had extruded discs. Follow-up was 12 to 52 months with a mean of 35.8 months. Pain relief was judged to be excellent in 17 patients, good in 3 patients, fair in 2 patients, and poor in 7 patients. Six patients had early recurrence of leg pain and required re-operation. Sixteen of 28 patients were unable to work postoperatively at a mean of 3.5 weeks.

Complications. For the 29 patients that underwent laparoscopic discectomy, entry into the disc space could not be performed in one case because of obesity. A hernia which required repair was seen at the trocar site in a second patient, and two cases of discitis were also observed.

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