O'Toole John E, Eichholz Kurt M, Fessler Richard G
Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison Street, Chicago, IL 60612, USA.
Spine J. 2007 Jul-Aug;7(4):414-21. doi: 10.1016/j.spinee.2006.07.008. Epub 2007 Jan 30.
Extraforaminal lumbar disc herniations (ELDHs) at the lumbosacral junction are an uncommon cause of L5 radiculopathy. The surgical anatomy of the extraforaminal space at L5-S1 is uniquely challenging for the various open surgical approaches that have been described for ELDHs in general. Reports specifically describing minimally invasive surgical approaches to lumbosacral ELDHs are lacking.
To report the novel use of a far lateral microendoscopic (FLMED) approach to lumbosacral ELDH. To better define the unique anatomical features of extraforaminal approaches to the lumbosacral junction as they apply to minimal access techniques.
STUDY DESIGN/SETTING: A cadaveric investigation and clinical case were performed at a single institution. A thorough review of the literature was conducted.
A single patient with an extraforaminal disc herniation at the lumbosacral junction underwent evaluation and surgery.
The patient's self-reported pain levels were documented. Physiologic outcome was judged on pre- and postoperative motor and sensory examinations. Functional capacity was assessed by work status and ability to perform activities of daily living.
FLMED was performed in two fresh human cadavers at the lumbosacral junction. Qualitative assessments of the surgical anatomy were made, and intraoperative fluoroscopy and endoscopic photographs were obtained to document the findings. A patient with refractory pain and sensorimotor deficits from compression of the L5 nerve root by an ELDH underwent FLMED. The literature was carefully reviewed for the epidemiology of ELDHs at the lumbosacral junction and the surgical techniques used to treat them.
The posterolateral surgical corridor to the lumbosacral disc was consistently constrained by the sacral ala and to a lesser extent the lateral facet and L5 transverse process. Resection of the superior ala exposed the exiting nerve root and provided ample access to the disc. In the clinical case, the patient enjoyed immediate pain relief, was discharged in 3 hours, and returned to full work and social activities. Follow-up neurological examination revealed no sensory or motor deficit.
FLMED offers a safe and efficacious approach to ELDHs at the lumbosacral junction by combining satisfactory visualization for adequate resection of the sacral ala with the benefits of reduced tissue injury and faster recovery times that accompany minimally invasive techniques.
腰骶部椎间孔外型腰椎间盘突出症（ELDH）是L5神经根病的罕见病因。一般来说，针对ELDH所描述的各种开放手术入路中，L5 - S1椎间孔外间隙的手术解剖结构具有独特的挑战性。目前缺乏专门描述腰骶部ELDH微创外科手术入路的报道。
报告远外侧显微内镜（FLMED）入路治疗腰骶部ELDH的新应用。更好地明确腰骶部椎间孔外入路应用于微创技术时的独特解剖特征。
研究设计/地点：在单一机构进行尸体研究和临床病例分析。对文献进行全面回顾。
一名腰骶部椎间孔外型椎间盘突出症患者接受评估和手术。
记录患者自我报告的疼痛程度。通过术前和术后的运动及感觉检查判断生理结果。通过工作状态和日常生活活动能力评估功能状态。
在两具新鲜人类尸体的腰骶部进行FLMED手术。对手术解剖结构进行定性评估，并获取术中透视和内镜照片记录结果。一名因ELDH压迫L5神经根而出现顽固性疼痛和感觉运动功能障碍的患者接受了FLMED手术。仔细回顾文献中腰骶部ELDH的流行病学及治疗所用的手术技术。
通向腰骶椎间盘的后外侧手术通道始终受到骶骨翼的限制，在较小程度上还受到外侧小关节和L5横突的限制。切除上半侧骶骨翼可暴露穿出神经根，并为进入椎间盘提供充足通道。在临床病例中，患者疼痛立即缓解，术后3小时出院，恢复了全部工作和社交活动。随访神经学检查未发现感觉或运动功能障碍。
FLMED通过将对骶骨翼进行充分切除的满意视野与微创技术带来的组织损伤减少和恢复时间更快的优点相结合，为腰骶部ELDH提供了一种安全有效的手术入路。
