Modified Less İnvasive Microdiscectomy; Interlaminar Aproach And Unflavectomy
Modified lessi invasive microdiscectomy; Interlaminar aproach and unflavectomy with epidural analgesia. Technical Report
Kilincoglu BF, * Zoroğlu F., Koc ÖN
Department of Neurosurgery, İstanbul - TÜRKİYE
Background: The failed back surgery is an important problem in the spinal surgery. Commonly causes are misdiagnosis, inappropriate operation, instability, residual and persistent disc, lateral or central spinal stenosis, epidural fibrosis, infection and neuronal injury. The epidural fibrosis has still occurs even new and less invasive surgical techniques
and the rate is over than estimated. Facet joint damages, instability, haematoma, flavectomy, laminectomy, used some biomaterials, cauterization, residual disc and tissue injuries may be triggered epidural fibrosis.
Objective: If we can diminish the tissue injury and limited to use some biomaterials (cotton, haemostatic agent) and electrical coagulation, the epidural fibrosis can be minimize.
Technique: We describe less invasive microdiscectomy technique to lower lumbar region. The first, we use epidural analgesia to avoid complications of general anesthesia and can cooperate to the patients. The second step, the patient is placed knee-chest position on the operating table. This placement may cause to maximum expanding of the interlaminar space and laminectomy is not necessary to reach intervertebral space. In this procedure, ligamentum flavum is cutting like a flap shape and retracted medially without removed. Then it is replaced the original positions end of the operation. Finally, the root and epidural space surrounded by authogene lipid guts from subcutaneous tissue. The avoiding of the electrical coagulation and to use haemostatic agents is also advised.
Conclusion: This procedure can allow to minimal tissue injury, less pain, early mobilization, less risk of the epidural fibrosis lower lumbar region especially on the L5-S1, L4-5 space.
Key words: Microdiscectomy, knee-chest position, hyper flexion, interlaminar space, epidural fibrosis, adhesion, minimal invasive.
Corresponding: Bülent Fahri KILINÇOĞLU, Nisa Hastanesi Nöroşirürji Kliniği
Çobançeşme Okul Sok. No: 1 Yenibosna İstanbul - Türkiye
The failed back surgery syndrome (FBSS) is an important problem in the spinal surgery in spite of different and minimal invasive techniques. Commonly causes are misdiagnosis, inappropriate operation, lateral-foraminal or central spinal stenosis, instability, residual and persistent disc, epidural fibrosis (EF), infection, neuronal injury and non-neurospinal disorders (3, 7, 17).
Facet joint damages, cauterization, flavectomy, laminectomy and other surgical procedures or used some biomaterials, may be trigger the epidural fibrosis and instability.Fibrosis of epidural space and nerve roots is limited to the movements of neural structures in spinal canal and this is presented with painful lumbar movements (2, 12). The epidural fibrosis is present in different rates after each laminectomy or disc surgery and the rate is over than estimated. The rate of segmental instability after laminectomy is present in high percentaces. Dejenerative procedures of spine and facet joint fractures are presented instability and listhesis. Removal of more than 25 percent of the bone at base of medial inferior articular proces may cause facet demages and loss of stability (18).
If we should diminish the tissue injury and limit to use some materials (cotton, coagulation of the peridural veins, haemostatic agent), EF should be minimize. In this technical report, we presented the less invasive microdiscectomy procedures to diminish EF and instability.
The evaluation of the surgical technique is less tissue injury, less morbidity and less invasive interlaminar microdiscectomy procedure. This procedure is mainly useful to L5-S1, L4-5 space and lesser then to upper segments. The procedure should not be appropriate in spondylopathy, congenital short lamina, great obese, elderly and non cooperated patients.
All patients are sedated in bed before the operation. The operation is performed under epidural analgesia to avoid of complications of general anesthesia and to cooperate of patients in operation. If it is failure, spinal or general anesthesia should be preferred. After the related vertebral segment demonstrated by C-arm X-ray images, local anesthetic agent infiltrated to skin and paravertebral muscles. The second step, the patient is placed knee-chest position on the operating table. This placement may cause to maximum expanding of the interlaminar space and maximum flexed to lumbar region. The patient prepared to surgical procedure and incision on the midline about 1.5-2 cm. The Taylor retractor is inserted after opening the fascia and retracted the paravertebral muscles. The operation is begun by exposing of the foraminatomy and cutting of the ligamentum flavum laterally like flap shape. Mesial of facet should be removed if necessary. After retracted of the ligamentum flavum medially, extrude disc, root, lateral recesses can be visualized. The removing of dural fat can increase to the risk of epidural fibrosis. Laminectomy may be necessary to cranially presented disc herniation. The posterior longitudinal ligament and annulus are incised as (+) and discectomy is performed. The disc material should be removed approximately 2/3 of totally. Extremely deep removing or try to total removing of these materials may cause to increase of the vascular or intraperitoneal injuries. The excessively removing of end plates should be also avoided. After this part, free disc fragments must be looking for and checked the root for freely mobilization. In operation the surgeon can communicate to the patient if necessary or the patient can warn to surgeon for unexpected situation. The last, the ligament replaced the original positions and the epidural space and root surrounded by authogene lipid guts from subcutaneous tissue. We are avoiding of the electrical coagulation and to use haemostatic agents expect than to use in excessive bleeding. After the operation, we also recommended early mobilization (in six or ten hours) and begin to range of motion (RoM) exercises in bed.
We have described minimal tissue dissection technique and less invasive microdiscectomy procedure on lower lumbar region. This procedure should be diminishing to the risk of EF and adhesion after discectomy and the risk of general anesthesia. The minimal invasive spinal procedures prefer most of the surgeon and patients in last years. The early recovery, less morbidity, low recurrence risk and short hospitalization time are main causes of this preference. The epidural fibrosis has still occurs even new and less invasive surgical techniques from first described by LaRocca and McNab (13). The rate of EF is as reach as 80% in reoperated patients (8). The post operative heamatoma, irritative effect of nucleus pulposus, laminectomy, flavectomy, coagulation of the epidural veins, cotton, and foreign bodies are possible etiologic factors (1, 4, 8, 10, 11, 14, 13, 15). The main topic is the diminishing of the fibrinotic activity. If we can limit or prevent of these effects, we should be decrease to EF, the rate of the low back pain and FBSS.
Our technique is base on minimal tissue damage and prevent to normal anatomical structure. The epidural analgesia is well tolerated technique with several potential advantages and an acceptable incidence of complications, as compared with general endotracheal anesthesia (9, 16). Decreasingthe amount of added epinephrine to local anesthetic agent should reduce the incidence of hypotension and tachycardia without reduction significant anesthetic effect (5). In this method, the surgeon can contact to his patient and the patient should warn to surgeon to excessive retraction or hard manipulation of neural structures. To less use of anesthetic drugs, early recoveries on post operative stage, to allow testing of motor function intraoperatively are other advantages. But the anesthetic technique should not be use on the patients of insisted to general anesthesia, non cooperative, elderly, great obese or spondylopaty. Spinal or general anesthesia should be choice, if it failure.
The second step, the patient is placed knee-chest position on the operating table. This placement may cause to maximum expanding of the interlaminar space and the space is distracted 8-12 mm additionally. Ebraheim NA et al reported that superior margin of lamina is showed inferior margin of disc level in lumbar region. They noticed that interlamimar spaces are superposed to disc space and the surgeon could reach the disc space without laminectomy. The avoidance of unnecessary bony resection of the lamina may prevent normal anatomical structure and decrease postoperative scar formation or instability (6).
We noticed that the ligamentum flavum is releasing and preserving as a 3-sided flap medially and replaced to the original positions end of the operation. The ligamentum flavum preserving technique is useful in achieving a favorable long-term outcome and reoperation if necessary is easier and safer (1). The last, root and epidural space surrounded by authogene lipid guts from subcutaneous tissue. Due to the lipid grafts can cause root and cord compression and triggered fibrosis, only the replacement of multiple small lipid guts is more effective to prevent the scar formation (4, 11). The mechanisms of EF in the latter may be related to vascular damage and persisting cotton debris from sponges used during the operation. This debris may act as a fibrogenic stimulus and can cause epidural fibrosis (18). The avoiding of the electrical coagulation and to use haemostatic agents may prevent EF and scar formation.
Finally; the evaluated procedure is simple and useful technique which can cause to minimal tissue injury, less pain, early mobilization and less risk of the EF or adhesion. The unlaminectomised, unflavectomised microdiscectomy with epidural is the less invasive procedure for young, non obese and cooperatable patients in lower lumbar spaces. This procedure can help to prevent epidural fibrosis and adhesion after disc surgery and can increase to the patient comfort.
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