Acute Onset of Back and Left Leg Pain
The patient is a 52-year-old male with the acute onset of back and left anterior thigh pain for 2 weeks. Pain is unresponsive to oral steroids and nonsteroidal anti-inflammatory drugs.
His hypertension is treated with metoprolol. Other medications are Advil® and Vicodin®.
- Full strength except left quadriceps: 4/5
- Decreased left knee reflex
- Positive left-side femoral stretch
- Negative bilateral straight leg raise
- The patient ambulates with a cane
Give the patient's pain, quadriceps' weakness and loss of knee reflex, MRI studies were obtained. Figures 1 (Sagittal T2 MRI), 2 (Axial T2 MRI) and 3 (Axial T1 MRI) are below.
Figure 1. Sagittal T2 MRI
Figure 2. Axial T2 MRI
Figure 3. Axial T1 MRI
The lumbar MRIs demonstrate a large left L3-L4 herniated nucleus pulposus with severe compression of the L3 nerve root.
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Based on the patient's severe pain, abnormal neurological examination and concordant positive MRI findings, a surgical intervention was recommended.
A minimally invasive left L3-L4 far lateral/extraforaminal laminectomy and discectomy was performed through an 18mm tubular retractor. Blood loss was 10cc.
As illustrated in this case, the minimally invasive far lateral approach provides:
- A direct corridor to the disc fragment with minimal bleeding
- Affords easy identification of important bony landmarks, including the transverse process (TP), lateral facet, nerve root, and disc (Figure 4)
- Spares the facet complex, substantially reducing the risk of postoperative instability
Surgeons' Discussion Points
Far lateral disc herniations tend to be exquisitely painful due to compression of the ganglion by the disc fragment.
Three surgical approaches exist:
1. Laminectomy and facetectomy (medial to lateral)
- Pro: Familiar approach to all spine surgeons
- Cons: Extensive soft tissue dissection, requires resection of a large portion of the facet complex, potentially leading to instability
2. Far lateral (Wiltse) approach
- Pros: Minimal tissue dissection through the natural plane between the multifidus and longissimus muscles, spares the facet complex
- Cons: Less familiar approach, can be associated with bleeding if tissue planes are difficult to identify, few landmarks
- Pro: Limited biomechanical data suggest it does not lead to instability
- Cons: Little data available, nerve root directly beneath the area of bone resection, unfamiliar to most surgeons
The patient experienced immediate resolution of leg pain and was discharged home the same surgical day. His motor strength return to normal by the 2 week postoperative visit.
The rare incidence of extreme or far lateral disc herniations at 1.7%1 makes an effective and easily mastered solution somewhat elusive. The abundance of midline, lateral and foraminal herniations makes the surgical algorithm and approach much more refined. The standard open discectomy approach is not only effective, but well tolerated by the patient and physician. This pathology and approach is also amendable to a progression of less invasive measures, including mini-open, microscopic, tubular, and ultimately endoscopic approaches.
Far lateral or extreme lateral herniations, however, are much more difficult to treat in an open fashion. In cases such as this, a minimally invasive approach is ideal. For surgeons comfortable doing discograms and K-wire based dilation—such as OLIF, the far lateral approach is familiar. At L3-L4 the iliac crest is not a concern as it can be at L4-L5 and certainly at L5-S1. Another advantage for a far lateral approach at this level is that it does not require reaming of the lateral portion of the superior articular process. This patient does have some facet arthropathy and moderately short pedicles, which can impede access.
Not surprisingly, a recent Cochrane Review2 noted the expected benefits of minimally invasive (MIS) discectomy in many studies. Anatomically a case such as this is certainly well suited to an MIS approach. Specifically, I would favor the tubular retractor-based approach the authors performed because of the broad size of the herniation and significant pre-operative deficits. The authors are to be commended on an excellent clinical outcome.
Abdullah AF, Ditto EW 3rd, Byrd EB, Williams R. Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J. Neurosurg. 1974. Aug;42(2):229-234.
Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev. 2014 Sep 4;9:CD010328.