Surgical Procedures: Discectomy and Herniectomy 361

Surgical Procedures: 14
Discectomy and Herniectomy
Erik Van de Kelft

CONTENTS ment of a lumbar disc herniation depends increas-

ingly on radiological images. The decision on how
14.1 Introduction 361 to treat the so-called failed back surgery syndrome
(FBSS) also depends largely on the specific postop-
14.2 Pathology of Lumbar Disc Herniation 361
erative imaging findings.
14.3 Pathophysiology of
Lumbar Disc Herniation 362
14.4 Surgical Treatment 363
14.4.1 Indications 363
14.4.1.1 Absolute Indications for
Surgical Treatment 363 14.2
14.4.1.2 Relative Indications for Pathology of Lumbar Disc Herniation
Surgical Treatment 364
14.4.2 Risks and Benefits 364 Joints are subjected to the ravages of aging, degen-
14.4.3 Surgical Technique 365
14.4.3.1 Percutaneous Disc Decompression 366
eration and trauma. The degeneration of the inter-
14.4.3.2 Micro-endoscopic Discectomy 367 vertebral disk is a complex process that involves
14.4.3.3 Resection of changes in both composition and function of the
Extraforaminal Disc Herniations 368 disk.
14.5 Conclusions 369 This degenerative process most frequently mani-
fests itself as spondylosis, the development of osteo-
References 369
phytes and disc herniation. Indeed, a symptomatic
disc herniation without any other sign of disc degen-
eration is rarely noticed. Even so-called post-trau-
matic disc herniations usually have an underlying
degenerative process. Sudden strains, particularly if
associated with rotational torque, may cause tear-
14.1 ing and ultimately rupture of the annular ring. More
Introduction commonly the annulus fibrosus deteriorates more
gradually, as a product of cumulative stresses over
In this chapter we will discuss the pathology of time, causing microscopic tears rather than a single
lumbar disk herniation. The clinical symptoms of a explosive rupture. A significant compressive force
lumbar disk herniation will be discussed as well as at the level of a healthy disc will cause a fracture of
the different therapeutical options, especially surgi- the vertebral body before tearing the annulus. This
cal therapy. is important when considering the relationship of a
The different surgical techniques will be de- traumatic event to a herniated disc that may mani-
scribed in detail with the intention to help the radi- fest itself several years later.
ologist in interpreting both pre- and postoperative Many procedures have been developed to treat
lumbar spine imaging studies. The choice of treat- abnormalities and degeneration of the intervertebral
disc. The associated pathological entities include
disc herniation, degenerative disc disease (DDD)
E. Van de Kelft, MD, PhD and segmental instability (Mouw and Hitchon
Department of Neurosurgery, Nikolaas General Hospital, 1996; Dowd et al. 1998). Over the past three decades,
Moerlandstraat 1, 9100 Sint-Niklaas, Belgium much attention has been given by clinicians and
362 E. Van de Kelft
KEY- POINTS
 Indications for surgery in patients with lumbar  Surgical techniques:
disc herniation:
 Absolute indications:
– Cauda equina syndrome
– Weakness and sensory loss
 Risks and benefits of surgery compared to con-
– Persistent pain
 Relative indications:
– Failure of symptom relief after 2–4 weeks of
appropriate conservative therapy
– Radicular pain in a dermatomal pattern
– Sensory loss in the same dermatome
– Weakness in the correct distribution
– Depressed tendon reflex appropriate to pain,
weakness and sensory loss
– Limited straight-leg raising with reproduc-
tion of radicular pain
– Abnormal neuro-imaging (CT or MRI) con-
sistent with the neurological deficit
radiologists to the degeneration of the disc itself as
a result of the growing awareness of the clinical en-
tity “lumbar disc herniation”, its surgical treatment
and the impact this treatment has on national health
services. Lumbar discectomies are among the most
common elective surgical procedures performed in
North America (Taylor et al. 1994). In Belgium, the
incidence of lumbar discectomies was 1 in 1000 in
2004.
In the near future, however, pathology of the
facet joints will become as important as that of the
disc itself. Spine surgeons all over the world are be-
coming increasingly interested in total disc replace-
ment strategies. The use of lumbar disc prosthesis
is already common in Europe and will soon ex-
plode in North America, as soon as clinical results
can demonstrate its superiority over other surgical
treatment options (Geisler et al. 2004). Total disc
replacement by a disc prosthesis can only be of any
use if the facet joints are intact and are as such not
responsible for any clinically relevant pain. When
both the intervertebral disc and the facet joints are
degenerated and both are responsible for pain, they
should both be replaced. Some facet joint implants
have already been designed and patented. They are
currently undergoing mechanical testing but have
not been used in clinical trials. Thus the three de-
generated joints (one disc and two facets) will be re-
 Percutaneous disc decompression
 Micro-endoscopic discectomy
 Resection of extraforaminal disc herniations
servative therapy:
 Risks – complications:
– Spondylodiscitis
– Hemorrhage
– Wound infection
– Nerve root damage
– FBSS
 Benefits:
– Early pain relief
placed by three artificial joints (one disc prosthesis
and two facet joint prostheses).
14.3
Pathophysiology of Lumbar Disc Herniation
Although the incidence of low back pain is about
60%, the incidence of low back pain with sciatica is
only 1%. Sciatica is most commonly due to hernia-
tion of parts of a lumbar disc. Since 90% of disc her-
niations occur at the level of the two lowest lumbar
discs, the referred pain is within the distribution of
the sciatic nerve, hence the name sciatica. Such a
disc herniation, however, may not be a prerequisite
for radicular pain.
Root entrapment syndrome may affect the lum-
bar root in the spinal canal, in the foraminal canal
or even outside this foraminal canal. In our own se-
ries, we reported such “extraforaminal” location in
13% of all lumbar disc herniations (Van de Kelft et
al. 1994). The radiologist, when he has no clinical in-
formation, often overlooks this pathology, especially
on poor resolution CT images. A clear L4 pathology
with a normal spinal canal at L3–L4 should urge the
radiologist to look for an extraforaminal location of

an extruded disc fragment at L4–L5. It is also im-
portant to notice that a disc bulging or protrusion
seldom reaches the root at a foraminal and never at
its extraforaminal location. This is only possible for
an extruded disc fragment.
In an extreme situation there may be a massive
nuclear protrusion in which a large volume of disc
material is suddenly thrust into the spinal canal, pro-
ducing a “profound neurological catastrophe”, such
as a cauda equina syndrome. In this case progressive
sensory loss and motor weakness of the legs is associ-
ated with sphincter disturbances. The physician on
duty will urge the radiologist for an immediate diag-
nosis, since this condition has to be treated surgically
as soon as possible. The best option for the correct
diagnosis is MRI. If unavailable, a CT myelogram
should be carried out, even at night, since a poor res-
olution CT scan may give false negative results; the
herniation may be so large that it completely fills the
spinal canal making the differentiation from its nor-
mal content extremely difficult.
The initial symptoms of sciatica often occur with-
out a precipitating event or following a seemingly
trivial movement or maneuver and are typically
not particularly incapacitating. At this moment, a
tear in the annular ring appears which can be well
demonstrated on MRI. As the inflammation (as a re-
sult of the annular tear) progresses, the symptoms
crescendo in a relentless fashion. Most patients ex-
perience paraspinal muscle spasms directed at sta-
bilizing the affected level. At that time the sciatica
appears with irradiating pain in the leg according
to the dermatomal distribution of the affected nerve
root. Through the annular tear, the nucleus pulposus
has protruded as a herniated fragment compressing
the nerve root. The irradiating pain is the result of
mechanical compression of the nerve root. The pre-
cise distribution of leg pain varies according to the
root involved. Compression of the S1 nerve root usu-
ally starts as a dull pain in the back or the thigh or
buttock, but can later involve the posterior or lateral
aspects of the calf, as well as the heel and the sole of
the foot. Compression of the L5 nerve root is charac-
terized by pain that runs more at the anterior side of
the leg into the big toe. A typical L4 pain runs more
in front of the leg and around the knee, to end half
way the tibia. This typical pain is often caused by an
extraforaminal disc herniation at L4–L5.
Following mechanical compression, the root be-
comes inflamed due to this mechanical trauma. This
inflammation can be dealt with during the conser-
vative treatment, but is often responsible for a long-
Surgical Procedures: Discectomy and Herniectomy 363
lasting dull aching or burning limb pain, even when
the nerve root is fully decompressed. The initial
goal of conservative therapy is to diminish the pain
caused by inflammation. Usual conservative treat-
ment consists of bed rest, non-steroidal anti-inflam-
matory drugs, muscle relaxation and, if necessary,
epidural steroids. There seems to be no significant
difference in outcome when conservative treatment
is compared to the natural history of sciatica. Af-
ter the acute onset of sciatica, more than 50% of pa-
tients will improve significantly under conservative
treatment after 2 months (Saal 1996).
14.4
Surgical Treatment
14.4.1
Indications
There is some controversy about the usefulness of
surgery versus nonoperative treatment in managing
these patients. The majority of patients with lumbar
disc herniations and sciatica will improve over time
with conservative treatment. There is a tendency,
however, to operate on these patients a few weeks
after the onset of their initial symptoms. The sur-
gical technique becomes minimally invasive (nu-
cleoplasty, micro-endoscopic discectomy) and can
be performed on an outpatient basis (Foley and
Smith 1997; Smith and Foley 1998). It is our task to
return a patient with sciatica in a prompt and effec-
tive manner to his or her previous level of function
as soon as possible.
Indications for surgery can be divided into abso-
lute and relative indications (Table 14.1).
14.4.1.1
Absolute Indications for Surgical Treatment
There are three absolute indications for surgical
treatment of acute sciatica due to a herniated lum-
bar disc which will be discussed in the following
sections.
14.4.1.1.1
The Cauda Equina Syndrome
In cauda equina compression with bladder and/or
bowel incontinence, which is often not obvious at
364 E. Van de Kelft
Table 14.1. Indications for surgery in patients with a herni-
ated lumbar disc
Absolute indications
Cauda equina syndrome
Weakness and sensory loss
Persistent pain
Relative indications
Failure of symptom relief after 2–4 weeks of appropriate
conservative therapy
Radicular pain in a dermatomal pattern
Sensory loss in the same dermatome
Weakness in the correct distribution
Depressed tendon reflex appropriate to pain, weakness
and sensory loss
Limited straight-leg raising with reproduction of radicu-
lar pain
Abnormal neuro-imaging (CT or MRI) consistent with
the neurological deficit
the time of admission, urgent decompression of the
cauda is mandatory. This is the only indication for ur-
gent lumbar disc surgery. Every attempt to treat this
disorder conservatively will end in court. Often, even
after adequate surgical decompression with complete
relief of pain, the bowel or bladder incontinence per-
sists for months or becomes permanent.
14.4.1.1.2
Weakness and Sensory Loss
The presence of significant neurological deficits such
as weakness and/or sensory loss, which affects 5%–
20% of patients with acute sciatica, is a good indica-
tion for surgery without delay. It seems obvious that
a neurological deficit due to mechanical compression
of the nerve root will resolve better the earlier the root
can be liberated. Some authors showed, however, that
delays of up to 3 months had a minimal effect on the
ultimate recovery of strength (Hakelius 1970).
14.4.1.1.3
Severe Persistent Pain
Clearly not all patients have the opportunity to rest
and undergo conservative treatment of their sciat-
ica. Busy people with severe incapacitating leg pain
due to a herniated disc fragment often urge us to find
an immediate yet elegant solution for their problem.
The more surgery becomes minimally invasive due
to microsurgical and endoscopic techniques, and
the more this surgery can be done on an outpatient
basis, the more it becomes an attractive alternative
for relief of symptoms, even after the fi rst week of
symptoms. As will be discussed later, the benefit of
surgery is the swift relief of symptoms. The long-
term outcome is comparable to that of conservative
treatment and even with that of natural evolution.
14.4.1.2
Relative Indications for Surgical Treatment
The American Association of Neurological Surgeons
(AANS) and the American Academy of Orthopaedic
Surgeons have listed seven indications for surgical
treatment of a herniated lumbar disc disease:
 Failure to relieve symptoms after 2–4 weeks of
appropriate conservative therapy
 Radicular pain in a dermatomal pattern
 Sensory loss in the same dermatome
 Weakness in the correct distribution
 Depressed tendon reflex appropriate to pain,
weakness and sensory loss
 Limited straight-leg raising with reproduction of
radicular pain
 Abnormal neuro-imaging (CT scan or MRI) con-
sistent with the neurological deficit (Long et al.
1988)
In these cases it is up to the patient whether he de-
cides to resolve the pain by surgery or whether he pre-
fers to wait for the results of conservative treatment.
Weber (1983) reported a prospective, randomized
study in which surgery was compared to conservative
therapy. The study showed that, although surgery of
lumbar disc herniations was superior to nonoperative
treatment at 1 year, results at 4- and 10-year follow-
up showed no statistical difference (Weber 1983).
Although surgery may provide more rapid relief of
pain, the ultimate result is approximately the same
regardless of treatment, with long-term resolution of
sciatica approaching 87%. This study was undertaken
25 years ago; conservative treatment did not change
spectacularly in this period; surgery, however, did.
14.4.2
Risks and Benefits
If, according to a 25-year-old study, there is no dif-
ference in outcome when surgery is compared to
conservative therapy, and if surgery always carries
some operative risk, what then is its benefit (Fig. 14.1)

Fig. 14.1. Evolution of pain in patients with a lumbar disc
herniation. According to Weber’s study, there is no statistical
difference in outcome after 4 years when comparing natural
history, percutaneous techniques or surgery in the treatment
of a lumbar disc herniation. It is obvious, however, that sur-
gery is able to relieve symptoms more quickly. Degenerative
disc disease can be responsible for recurrent low back pain
in all non-disc-replacing therapeutic options
(Weber 1983)? Clearly there is a benefit in terms
of the so-called absolute indications, especially the
cauda equina syndrome. For the relative indications
the benefit lies in early pain relief in comparison
to conservative treatment. Therefore, it is better to
operate a patient with acute sciatica of 4 weeks’ du-
ration, than one with chronic sciatica over a period
of 6 months, since the latter may be close to the
spontaneous resolution of his problems. The relative
benefit of surgery will be comparatively small in this
case. Additionally, recovery of the root might also
be problematic after mechanical compression of 6
months’ duration.
Most patients are afraid of lumbar disc surgery
and many have heard stories of someone who was
left plegic following surgery. Although the theo-
retical risk of serious nerve root damage exists, in
practice it almost never occurs. The most serious
risk of lumber surgery, with an incidence of 0.04%,
is spondylodiscitis (Van Goethem et al. 2000). This
involves extreme low back pain occurring weeks to
months after surgery and a hospital stay of several
weeks since the treatment consists of antibiotics
over at least a 6-week period. Wound hematoma and
superficial wound infection are minor risks.
Procedures for removal of the herniated disc frag-
ment have two major goals: to relieve pain immedi-
ately and to prevent recurrence. The first goal can be
accomplished in more than 90% of cases. The second
is more difficult. The more the surgeon tries to prevent
any recurrence, implying near total disc removal, the
more the intervertebral disc will collapse, resulting
Surgical Procedures: Discectomy and Herniectomy 365
in facet joint pain. Furthermore, recurrence of a her-
niated disc is not typical in operated patients: there
is no difference in recurrence between operated and
non-operated patients (Weber 1983). The disc itself
will degenerate once an annular tear has appeared.
Consequently, low back pain can occur due to disc
degeneration in operated as well as in non-operated
patients. Therefore, in the author’s opinion, recur-
rence and persistent low back pain after conservative
or surgical therapy is not a complication, but rather
a logical consequence of the natural history of disc
degeneration (Van de Kelft et al. 1996). In 2004 we
started a phase three clinical trial as part of a multi-
center study using a mixture of elastin and silk in-
jected into an operated disc to seal the annular tear
or the surgically created annular opening. This pro-
cedure has two goals: to prevent recurrent herniation
of previously operated discs and to restore the disc
height by replacing the amount of resected nucleus
with the product mentioned above.
A major “complication” after surgery is the so-
called FBSS occurring in less than 1% of all operated
patients (Samy Abdou and Hardy 1999). Its origin is
unknown, but the syndrome consists of a dull burn-
ing pain in the limbs, occurring weeks to months
after surgery. Successful treatment of these patients
requires a correct diagnosis of the underlying process
prior to further intervention. Surgery may benefit pa-
tients with recurrent disc herniation, segmental in-
stability, or spinal stenosis, but patients with epidural
fibrosis and arachnoiditis (together accounting for
about 20% of all FBSS patients) are less likely to obtain
a satisfactory outcome from surgical re-intervention
(Van de Kelft and De La Porte 1994). Spinal cord
stimulation may benefit about half of these patients
(Samy Abdou and Hardy 1999). Today, there are
neither technical guidelines nor products available to
prevent peridural scarring (Robertson et al. 1999).
14.4.3
Surgical Technique
As indicated earlier, there is a strong tendency to
minimize tissue damage and to operate patients
early in order to rehabilitate them faster. Therefore,
many percutaneous techniques have been developed
in recent years. Other than the chemical dissolu-
tion of the nucleus (chymopapain), a technique that
is no longer in use, new techniques focus on the
mechanical treatment of the pathological disc. It
is of extreme importance to notice that all of these
366 E. Van de Kelft

techniques have the same clinical indications as the
classical surgical one (i.e. microdiscectomy), but can
only be carried out with a reasonable success rate if
the herniation is contained by an intact outer an-
nular ring. Even discography cannot help establish
this diagnosis.
Minimally invasive intradiscal techniques that
provide percutaneous access to the discs are chemo-
nucleolysis, percutaneous nucleotomy, automated
percutaneous lumbar discectomy, intradiscal laser
discectomy, and intradiscal radiofrequency ablation.
Nucleoplasty is a non-heat driven process that employs
coblation technology using bipolar radiofrequency
technology applied to a conductive medium (i.e. sa-
line) to achieve tissue removal with minimal thermal
damage to collateral tissues (Nazariaz 1985).
14.4.3.1
Percutaneous Disc Decompression
The technique we use in our department is a nu-
cleoplasty based on coblation (Robertson et al.
1999; Nazariaz 1985; Singh et al. 2003; Mochida
et al. 2001). Percutaneous disc decompression using
coblation (nucleoplasty) is performed on an outpa-
tient basis under monitored anesthesia care in the
operating room.
All procedures are performed under strict sterile
conditions using fluoroscopic guidance with the pa-
tient in a prone or semi-oblique position. A 17-gauge
6-in. Crawford-type spinal access cannula is placed
at the junction of the annulus and nucleus. A Perc-
DLE wand (ArthroCare, Inc., Sunnyvale, CA) is ad-
vanced into the disc via the spinal access cannula.
After confirming that proximal and distal channel
limits are within the disc, decompression is initi-
ated. The decompression process involves advanc-
ing the wand, in ablation mode, to the distal chan-
nel limit at a speed of 0.5 cm/s and retraction of the
wand in coagulation mode, to the proximal channel
limit at the same speed (Fig. 14.2).
Six channels are created at the twelve, two, four,
six, eight, and ten o’clock positions. Postoperatively,
patients are allowed limited walking, standing and
sitting as needed in daily-life activities; however,
they are instructed to limit bending, stooping and

Fig. 14.2a–c. Disc coblation. a The coblation technique

is based on a heat producing canula that coagulates
and aspirates parts of the nucleus. b Under fluoroscop-
ic guidance, a 17-gauge spinal cannula is placed in the
center of the nucleus. c In a forward-backward mode,
six channels are created in the nucleus

b c
 Surgical Procedures: Discectomy and Herniectomy 367

lifting more than 5 kg (10 lbs) for 2 weeks. Patients

with sedentary or light work environments are al-
lowed to return to work after 2 weeks. A qualified
instructor provides patients with home exercise
instructions.

14.4.3.2
Micro-endoscopic Discectomy

Annular integrity is an important variable in achie-

ving a beneficial outcome in patients undergoing disc
decompression. Annular repair occurs very gradually
and a large incision into a degenerated-herniated disc
will result in a decrease in annular strength during
the healing process (Ahlgren et al. 2000). Analysis
of proteoglycan synthesis and degradation indicate
that replacement of proteoglycan molecules within
the disc may take up to 3 years (Stathopoulos and
Cramer 1995). Three separate analyses have con-
cluded that the box incision method leads to sig-
nificantly poorer healing, a decrease in strength of
40%–50%, and an increase in severe and early disc
degeneration (Ahlgren et al. 1994; Ethier et al.
1994). Another study indicates that square, circular,
cross, and slit incisions each produce a larger range in
motion during axial moment loading (Ahlgren et al.
2000). Annular entry with a 2.5-mm OD trocar main-
tained disc integrity during biomechanical loading
(Natarajan et al. 2002). Once the annular ring has
been opened, subtotal or total discectomy can be car-
ried out. Biomechanical studies show, however, that
translational as well as rotational instability is less
following subtotal discectomy (Nazariaz 1985). It
is these findings that have further lent support to
the approach of discectomy without curettement. In
special indications we do remove the total nucleus
with the intention of replacing it with a prosthesis
like the prosthetic disc nucleus (PDN) (Fig. 14.3).
This technique, while very challenging, is also very
promising. It is not always obvious to see the PDN on
MR, especially if the surgical procedure is not known
while interpreting the images.
The most important goals for surgical treatment
of lumbar disc herniation are therefore:
 Removal of the herniation causing symptoms.
 If unnecessary, try to avoid making holes in the
annulus.
 Remove as little as possible of the remaining disc
material.
 Choose a minimally invasive access to promote
early recovery and rehabilitation and to minimize
hospital stay and cost.
Fig. 14.3. Prosthetic disc nucleus (PDN device). Note the PDN
device in the center of the L5–S1 disc (white arrow). Without
relevant clinical information, recognizing the device itself
can be problematic
Bearing these goals in mind, we actually perform
a micro-endoscopic discectomy in all patients with
an indication for surgical treatment and a contra-
indication for percutaneous nucleoplasty.
The main advantage of the METRx system
(Medtronic Sofamor Danek, Memphis, TN) in com-
parison to a traditional discectomy is a smaller inci-
sion and less damage to the muscles of the spinal
column (Foley and Smith 1997). This advantage is
achieved by allowing the surgeon to expose the area
where the herniated disc is located without making
a large incision. A discectomy that is done with the
METRx system begins with the surgeon precisely
localizing the level of the herniated disk with a very
small needle that is inserted through the muscles of
the back down to the area where the disk fragments
are located (Fig. 14.4). The correct position of this
needle is confirmed by fluoroscopy, after which a se-
ries of soft-tissue dilators are used to create a small
tunnel measuring 16 mm in diameter (less than ¾ of
an inch) through the muscles of the back, enabling
a hollow tube to be inserted down to the level of the
spinal column. This tube, which is called a tubular
retractor, contains a highly specialized video cam-
era with a magnifying lens and a fiber optic light
source that illuminates the tissues and relays the im-
368 E. Van de Kelft

a b

c d

Fig. 14.4a–d. Micro-Endoscopic Discectomy. a K-wire inserted percutaneously at the L4–L5 junction. The correct position
of this needle is confi rmed by fluoroscopy. b After the correct position of the needle has been confi rmed with fluoroscopic
guidance, a series of soft-tissue dilators are used to create a small tunnel that measures 16 mm in diameter (less than ¾ of
an inch) through the muscles of the back so that a hollow tube can be inserted down to the level of the spinal column. c This
tube, which is called a tubular retractor, contains a highly specialized video camera with a magnifying lens and a fiberoptic
light source that illuminates the tissues and relays the images to a separate video screen so that the surgeon can operate
safely. Once the tubular retractor is in the correct place the surgeon is able to visualize the area where the herniated disk is
located. d After a small laminotomy and flavectomy, he or she is able to remove the fragments of the disk with special in-
struments that fit down the inside of the tubular retractor. (Reproduced with permission from Medtronic Sofamor Danek)

ages to a separate video screen so that the surgeon 14.4.3.3

can operate safely.
Once the tubular retractor is in the correct place
the surgeon is able to visualize the area where the
herniated disc is located. After a small laminotomy
and flavectomy, he or she is able to remove the frag-
ments of the disc with special instruments that fit
into the tubular retractor. When the operation is
finished, the tubular retractor is removed and the
incision, which is less than 16 mm (1 in). in length,
is closed and the wound is allowed to heal.
Resection of Extraforaminal Disc Herniations
It is a relatively common phenomenon to encounter
extreme lateral nerve root entrapment in patients
with L4 symptoms when one is looking for it (Van
de Kelft et al. 1994). In 1994 we presented a sur-
gical technique that approaches the disc fragment
not from intraspinally, but from outside the spinal
structures (Van de Kelft et al. 1994). In this mi-
crosurgical approach the incision is centered on the

spinous process of the upper vertebra, i.e. slightly
more upwards compared to the classical interlami-
nar approach. We prefer a paramuscular approach
and therefore retract the muscle by a self-retaining
retractor. We then aim for the junction between the
pedicle and the transverse process. The nerve root
in these cases is always pushed cranially against the
pedicle. Once the pedicle is identified, the nerve root
can be easily tracked. Caudally we find the extruded
fragment. In fact, we only remove this fragment and
perform a non-classical discectomy. Once the nerve
root is no longer compromised between the disc frag-
ment and the pedicle, we retract the retractor and
close the skin. This technique has the advantage of
seeing the herniated fragment clearly, as well as the
nerve root, while preserving all spinal structures.
If one aims for an extraforaminal disc fragment by
the classical intraspinal interlaminar approach, one
ends up with a destroyed or even removed facet joint,
because the herniated fragment can otherwise not be
seen or reached.
More recently we carry out the same procedure in
an endoscopic way, with the tools as described ear-
lier.
14.5
Conclusions
Once a trial of conservative treatment has been at-
tempted, it may be wise to proceed with a surgical
intervention on a patient suffering from sciatica due
to a herniated lumbar disc. With the exception of the
absolute indications, we see that the relative indica-
tions become more popular because of the advent of
minimally invasive disc surgery that is performed
on an ambulatory basis. Given this, the patient can
benefit maximally from surgery as a result of early
relief of symptoms and full resumption of previous
functions. Nevertheless, the patient should be in-
formed that the long-term outcome is comparable
to the outcome of conservative therapy.
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