Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation.
OBJECTIVE
Removal of a sequestered lumbar disk; in instances of foraminal stenosis a decompression (foraminoplasty) can also be performed. The objective is to restore the best possible pain-free function of the spinal column.


METHODS
Prolapsed lumbar vertebral disk, sequestered caudally or cranially, that is no longer responding to nonoperative treatment. Cauda equina syndrome.


METHODS
Sequestered herniated lumbar disk posterior to the dura mater.


METHODS
Lateral decubitus on a radiolucent table allowing the use of an image intensifier. The usual access to a sequester at segments L5/S1 and L4/5 is approximately 12-14 cm lateral to the midline, at segments L3/4 and L2/3 approximately 10 cm lateral to the midline. In the case of sequestration in a cranial direction a somewhat smaller angle of access should be chosen, for caudal displacement the angle should be greater. Reaming of a lateral transforaminal approach to the spinal canal. The sequester is removed endoscopically through a working cannula.


METHODS
The patient remains in the recovery room for approximately 2 h, is fitted with a brace and transferred to the ward. No medicinal thrombosis prophylaxis. Follow-up examination the next morning. Physiotherapy after 1 week. The brace is worn for approximately 2-6 weeks. MRI checkup and after 3 months evaluation of the development of strength and the state of the back musculature.


RESULTS
Between January 1999 and January 2002, 611 patients underwent surgery, 32% women and 68% men, age between 18 and 65 years (average age 43.8 years). Clinical follow-up examinations were carried out after 3 months, follow-ups with questionnaire after 1 and 2 years. The evaluation criteria were based on an own questionnaire, and also on MacNab's score and the visual analog scale (VAS). After 2 years 558 patients (91.2%) responded to the questionnaires. Excellent or good results were achieved in 95.3% of the patients. 74.7% were very satisfied, 20.6% satisfied. The result was judged unsatisfactory by 4.7% of patients (less satisfied 3.9%, unsatisfied 0.8%). The numbness of the leg, present in 448 patients preoperatively, was either no longer present (63.9%) or had improved (30.3%). There were no serious complications, in particular no infections. The recurrence rate was 3.6%.
Schubert
Michael
M
Department Wirbelsäulenchirurgie, Alpha-Klinik München, Effnerstrasse 38, D-81925, München. schubert@alphaklinik.de
Hoogland
Thomas
T
D000293:Adolescent; D000328:Adult; D000368:Aged; D001416:Back Pain / Q000209:etiology / Q000517:prevention & control*; D017587:Diskectomy, Percutaneous / Q000379:methods*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000601:surgery*; D007796:Laminectomy / Q000379:methods*; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged