title: The surgical treatment of single level multi-focal subarticular and paracentral and/or far-lateral lumbar disc herniations: the single incision full endoscopic approach.
abstract: BACKGROUND
  Surgery for same level multi-focal extruded lumbar disc herniations is technically challenging and the optimal method controversial. The subarticular disc herniation may pose the most challenging subtype requiring partial or complete facetectomy with or without fusion. The far-lateral disc herniation, often treated using a Wiltse approach, can also be difficult to access especially in the obese patient. When both the subarticular and far-lateral subtypes are simultaneously present at the same level with or without a paracentral disc herniation, a total facetectomy and interbody fusion (TLIF) or a total disc replacement (TDR) may be necessary. Endoscopic surgical techniques may reduce the need for these more invasive methods.
  
  
  METHODS
  Fifteen patients (6 male and 9 female) who had same level multi-focal (subarticular as well as far-lateral and/or paracentral) extruded disc herniations underwent single incision unilateral endoscopic disc excision by the same surgeon at a single institution. Patients were prospectively followed for an average of 15.3 months (range 14-18 months) and outcomes were evaluated radiographically and clinically (Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI).
  
  
  RESULTS
  The mean operative time was 52 minutes with minimal blood loss in all cases. Fourteen of the 15 patients were discharged to home on the day of their surgery. The mean ODI and leg VAS scores improved from 22.9 ± 3.2 to 12.9 ± 2.7 (p < 0.005), and from 8.6 ± 1.6 to 2.1 + 0.4 (p < 0.005), respectively.
  
  
  CONCLUSIONS
  After an average of 15.3 months of follow-up, the clinical and radiographic results of full endoscopic surgical treatment of single level multi-focal (subarticular as well as far-lateral and/or paracentral) disc herniations are excellent. This study is a case series with mid-term follow-up (Level IV).
  
  
  CONCLUSIONS
  Foraminal and extra-foraminal full endoscopic decompression appears to offer a safe minimally invasive solution to a complex pathologic problem.
authors.affiliation: Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, New Haven CT 06520.
authors.forename: James J
authors.initials: JJ
authors.lastname: Yue
authors.affiliation: Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, New Haven CT 06520.
authors.forename: David L
authors.initials: DL
authors.lastname: Scott
authors.affiliation: Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, New Haven CT 06520.
authors.forename: Xiao
authors.initials: X
authors.lastname: Han
authors.affiliation: Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, New Haven CT 06520.
authors.forename: Alem
authors.initials: A
authors.lastname: Yacob
keywords: Disc Herniation; Endoscopic Spine Surgery; Far-lateral; Lumbar; Paracentral; Subarticular