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Lumbar Microdiscectomy: Surgical Pearls
Mark F. Kurd, MD
Associate Professor, Sidney Kimmel Medical College Thomas Jefferson University
The Rothman Institute
Disclosures
- Duratap, LLC: Shareholder
Lumbar Microdiscectomy: Surgical Pearls Mark F. Kurd, MD Associate - - PowerPoint PPT Presentation
Lumbar Microdiscectomy: Surgical Pearls Mark F. Kurd, MD Associate - - PowerPoint PPT Presentation
Lumbar Microdiscectomy: Surgical Pearls Mark F. Kurd, MD Associate Professor, Sidney Kimmel Medical College Thomas Jefferson University The Rothman Institute Disclosures Duratap, LLC: Shareholder No such thing as a Simple disc
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No such thing as a “Simple disc”
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Lumbar Microdiscectomy
- Remove all compressive pathology
- Mobilize the nerve root
- Relieve buttock and leg pain
- Preserve spinal stability
- Early return to activity
Goals of the Procedure
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- 10-15% risk of reoperation
- 7-10% risk of recurrent HNP
- Risk factors
– Smoking – Diabetes – Obesity – WC
Lumbar Microdiscectomy Preop Discussion
Leven et al. JBJS. 2015
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Microdiscectomy Technique
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Lumbar Microdiscectomy
- Look at Xray / MRI!
– Laminar anatomy
Preparation
3rd 2nd 1st C F EF L 3rd 2nd 1st C F EF L
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Lumbar Microdiscectomy
- Positioning is important
– Flex hips > 90 degrees – Open interlaminar space – Free abdomen
- Position of symptoms
Preparation
3rd 2nd 1st C F EF L 3rd 2nd 1st C F EF L
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Lumbar Microdiscectomy
- Skin incision
– just lateral to midline
- Fascial incision
– 2 – 3 mm lateral – subperiosteal dissectio
Approach - Open
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Lumbar Microdiscectomy
Approach - MIS
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Localization
- Lateral xray with
marker in interlaminar interval
– Avoid wrong level surgery!!!!!
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Lumbar Microdiscectomy
- Standard discectomy
procedure
– Laminotomy
- Maintain pars
– Take down flavum – Identify pedicle / root – Mobilize traversing root – Locate pathology / remove
Decompression
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Avoid iatrogenic pars fracture!
Leave ≥ 7 mm of pars
L2 L5
“Lateral” pars
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Lumbar Microdiscectomy
- “Fragmentectomy” preferred to
annulotomy
- Identify annular defect, if possible
- Flush with 20 cc saline
– Disc space (fragments) – Floor of canal (inflammatory agents)
- Meticulous hemostasis → less scarring
Technical Tips
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Confirm Decompression
- Does amount of disc
removed correlate with preop imaging?
- Palpate:
– ventral to root/ dura – foramen x 2 – lateral (subarticular) recess
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Lumbar Microdiscectomy
- Outpatient in over 95% of cases
- Multi-modal analgesai protocol
- Anesthesia protocol minimizes nausea
- No strenuous activity 6 weeks
Postoperative Regimen
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