JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 1, Number 3, 1991 Mary Ann Liebert, Inc., Publishers
Laparoscopic Lumbar Discectomy: Case Report THEODORE G. OBENCHAIN, M.D.
ABSTRACT
Laparoscoic lumbar discectomy is an extension of two accepted technologies, laparoscopy and percutaneous discectomy. A young male with an L5-S1 disc herniation had the anterior aspect of the lumbosacral disc exposed laparoscopically. The disc space was entered with a trephine under fluoroscopic and video control. The discectomy was carried out with curettes and rongeurs. Evoked potentials monitored continuously, reverted to normal with decompression of the SI nerve root. This was accomplished in an outpatient setting with minimal use of oral narcotics.
INTRODUCTION
Spi n e increasing
surgeons
are,
in increasing
numbers, making attempts to avoid entry into the spinal canal in the
treatment of herniated lumbar discs. Percutaneous use
techniques via a posterior approach have enjoyed following describes a novel anterior route for
since 1985, but have certain limitations. The
lumbar discectomy.
METHODS
Preliminary work leading to laparoscopic lumbar discectomy included approval of a full disclosure clinical study protocol by the Investigational Review Board. Anatomic and operative experience was gained by work on cadavers. Special equipment was fashioned and/or modified from other existing instrumentation for disc space entry and removal of the disc under fluoroscopic control (Fig. 1). CASE HISTORY RR is a 30-year-old male with a 4-month history of severe pain in the left leg consequent to lifting. Examination revealed positive straight leg raising on the left at 20°. Neurologically he was intact except for an absent left ankle reflex and hypesthesia in the lateral aspect of his foot. The patient was placed on anti-inflammatory agents and oxycodone (Tylox, McNeil Pharmaceuticals). Physical therapy was instituted. He was followed for 3 months without any improvement. He had to discontinue work because of his pain.
Department of Neurosurgery, Palomar Memorial Hospital, Escondido, CA 145
OBENCHAIN
M R
> *?!
«~
FIG. 1. Instruments used for discectomy. (A) Two sizes of trocars for entering the disc space. (B) Curettes (rotary and conventional cup). (C) Long interspace rongeurs for removing disc fragments.
Oxycodone gave only partial pain relief. Magnetic resonance imaging revealed changes consistent with large herniation on the left at the lumbosacral joint (Fig. 2).
a
Treatment Under general anesthesia the patient was placed in the lithotomy position. Standard pneumoperitoneum followed by a 10 mm umbilical portal was established. Three suprapubic portals were established. The patient JL3
FIG. 2.
MRI
-34. a««
scan
shows herniated disc at the lumbosacral level.
146
LAPAROSCOPIC LUMBAR DISCECTOMY
then placed at 5-10° Trendelenburg position and the posterior peritoneum was dissected off of the lumbosacral disc space (Fig. 3). A 7 mm trephine was inserted into the disc space under lateral fluoroscopic control (Fig. 4). Spot anteroposterior views were used to ensure entry into the appropriate side. The disc was then removed with circular and cup curettes and rongeurs. Continuous monitoring of evoked potentials in the L5 and SI nerve roots was carried out bilaterally throughout the procedure. was
FIG. 3. Laparoscopic view of anterior aspect of lumbosacral joint. The disc space (markers on periphery).
FIG. 4.
Lateral
peritoneum has been dissected off the anterior
fluoroscopic view of trocar in the disc space. Open jaws of the rongeur are evident. 147
OBENCHAIN
LEFT SI
DSEF" DECOMPRESSION SF.H 1 Eï-S
I Opening €> 3
&
RIGHT ES ï
DSEP DECOMPR ESS I ON SER 1 SSE
m^~«-i
.
lBes.lnD.coBP.
KO
lopenlr«
4 .
I Continu« Decomp *>v
57
.'.
6 .
.
D^c^omr*
Complete SG.^1
Coinpli
FIG. 5. Recording of somatosensory evoked potentials (SSEP) before and after decompression of the left series shows the P40 portion of the wave form shifting in latency with decompression.
nerve root.
The
A 20 g measure of disc tissue was removed without incident. During dissection the posterior aspect of the disc space could be readily visualized fluoroscopically. During decompression of the posterior L5-S1 disc space, the evoked potentials changed from abnormal to normal as illustrated in Figure 5. The patient's leg pain had ceased upon waking from anesthesia and it remains absent 1 month postoperatively. He was discharged home 2.5 hours after surgery. Analgesic use consisted of 8 hydrocodone (Vicodine, Knoll Pharmaceuticals) over the first several postoperative days. He returned to work on the eighth
postoperative day.
DISCUSSION Results of discectomy via laminectomy remains the standard toward which all other alternative approaches aspire. Open laminectomy, however, has significant drawbacks including the potential for epidural fibrosis and/or arachnoiditis. Because of bony removal in a laminectomy, there is a potential for spinal instability as well. In addition, postoperative pain is significant, requiring parenteral narcotics for several days postoperatively. Average hospital stay for a laminectomy is 5 days. The average cost for that hospitalization is approximately twice the cost incurred with this case. Percutaneous discectomy techniques via a posterolateral approach have been employed increasingly since 1985. It is an attractive alternative in that it is done under local anesthesia on an outpatient basis or with a 1 to 2 day hospital stay. Drawbacks of percutaneous techniques include a 50-60% success rate for pain relief. Although very safe,' -2there have been recent reports of complications or potential complications via the posterolateral route. In many cases the posterolateral approach is 45-60° off target. The needle is aimed for the middle portion of the disc space, whereas the herniations by definition occur in the posterior portion of the disc space. Theoretically, laparoscopic lumbar discectomy is a more desirable approach. Laparoscopy is a wellestablished safe procedure with a complication rate of 0.028%.3 Entry into the L5-S1 disc space should prove to be safe if done under fluoroscopic and endoscopie guidance. Bifurcation of the aorta and inferior vena cava occur approximately one segment higher and the common iliac vessels should not pose a threat in most instances due to their lateral position at the lumbosacral level. Once inside the disc space, the same instruments can be utilized as in a standard discectomy via open laminectomy. Upon entry into the disc space one has full range of the space, making central, lateral, and foraminal herniations equally accessible. Laparoscopic lumbar discectomy should be a safe and effective procedure for subligamentous herniations at the L5-S1 interspace. It remains to be established through further experience whether it can be extended to the L4-5 space. Future efforts are also being directed toward endoscopie guidance of the disc removal process. Pain associated with this procedure is mild. It should be possile to perform this procedure on an outpatient basis. must
148
LAPAROSCOPIC LUMBAR DISCECTOMY
ACKNOWLEDGMENTS
Special acknowledgment to David Cloyd, M.D. and Max Savin, M.D., without whose expert laparoscopic help the procedure would have been much more difficult. Thanks to William P. Hummel, M.D. for his invaluable instruction in laparoscopic technique. Lastly, a special thank you to Dorothy Farrow, R.N., Palomar Hospital Operating Room Director and her crew for many indulgences during the development of this procedure. REFERENCES 1.
2. 3.
Epstein NE: Surgically confirmed cauda equina and nerve root injury following percutaneous discectomy at an outside institution: a case report. J Spine Disord 1990;3:380-382. PatsiaourasT, Bulstrode C, Cook P, Wilson D: Percutaneous nucleotomy, an anatomic study of the risks of nerve root injury. Spine 1991;16:39-42. Semm K: Die Pelviskopische Appendecktomie. Dtsh Med Wschr 1988:113:3-5. Address reprint requests to: Theodore G. Obenchain, M.D.
Department of Neurosurgery Palomar Memorial Hospital Escondido, CA 92025
149
Laparoscopic Lumbar Discectomy: Case Report THEODORE G. OBENCHAIN, M.D.
ABSTRACT
Laparoscoic lumbar discectomy is an extension of two accepted technologies, laparoscopy and percutaneous discectomy. A young male with an L5-S1 disc herniation had the anterior aspect of the lumbosacral disc exposed laparoscopically. The disc space was entered with a trephine under fluoroscopic and video control. The discectomy was carried out with curettes and rongeurs. Evoked potentials monitored continuously, reverted to normal with decompression of the SI nerve root. This was accomplished in an outpatient setting with minimal use of oral narcotics.
INTRODUCTION
Spi n e increasing
surgeons
are,
in increasing
numbers, making attempts to avoid entry into the spinal canal in the
treatment of herniated lumbar discs. Percutaneous use
techniques via a posterior approach have enjoyed following describes a novel anterior route for
since 1985, but have certain limitations. The
lumbar discectomy.
METHODS
Preliminary work leading to laparoscopic lumbar discectomy included approval of a full disclosure clinical study protocol by the Investigational Review Board. Anatomic and operative experience was gained by work on cadavers. Special equipment was fashioned and/or modified from other existing instrumentation for disc space entry and removal of the disc under fluoroscopic control (Fig. 1). CASE HISTORY RR is a 30-year-old male with a 4-month history of severe pain in the left leg consequent to lifting. Examination revealed positive straight leg raising on the left at 20°. Neurologically he was intact except for an absent left ankle reflex and hypesthesia in the lateral aspect of his foot. The patient was placed on anti-inflammatory agents and oxycodone (Tylox, McNeil Pharmaceuticals). Physical therapy was instituted. He was followed for 3 months without any improvement. He had to discontinue work because of his pain.
Department of Neurosurgery, Palomar Memorial Hospital, Escondido, CA 145
OBENCHAIN
M R
> *?!
«~
FIG. 1. Instruments used for discectomy. (A) Two sizes of trocars for entering the disc space. (B) Curettes (rotary and conventional cup). (C) Long interspace rongeurs for removing disc fragments.
Oxycodone gave only partial pain relief. Magnetic resonance imaging revealed changes consistent with large herniation on the left at the lumbosacral joint (Fig. 2).
a
Treatment Under general anesthesia the patient was placed in the lithotomy position. Standard pneumoperitoneum followed by a 10 mm umbilical portal was established. Three suprapubic portals were established. The patient JL3
FIG. 2.
MRI
-34. a««
scan
shows herniated disc at the lumbosacral level.
146
LAPAROSCOPIC LUMBAR DISCECTOMY
then placed at 5-10° Trendelenburg position and the posterior peritoneum was dissected off of the lumbosacral disc space (Fig. 3). A 7 mm trephine was inserted into the disc space under lateral fluoroscopic control (Fig. 4). Spot anteroposterior views were used to ensure entry into the appropriate side. The disc was then removed with circular and cup curettes and rongeurs. Continuous monitoring of evoked potentials in the L5 and SI nerve roots was carried out bilaterally throughout the procedure. was
FIG. 3. Laparoscopic view of anterior aspect of lumbosacral joint. The disc space (markers on periphery).
FIG. 4.
Lateral
peritoneum has been dissected off the anterior
fluoroscopic view of trocar in the disc space. Open jaws of the rongeur are evident. 147
OBENCHAIN
LEFT SI
DSEF" DECOMPRESSION SF.H 1 Eï-S
I Opening €> 3
&
RIGHT ES ï
DSEP DECOMPR ESS I ON SER 1 SSE
m^~«-i
.
lBes.lnD.coBP.
KO
lopenlr«
4 .
I Continu« Decomp *>v
57
.'.
6 .
.
D^c^omr*
Complete SG.^1
Coinpli
FIG. 5. Recording of somatosensory evoked potentials (SSEP) before and after decompression of the left series shows the P40 portion of the wave form shifting in latency with decompression.
nerve root.
The
A 20 g measure of disc tissue was removed without incident. During dissection the posterior aspect of the disc space could be readily visualized fluoroscopically. During decompression of the posterior L5-S1 disc space, the evoked potentials changed from abnormal to normal as illustrated in Figure 5. The patient's leg pain had ceased upon waking from anesthesia and it remains absent 1 month postoperatively. He was discharged home 2.5 hours after surgery. Analgesic use consisted of 8 hydrocodone (Vicodine, Knoll Pharmaceuticals) over the first several postoperative days. He returned to work on the eighth
postoperative day.
DISCUSSION Results of discectomy via laminectomy remains the standard toward which all other alternative approaches aspire. Open laminectomy, however, has significant drawbacks including the potential for epidural fibrosis and/or arachnoiditis. Because of bony removal in a laminectomy, there is a potential for spinal instability as well. In addition, postoperative pain is significant, requiring parenteral narcotics for several days postoperatively. Average hospital stay for a laminectomy is 5 days. The average cost for that hospitalization is approximately twice the cost incurred with this case. Percutaneous discectomy techniques via a posterolateral approach have been employed increasingly since 1985. It is an attractive alternative in that it is done under local anesthesia on an outpatient basis or with a 1 to 2 day hospital stay. Drawbacks of percutaneous techniques include a 50-60% success rate for pain relief. Although very safe,' -2there have been recent reports of complications or potential complications via the posterolateral route. In many cases the posterolateral approach is 45-60° off target. The needle is aimed for the middle portion of the disc space, whereas the herniations by definition occur in the posterior portion of the disc space. Theoretically, laparoscopic lumbar discectomy is a more desirable approach. Laparoscopy is a wellestablished safe procedure with a complication rate of 0.028%.3 Entry into the L5-S1 disc space should prove to be safe if done under fluoroscopic and endoscopie guidance. Bifurcation of the aorta and inferior vena cava occur approximately one segment higher and the common iliac vessels should not pose a threat in most instances due to their lateral position at the lumbosacral level. Once inside the disc space, the same instruments can be utilized as in a standard discectomy via open laminectomy. Upon entry into the disc space one has full range of the space, making central, lateral, and foraminal herniations equally accessible. Laparoscopic lumbar discectomy should be a safe and effective procedure for subligamentous herniations at the L5-S1 interspace. It remains to be established through further experience whether it can be extended to the L4-5 space. Future efforts are also being directed toward endoscopie guidance of the disc removal process. Pain associated with this procedure is mild. It should be possile to perform this procedure on an outpatient basis. must
148
LAPAROSCOPIC LUMBAR DISCECTOMY
ACKNOWLEDGMENTS
Special acknowledgment to David Cloyd, M.D. and Max Savin, M.D., without whose expert laparoscopic help the procedure would have been much more difficult. Thanks to William P. Hummel, M.D. for his invaluable instruction in laparoscopic technique. Lastly, a special thank you to Dorothy Farrow, R.N., Palomar Hospital Operating Room Director and her crew for many indulgences during the development of this procedure. REFERENCES 1.
2. 3.
Epstein NE: Surgically confirmed cauda equina and nerve root injury following percutaneous discectomy at an outside institution: a case report. J Spine Disord 1990;3:380-382. PatsiaourasT, Bulstrode C, Cook P, Wilson D: Percutaneous nucleotomy, an anatomic study of the risks of nerve root injury. Spine 1991;16:39-42. Semm K: Die Pelviskopische Appendecktomie. Dtsh Med Wschr 1988:113:3-5. Address reprint requests to: Theodore G. Obenchain, M.D.
Department of Neurosurgery Palomar Memorial Hospital Escondido, CA 92025
149
