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”

Lumbar Microdiscectomy Goals of the Procedure • Remove all compressive pathology • Mobilize the nerve root • Relieve buttock and leg pain • Preserve spinal stability • Early return to activity

Lumbar Microdiscectomy Preop Discussion • 10-15% risk of reoperation • 7-10% risk of recurrent HNP • Risk factors – Smoking – Diabetes – Obesity – WC Leven et al. JBJS. 2015

Microdiscectomy Technique

Lumbar Microdiscectomy Preparation C L F EF • Look at Xray / MRI! C L F EF – Laminar anatomy 3rd 3rd 2nd 2nd 1st 1st

Lumbar Microdiscectomy Preparation • Positioning is important C L F EF C L F EF – Flex hips > 90 degrees 3rd – Open interlaminar space 3rd – Free abdomen 2nd 2nd 1st 1st • Position of symptoms

Lumbar Microdiscectomy Approach - Open • Skin incision – just lateral to midline • Fascial incision – 2 – 3 mm lateral – subperiosteal dissectio

Lumbar Microdiscectomy Approach - MIS

Localization • Lateral xray with marker in interlaminar interval – Avoid wrong level surgery!!!!!

Lumbar Microdiscectomy Decompression • Standard discectomy procedure – Laminotomy • Maintain pars – Take down flavum – Identify pedicle / root – Mobilize traversing root – Locate pathology / remove

Avoid iatrogenic pars fracture! “Lateral” pars L2 Leave ≥ 7 mm of pars L5

Lumbar Microdiscectomy Technical Tips • “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

Confirm Decompression • Does amount of disc removed correlate with preop imaging? • Palpate: – ventral to root/ dura – foramen x 2 – lateral (subarticular) recess

Lumbar Microdiscectomy Postoperative Regimen • Outpatient in over 95% of cases • Multi-modal analgesai protocol • Anesthesia protocol minimizes nausea • No strenuous activity 6 weeks

Thank you!