Commentary

Abstract

Improvements in imaging techniques have allowed surgeons to diagnose more accurately and visualize herniated lumbar discs, which in turn allows precise surgical planning and obviates the need for “exploratory” spinal surgery in most cases. Efforts have been underway by many investigators for many years to lessen the collateral damage to the muscular, ligamentous and osseus structures that was responsible for much of the morbidity associated with traditional surgical approaches. Advances in lighting, microscopes, endoscopes, instrumentation and “retractors” have allowed safer visualization of the neural structures and removal of disc fragments through ever-smaller exposures with less of the painful muscle stripping and retraction of the past. The current study represents one such effort of a surgeon who has developed a technique using a speculum-type retractor and the microscope to remove discs located in the far lateral, foramenal and canalicular locations. The results in terms of immediate perioperative status, short-term follow-up and return to work are similar to other modern series using a variety of minimally invasive techniques. Although the potential usefulness of this technique in terms of far lateral or even foramenal discs is obvious, it is less clear that it offers an advantage in terms of more centrally located fragments. Most surgeons will probably be more comfortable using a more traditional, muscle-splitting, micro-lamino-foramenotomy-type approach with a tubular or speculum-type retractor, which will give better visualization of the axilla of the root, lateral recess and ventral epidural area. This type of approach is also easily accomplished in the outpatient setting with comparable outcomes, and less risk to the dorsal root ganglion from manipulation. Also, the very lateral trajectory of the technique described in this series will not easily allow conversion to a laminectomy without a separate incision, in cases where this is deemed necessary. In summary, then, this series represents another technical variation in the evolution of less-invasive surgical treatment of the herniated lumbar disc.