SPINE Volume 30, Number 22, pp 2570 –2578

©2005, Lippincott Williams & Wilkins, Inc.

An Extreme Lateral Access for the Surgery of Lumbar

Disc Herniations Inside the Spinal Canal Using the
Full-Endoscopic Uniportal Transforaminal
Approach–Technique and Prospective Results
of 463 Patients

Sebastian Ruetten, MD, PhD, Martin Komp, MD, PhD,

and Georgios Godolias, MD, Prof

Study Design. Prospective study of patients with lum- The extreme lateral access is required for the indications
bar disc herniations who were operated on with a full- described. There are clear limitations outside these indi-
endoscopic uniportal transforaminal approach using an cations. The possibility of selecting an access from pos-
extreme lateral access. terolateral to extreme lateral now enables surgery of lum-
Objectives. To examine the technical possibilities of bar disc herniations inside and outside the spinal canal.
an extreme lateral access for full-endoscopic uniportal Key words: discotomy, endoscopic nucleotomy, trans-
transforaminal surgery of lumbar disc herniations within foraminal nucleotomy, minimally invasive spine surgery,
the spinal canal. Also, to assess sufficient decompression, disc prolapse. Spine 2005;30:2570 –2578
and the advantages and disadvantages of the minimally
invasive procedure.
Summary of Background Data. Conventional pro- The goal of therapy in symptomatic lumbar disc pro-
lapsed disc operations can result in consecutive damage lapses is a successful conservative procedure. However,
as a result of traumatization. The usual transforaminal when these possibilities have been exhausted, an opera-
access is posterolateral, and is associated with problems tion may be necessary. Despite sufficient results, experi-
in reaching the epidural space directly with unhindered
ence with revision procedures has shown that scarring of
vision and, thus, with problems of sufficient decompres-
sion in lumbar disc herniations within the spinal canal. the epidural space occurs,1– 6 although this may remain
Methods. A total of 463 patients were observed for 1 unremarkable in magnetic resonance imaging (MRI).3,7
year. In addition to general and specific parameters, the According to the literature, more than 10% of these
following measuring instruments were used: visual ana- cases may become clinically symptomatic.4 – 6 Revision
log scale, German version North American Spine Society
of such scars is demanding, apt to recur, and usually not
Instrumentarium, Oswestry low back pain disability ques-
tionnaire. completely possible. Even when a pain syndrome is
Results. There were no complications. Of the patients, present, an attempt is made to avoid such procedures.4,6
81% reported no longer having leg pain, and 14% had An induced segment instability resulting from the neces-
occasional pain. There was no worsening. The results sary resection of ossary and ligamentary structures is
were constant and are equal to those of conventional
discussed.8 –15 The route of access may injure stabiliza-
procedures. No patients presented with neural scarring;
7% had recurrence of the prolapse. The extreme lateral tion and coordination systems, and encompass trauma-
access was necessary to reach the sequestered material. tization of the innervation area belonging to the dorsal
Conclusions. The technique presented is an adequate segment of the spinal nerves.1,16,17 These parameters are
and safe alternative to conventional procedures, and has held co-responsible for the failure of revision procedures
the advantages of a truly minimally invasive procedure.
in the post-discotomy syndrome.4,18,19
Microscopic or endoscopic-assisted dorsal procedures
can reduce the damage to the surrounding tissues, but
From the Department for Spine Surgery and Pain Therapy, Clinic for not to the structures of the spinal canal. Postoperative
Orthopaedics and Traumatology, St. Anna-Hospital, Herne, Depart- pain syndromes can be treated with surgery, medication,
ment for Radiology and Microtherapy, University of Witten/Herdecke, or neuromodulative therapy.2,20,21 Nonetheless, lumbar
Herne, Germany.
Acknowledgment date: January 7, 2004. First revision date: June 5, disc operations should be continuously optimized. Con-
2004. Second revision date: November 6, 2004. Acceptance date: sidering existing quality standards of conventional pro-
December 6, 2004. cedures, the goal should be to minimize operation-
The manuscript submitted does not contain information about medical
device(s)/drug(s). induced traumatization and negative long-term sequelae.
No funds were received in support of this work. No benefits in any Minimally invasive techniques can reduce tissue dam-
form have been or will be received from a commercial party related age and its consequences.22–24 Endoscopic operations
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Sebastian Ruetten, have advantages that raise these procedures to the stan-
MD, PhD, FABMISS, Head, Department Spine Surgery and Pain Ther- dard in many situations. Working with lens optics under
apy Clinic for Orthopaedics and Orthopaedic Surgery, Department for fluid enables excellent visual conditions. Bleeding can be
Radiology and Microtherapy, University of Witten/Herdecke St. Anna-
Hospital Herne Hospitalstrasse, 19 44649 Herne Germany; E-mail: reduced. The use of the laser or high-frequency bipolar
[email protected] current can be applied in the immediate vicinity of neural

2570
 Extreme Lateral Access • Ruetten et al 2571

structures.25,26 A prerequisite is that the technical possi- disc herniations within the spinal canal. The focus was
bilities of such operations guarantee that the surgical on sufficient decompression compared to the results of
goal can be attained.27 conventional procedures, possible effects of slighter trau-
Percutaneous operations of the lumbar discs, such as matization with avoidance of resection of segments of
intradiscal decompression, were published in the early the spinal canal, possible specific complications, and the
1970s.28 Optical systems only for inspection of the inter- technical creation of access depending on pathologic and
vertebral space after completed open surgery have been anatomic correlates.
used since the early 1980s.29 Currently, the interverte-
bral disc can be reached with the full-endoscopic unipor- Materials and Methods
tal technique via a posterolateral access within the fora- In this prospective study between 2001 and 2002, 2 surgeons
men intervertebrale, between exiting and traversing operated on 603 patients with the full-endoscopic uniportal
spinal nerves, without resection of bony or ligamentary transforaminal technique via the extreme lateral access. A total
segments.30 –34 By reducing intradiscal volumes and of 86 patients did not speak German. The perioperative com-
pressure, reduction of the disc-related compression munication was either in English or with the help of an inter-
should be achieved.35 Removal of the intra-foraminal or preter. Because the scores used for recording the results were, in
extra-foraminal sequester is technically possible.36 Re- part, specifically validated for German language use, they could
section of the prolapsed nucleus material within the spi- not be used without reservations. Thus, these nonGerman-
nal canal, such as a retrograde resection, performed in- speaking patients were excluded from the study. Assessment of
all parameters recorded preoperatively for these 86 patients
tradiscally through the existing anulus defect has been
showed no differences from the other patients. Thus, the study
described.33,34,37– 40 Most of these procedures are per- collectively consisted of 517 patients.
formed with the patient under local anesthesia. A total of 277 patients were women, and 240 were men. The
The most frequent localization of lumbar disc pro- age range was from 16 to 78 years, with a mean of 38 years.
lapses are in the lower levels. The diameter of the fora- The load profile was evenly distributed regarding occupation
men intervertebrale decreases in the lumbar area, from and sports. A total of 87 patients were self-employed or did
cranial to caudal. An additional narrowing may result freelance work, and 76 were employed in the household. The
from degenerative changes. Sequestered nucleus material educational status covered all ranges. No patient was retired as
is found within the spinal canal dorsal to the intraverte- a result of the reported complaints. There were 32 patients who
bral disc in the ventral epidural space, medial to the me- were unemployed, and 389 were on sick leave. A total of 112
dial pedicle line, and very often extending to the middle patients had private hospital insurance, and 223 had insurance
providing a daily hospital allowance. Height and weight were
line or toward the contralateral side.
evenly distributed.
Clinical experience has shown that the anulus defect is All patients presented with clinically symptomatic lumbar
often smaller than the diameter of the sequester volume, disc prolapse. A total of 479 had MRI, and 38 had computer-
and, especially in dislocated sequesters, there is often no ized tomography (CT) because of positioned implants or claus-
longer a continuous connection to intradiscal. In the case trophobia. The pain duration ranged from 11 months to 1 day
of badly degenerated discs or older disc prolapses, the (mean 97 days). A total of 271 patients had neurologic deficits.
sequester material often has no continuous substance There were 44 patients who had bilateral symptomatics, 13 a
any more but consists of a grainy substance or individual contralateral, and 46 presented with a bisegmental finding. In
fragments. Removal in one piece is usually not possible these patients, neurologic examination and interventional pain
in such cases. Thus, the intended retrograde sequester diagnostics were performed to verify the level. No patient had
resection from intradiscal is often technically limited. Ac- undergone prior surgery at the same level, and 31 had been
previously been operated on at a different level. A total of 414
tive flexible instruments that pass through the working
patients had received prior conservative therapy for a mean of
canal of the endoscope in uniportal procedures are of 9 weeks. There were 103 patients who underwent an acute
very limited availability because of technical difficulties operation. Indication was founded in accordance with current
and, used from intradiscal, do not permit going beyond standards on radicular pain symptomatics and existing neuro-
the disc level. For adequate decompression, the direct logic deficits.41,42 Back pain and spinal canal stenosis without
reaching of the ventral epidural space under visual con- disc prolapse were not considered indications for surgery. A
trol is frequently necessary. Especially at the lower levels total of 328 procedures were performed at level L4/5, 153 at
with smaller foramen intervertebrale, this may be im- L3/4, 27 at L2/3, and 9 at L1/2, whereby the term L4/5 indi-
peded in using the usual posterolateral approach in cates the definition of the penultimate-free level. Surgery was
uniportal procedure, so that an unequivocal preopera- on the right 223 times and left 267 times. There were 27 cases
tive prognosis of adequate decompression is not always that were operated bilaterally (sequentially first from 1 side
then from the other), of which 14 were in bilateral symptom-
possible.38 After access is created, directing the endo-
atics and 13 in contralateral disc prolapse. Each time, the
scope to reach the spinal canal tangentially is technically uniportal technique was used, consisting of concurrent work
impossible because of the preceding passage through the with endoscope and instruments via 1 access.
soft tissue. At the start of the study, the surgical procedure was stan-
The objective of this study was to examine the tech- dardized. CT, cadaver trials, and completion of the usual learn-
nical possibilities of an extreme lateral access for full- ing phases, including experience with the posterolateral trans-
endoscopic uniportal transforaminal surgery on lumbar foraminal and open retroperitoneal or transposase accesses,
2572 Spine • Volume 30 • Number 22 • 2005

preceded the study. Lumbar disc herniations within the spinal

canal were considered inclusion criteria for the extreme lateral
access. There was no limitation to the ventrodorsal or latero-
lateral extent of prolapse or in intradiscal space reduction fo-
ramen or spinal canal stenosis. Based on experience regarding
limited technical freedom of movement, the maximum limit of
sequester dislocation was set caudal at the middle of the pedicle
and cranial at the lower edge of the pedicle. Situations in which
radiologic examination with strict lateral radiation showed
that the pelvis on the corresponding side overlapped the fora-
men intervertebrale more than to the middle of the cranial
pedicle were excluded from the study. Other than general sur-
gical contraindications, there were no exclusion criteria regard-
ing general illnesses. Surgery was performed 293 times with
patients under local anesthesia, 224 times with them under
general anesthesia.
The surgical access was created with the patient in the prone Figure 1. Extreme lateral access for a full-endoscopic uniportal
position under orthograde radiologic control in 2 planes. First, transforaminal operation.
localization of the skin incision was marked. This procedure
was oriented depending on anatomy and pathology to the tar-
get point (i.e., localization of the prolapse). The smaller the tect neural structures. WOLF (Firma Wolf, Knittlingen, Ger-
foramen, the longer the pathway in the tissue between skin and many) is the manufacturer of the entire access instrumentar-
foramen or, the more dislocated the sequester, the more lateral ium, optics used, and mechanical instruments. The lens optic
the skin incision had to be. The aim was to make tangential had a diameter of 6 mm, with a 2.7-mm working canal. In
reaching of the spinal canal possible. For levels L3/4 and L4/5, addition, semiactive-flexible bipolar probes with high-
the dorsal edge of the processus articularis inferior limited the frequency current manufactured by Ellman (Ellman Innova-
area of entry toward ventral in lateral radiation. Paying atten- tions, Oceanside, NY) and Select Medizin Technik (Select
tion to the more dorsal extension of the intra-abdominal or Medizin Technik Herman Sutter GmbH, Freiburg, Germany)
intrathoracic space, a more individual, less lateral access could were used for preparation and coagulation.
be selected for L1/2 and L2/3 because of the enlargement of the Examinations defined in the preoperative protocol were
foramen intervertebrale, which increases toward cranial. In made 1 day, and 3, 6, and 12 months postoperatively. In addi-
these cases a preoperatively selective single slice CT including tion, patient examinations were performed in the event of spe-
the whole intraabdominal structures and the skin was per- cific problems. In addition to psychometric tests of pain ther-
formed, especially in cases of narrowed foramen or retroperi- apy, the following validated measuring instruments were used:
toneal preoperations. visual analog scale (VAS) for back and leg pain (always for the
A 1.5-mm atraumatic spinal cannula is inserted via the skin period 1 week before post-examination), German version
incision through the foramen, directly toward the spinal canal North American Spine Society Instrumentarium (NASS),43,44
into the target area (i.e., the disc prolapse). The point of the and Oswestry low back pain disability questionnaire.45 (This
needle lies in its final position in the lateral ray path at the level score is not unequivocally validated for German language use
of the dorsal anulus, whereas in the anterior-posterior view, the but was used in a translation because it is widely used interna-
middle line can be reached thanks to the lateral access and tionally.) Regarding general criteria, the following parameters
nearly horizontal needle positioning. Penetration of the needle predominated: sufficient decompression, complications, oper-
point ventral to the dorsal anulus usually characterizes a too- ating time, bleedings, scarring, postoperative pain, postopera-
sharp access angle. At the same time, it should be avoided that tive therapy, pain reduction, reduction of neurologic deficits,
the needle point lies further dorsal because the dorsal anulus rehabilitation time, work disability, work fitness, sports fitness,
defines a safe area regarding the spinal canal structures. After recurrences, revisions, and subjective satisfaction.
insertion of a 0.8-mm lead wire, the cannulated dilator with an To enable a high number of post-examined patients, consid-
outer diameter of 6 mm is pushed to the start of the foramen. ering the broad geographical area involved, all parameter and
At this point, the target wire may be removed so that further measuring instruments could be answered in the form of a
position correction toward dorsal in the direction of the epi- questionnaire. In addition, it was possible to contact the study
dural space can be made safely with the blunt dilator. The participants by telephone. Postoperative imaging was per-
passage through the foramen intervertebrale was made for formed randomly or in the event of unusual occurrences, and a
more precise control and possible expansion of the structures MRI was recorded 63 times after surgery. The descriptive as-
by hammering. The dilator is inserted to the medial pedicle line. sessment and analytic statistics were performed dependent on
A surgical sheath with a beveled opening and an outer diameter group characteristics using the program package SPSS (version
of 7 mm was then placed facing ventral over the dilatator at the 10.0.7, SPSS, Inc., Chicago, IL). A positive significance level
start of the foramen to protect exposed nerves. After the open- was set at P ⬍ 0.05.
ing was turned toward dorsal to protect the neural structures
lying dorsal within the spinal canal, the surgical sheath was Results
pushed through the foramen. From that time on, decompres-
sion was performed under visual control and gravity controlled A total of 463 (89.5%) patients were included in the
liquid flow (Figure 1). If further penetration into the epidural complete postoperative examination. There were 3 rea-
space is necessary, it is performed under visual control to pro- sons for the 54 subjects to dropout: (1) death unrelated
 Extreme Lateral Access • Ruetten et al 2573

to surgery, (2) 12 moved with no forwarding address,

and (3) 38 did not respond to letters or telephone calls.
All results obtained were independent of gender, age,
height, weight, educational level, and insurance status,
status on the job market, or secondary illnesses.
The operating time in a unilateral procedure was be-
tween 16 and 47 minutes (mean 27). No measurable
blood loss occurred. There were no surgery related com-
plications in any patient. No postoperative pain medica-
tion was necessary. Mobilization was possible without
exception within a few hours after surgery. All patients
were provided with a stabilizing lumbar orthosis for 6 Figure 2. The mean values of VAS leg and back, and Oswestry.
weeks. Rehabilitative measures were performed only in
patients with persistent pareses.
vation of the intravertebral space on the recurrence rate.
A total of 181 patients (39%) presented intraopera-
Endplate material was diagnosed to at least 75% in each
tively with extensive epidural adhesions that could not
case. The rest consisted of degenerated nucleus tissue.
be diagnosed before surgery. Contrary to the MRI find-
The pathologists did not find any anulus tissue.
ing, in 43 patients (9%), only hard tissue, histologically
The results of the measuring instruments of the 396
corresponding to anulus, ligament or knotty nucleus tis-
patients with nonrecurrence are presented in Table 1 and
sue could be found. In these patients, there was a signif-
Figures 2, 3. The 35 open spinal canal decompressions
icant relationship with the existing back pain and dura-
and fusions, as well as the 32 patients with recurrent
tion of complaint longer than 6 months. Of these
prolapse are not included. A constant improvement is
patients, 31 were reoperated on with spinal canal decom-
seen with the exception of isolated back pain assessment.
pression, and 4 with fusion.
Reduction refers especially to leg pain and activities of
Thirty-two patients (7%) had recurrent disc prolapse,
daily living. A total of 322 patients (81%) had no more
of these, 29 had it during the first 5 months. There were
leg pain, 53 (14%) had occasional or considerably re-
4 revisions made by a microscopic-assisted technique, 3
duced leg pain, and 21 (5%) had no essential improve-
times because of pronounced sequestering, once at the
ment. The latter belonged without exception to the
patient’s request. A total of 28 recurrences were operated
group of those patients with intraoperatively diagnosed
on using the same technique. In these cases, there was
epidural adhesions or hard tissue. No significant influ-
another recurrence in 4 of 463 (0.86%), which were
ence was observed on back pain. With the exception of
endoscopically operated on in 3 and conventionally in 1
the first postoperative day, there was no significant sur-
case. These 4 patients had presented at the start with
gery related deterioration in back or leg pain. Regression
kyphotic deviation in the segment and collapse of the
of neurologic deficits was significant only with a history
intravertebral space over the course. The collected mate-
⬍7 days; there was no correlation to electromyography
rial from the recurrent prolapses was histologically ex-
or nerve conductance speed. Hypesthesias were less often
amined, considering the possible effect of complete exca-
regradient than paresis. There was significant depen-
dency between poorer results and longer history of back
Table 1. Individual Results of the Measuring Instruments pain, and degenerative epidural adhesions.
VAS VAS NASS NASS
Of all 463 patients, 409 (88%) had subjective satis-
Leg Back Pain Neurology Oswestry faction and would undergo the procedure again. This
statement applies to 379 (96%) of the 396 patients with
Preop nonrecurrence. A total of 353 patients who were not
Min 45 0 2.2 2 36
Max 100 75 5.1 6 100 unemployed or retired continued their jobs or sports, ad
0 71 18 4.2 3.1 78
1 Day
Min 0 0 — — —
Max 35 80 — — —
0 4 14 — — —
3 Mos
Min 0 0 1 1 0
Max 45 55 3.4 3.6 64
0 8 18 2.4 2.0 22
6 Mos
Min 0 0 1 1 0
Max 55 45 5.3 3.8 52
0 9 16 2.5 2.1 24
12 Mos
Min 0 0 0.1 1 0
Max 50 45 4.5 3.8 68
0 8 16 2.4 1.9 20
Figure 3. The mean values of NASS pain and neurology.
2574 Spine • Volume 30 • Number 22 • 2005

16 were incapable of doing so because of persistent pa- even of disc prolapses sequestered within the spinal ca-
resis. The postoperative work disability lasted between 5 nal. As 1 of the main therapeutic criteria, the constant
and 24 days (mean 12). There were no significant differ- reduction of leg pain can be rated as a causal of success of
ences regarding degree of stress or occupational status. sufficient sequester removal under visual control. For
The routine performance of postoperative MRI for this, selection of the lateral access was necessary. The
pure study purposes without clinical symptoms was not results of microscopic-assisted operations, which are be-
possible in the authors’ health system because of costs as tween 75% and 100%, are attained.14,46 –51 The possi-
a result of the number of patients involved. A total of 78 bility of sufficient decompression with the endoscopic
postoperative MRI was performed, including 66 after a transforaminal technique equal to that of conventional
period of at least 3 months. Of these were 32 patients procedures is also shown in a prospective randomized
with recurrent disc herniation after a free clinical inter- study with specific inclusion criteria.52 Operating time,
val, 35 patients were treated later with spinal decompres- tissue traumatization, and complications, such as dural
sion or fusion and 11 patients without clinical symp- injury, nerve damage, bleeding, or infections, are mini-
toms. All MRI was performed using contrast dye. mized.2,53–59 The remaining levels in the NASS pain and
Radiologists who had preoperative MRI in hand made Oswestry result from the lack of reduction in back pain,
the assessment. Considering the clinical situation and which is to be expected in these indications.14,49,51,54,60
imaging, the findings of the 32 patients with recurrent Corresponding to the published advantages of a mini-
complaints after a clinically free interval were diagnosed mally invasive intervertebral and epidural procedure,61– 64
as having recurrent disc prolapse. The 35 patients with there was no increase of existing symptoms. The possi-
an intraoperative finding of only hard tissue had no bility to dispense with bony and ligamentary resection,
changes from the earlier finding. No further disc pro- and the selective evacuation of the intervertebral space
lapse could be diagnosed on the 11 MR images of pa- serve according to today’s knowledge to prevent surgery
tients without clinical symptoms. Intra-foraminal induced instabilities.14,62,63,65–72 The desirable compar-
changes, which could be rated as caused by surgery, were ison with a nonoperated control group would be difficult
diagnosed 31 times. No intra-foraminal or extra- to perform using the present indications. The not clearly
foraminal changes in neural structures, such as scar dis- predictable reduction of neurologic deficits4,73 showed
tortions, were observed. No scars were observed inside better response in shorter history and in paresis than in
the spinal canal in the epidural space; this was confirmed hypesthesias. Surgery related rehabilitative measures are
in revision procedures. The cover and base plates, as well not necessary. There is a comparatively high return to the
as neighboring vertebral bodies showed no increased re- occupational and athletic level of activities.74 Criteria
actions compared to preoperative measurements, such as like gender, age, height, weight, educational status, in-
those observed after conventional disc operations with surance status, or status in the job market had no influ-
excavation of the intradiscal space. No difficulties in sub- ence. There was no increased morbidity with secondary
sequent procedures as a result of the primary operation factors.53,55,58 There are no differences in results be-
were observed. Clinical symptoms of surgery related tween of the temporally sequential bilateral procedures
scarring, such as a post-discotomy syndrome, did not in uniportal technique and the purely unilateral opera-
occur. tions.
There were no differences in results within the various The recurrence rate of 7% is in the framework of
levels. A resection of bony segments could be avoided selective sequestrotomy75–78 and decreases after the fifth
without exception. The use of bipolar high-frequency postoperative month. Multiple recurrences occurred in
probes was necessary in all cases for preparation and to segmental kyphotic deviations as part of a degeneratively
arrest bleeding. For the controlled complete resection of caused collapse of the intravertebral space. Revisions can
the sequester material under visual control, the extreme be performed using the same technique. The extreme
lateral access was necessary without exception. The re- lateral access makes entry into the intravertebral space
sults of the temporally sequential bilateral procedures in difficult with the stiff instruments used. The negative ef-
uniportal technique did not differ from those of the fects of complete resection of a degenerated nucleus,
purely unilateral operations. There was no difference in with its questionable biomechanical worth, have not yet
results between local and general anesthesia. Measure- been completely elucidated.1,4,63,79 Minimization of the
ments of lavage inflow and outflow showed maximum anulus defect may have a higher protective influence than
100-mL fluid remaining in the body. nucleus preservation.79 Because evacuation of at least the
dorsal area appears to reduce the frequency of recur-
Discussion
rence, the authors used new flexible instruments to resect
The goal of the surgical treatment of lumbar disc pro- the nucleus material with minimal trauma, depending on
lapse is sufficient decompression, with minimization of the structure of the anulus defect. According to our own
surgery induced traumatization and its consecutive se- results, this reduced the recurrence rate to less than 1%.
quelae. The present study results show that the full- Complete prevention of recurrence cannot be expected
endoscopic uniportal transforaminal operation via the because of the proportion of more than 75% endplate
extreme lateral access offers therapeutic possibilities, material.
 Extreme Lateral Access • Ruetten et al 2575

Not one case of a post-discotomy syndrome occurred the authors see the necessity of the extreme lateral access
during the entire post-observation period. Epidural as a given because of possible consecutive damage and
scars, which would be expected with conventional tech- considering the goal of a minimally invasive procedure.
niques and which, in up to more than 10% of patients, The increase in size of the foramen at L1/2 and L2/3
may lead to clinical symptoms,1,3–7 were not detected usually makes a less lateral procedure possible, so that
either on MRI examinations or during revision surgery. the internal organs are protected. A large or sequestered
Subsequent endoscopic or conventional procedures can herniation, a long approach through the soft tissue and
be performed without difficulty and show none of the especially cases of narrowed foramen demand a lateral
extended operating time described.80 Moreover, the epi- access. Safety must take precedence in such cases (i.e.,
dural lubricating tissue is preserved. This effect corre- prevention of complications, such as injury to abdominal
sponds to the descriptions of better results with reduced structures). If preoperative, layer image diagnostics are
traumatization of the ligamentum flavum.81,82 initiated by the authors, an appropriate width of the scan
A risk of neural damage while performing the proce- window in the segment to be operated on is demanded to
dure with the patient under general anesthesia was not permit assessment of the approach pathway. In patients
confirmed and has already been published.83 With the with diagnostics performed at other hospitals, the win-
given indication, there is no necessity for intraoperative dow size of the scan often only permits evaluation of the
stimulation and operation in local anesthesia. This, com- spinal column structures. In such cases, at least a preop-
plied with the patient’s wishes, shortened the operating erative selective single CT with a broad window should
time and simplified the intraoperative procedure. The use be performed to define the safe access pathway. This
of semiactive-flexible bipolar probes and high-frequency procedure applies especially for patients in whom retro-
current was an essential instrument for preparation and peritoneal operations were performed earlier. At level
stopping bleeding. In light of the minimally invasive pro- L5/S1, the extreme lateral access is usually not possible
cedure, the authors do not currently consider the general because of the pelvis. Overall, anatomy and pathology
relationship between longer anamnesis and poorer pain determine the operative access so that a less lateral up to
reduction as a reason to decide on early operation. Pa- even a posterolateral access is necessary (e.g., in intra-
tients with poor results in the present study all presented foraminal or extra-foraminal disc prolapses) in intradis-
with additional secondary factors such as degenerative cal procedures or fusions (Figures 4, 5).
fibroses, which could not be unequivocally diagnosed by The optics used with a 2.7-mm working canal and
imaging,7,84 as known from endoscopic operations even corresponding not actively moveable instruments do not
when no disc prolapse is present.84 – 86 enable larger resections of hard tissue and cause a limited
Various investigators describe the removal from the radius of action within the bony foramen intervertebrale.
epidural space of prolapsed discs lying within special Cranial, the protruding spinal nerve limits mobility.
indication criteria, such as retrograde resection, per- Thus, problems occur as a result of compressions by hard
formed intradiscally via the anulus defect.33,34,37– 40 tissue and the sequesters that extend beyond the limits of
Some investigators describe resection of all forms of disc cranial and caudal dislocation.
prolapse.33,34 In contrast, considering the inclusion cri- Considering individual pathology and anatomy, the
teria in the introduction, the authors are of the opinion guiding indication for the present technique is radicular
that complete and safe resection of prolapsed discs compression symptoms caused by disc prolapse. There
within the spinal canal must be performed under visual are no limitations as to ventrodorsal and laterolateral
control because they frequently are not conjoined and extension of the prolapse or in additional reduction of
cannot be removed from intradiscal retrograde via the
anulus defect. This applies especially to transligamentary
and sequestered prolapses. Even if certain disc prolapses
can be resected with posterolateral access, it is the au-
thors’ opinion and experience that this cannot be pre-
dictably guaranteed with the inclusion criteria defined
for this study, and that should be the basic premise for
comparison with conventional surgical procedures. The
necessity of the lateral access in reaching the epidural
space was also found in the present study. Various inves-
tigators39,40,87–91 have already discussed and described
the necessity, and possibility of increased laterality of the
transforaminal access. In addition, the examinations
showed that there are clear exclusion criteria, even in
using the lateral access, as explained later. This means
that in the authors’ opinion, not all disc prolapses can be
operated on with the transforaminal technique, even with Figure 4. Posterolateral access for the full-endoscopic transfo-
lateral access. As long as bony resections can be minimized, raminal operation.
2576 Spine • Volume 30 • Number 22 • 2005

side the spinal canal can now be adequately operated on

with the full-endoscopic uniportal transforaminal tech-
nique, considering the pertinent criteria.
Although data are now available for a maximum of 4
years, we have presented only the 1-year results for better
comparability. The statements can be made without ab-
solutely requiring a control group, thanks to the patients
included and the study design. Nonetheless, studies have
already been started with prospective randomized con-
trol groups, but these can be performed only in partial
areas in the present indications for medical and ethical
reasons.
Thus, newly developed optics, larger and flexible in-
struments, shavers and burrs reduce the problems of the
procedure in light of available results of their own stud-
Figure 5. Working area shifted by extreme lateral access into the ies. In transforaminal-technically inoperable disc pro-
spinal canal.
lapses, the authors used a full-endoscopic uniportal in-
terlaminar access. Overall, a development potential was
intradiscal space, foramen, or spinal canal stenosis. The seen in technical aspects, which may lead to expanded
craniocaudal sequester dislocation cranial should not ex- indications also regarding spinal canal decompressions
ceed the lower edge of the pedicle and caudal, the middle and fusions. However, total avoidance of known prob-
of the pedicle. Radiologically, the foramen interverte- lems in spinal column operations can hardly be imag-
brale should be covered in strict lateral radiation maxi- ined. In addition, open procedures will remain as indis-
mally to the middle of the cranial pedicle. Isolated spinal pensable in the future as they currently are now.
canal stenoses and back pain are not an indication. Con-
sidering these criteria, the extreme lateral access enables
predictably sufficient decompression and its visual con- Key Points
trol. Outside these criteria or with a purely posterolateral ● The extreme lateral access is necessary to enable
access, the authors see clear limitations to the procedure, the full-endscopic transforaminal operation of
contrary to conclusions in various publications.33,34,37–39 lumbar disc herniations within the spinal canal,
Conclusion with clear vision in a sufficient and predictable
manner.
The present study results show the possibility of suffi- ● The results of decompression are equal to those
cient decompression equal to that of conventional pro- of open, microscopically- or endoscopically-
cedures, which must be attained as a minimum with any assisted procedures, taking the indication criteria
new procedure.27 At the same time, all the advantages of into consideration, and possess the advantages of a
a truly minimally invasive procedure with lower trauma- truly minimally-invasive procedure.
tization and shorter operating time are given. Scarring is ● The procedure has clear limitations outside the
avoided, and the intra-epidural lubricant structures re- indication criteria.
main intact. A post-discotomy syndrome or other sur- ● At level L5/S1 and often above, the necessary
gery related deteriorations do not occur. Revisions are lateral access is usually not possible due to the iliac
not made more difficult. As far as yet is known, the pro- crest.
cedure causes no surgery induced destabilizations. Com- ● With the possibility of selecting an access from
plications or increased morbidity in older patients are posterolateral to extreme lateral, lumbar disc her-
slight. Shorter hospitalization, more rapid rehabilitation, niations can now be sifficiently operated outside
and high patient acceptance are observed. There are and inside the spinal canal in a full-endoscopic
problems caused by the instruments during resection of transforaminal technique.
hard tissue, evacuation of the intradiscal space, and mo-
bility with the consequence of a risk of recurrence and
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