Herniated lumbar disc

 Herniated lumbar disc

Annulus fibrosus

Resist to tensile force


Nucleus pulposus

Cushion for compressive force

Herniated lumbar disc

Displacement of intervertebral disk material beyond the normal margins of the disk space

nucleus pulposus, annulus fibrosus, or both


Disk-related radiculopathy

biochemical and mechanical process


Contact of the nucleus pulposus with nerve root 

provokes the inflammation

Classification

Anatomic classification

Bulging

Protrusion

Extrusion

Sequestration


Location classification

Central

Posterolateral

Foraminal

Far-lateral

Classification

Bulging

Annular tissue extends beyond normal disc space

Classification

Protrusion

Greatest measure of displaced material is less than base of material

Classification

Extrusion

Greatest measure of displaced material is greater than base of material


Classification

Sequestration

Displaced disk material has lost all connection with the origin


Classification

Location classification

Surgical treatment

Indication

Nerve root compression confirmed on MRI

No response to conservative treatment > 6 weeks

Limitation of daily life


Considerations

Faster relief of radiating pain

Smaller advantage with respect to back pain

Depression, somatization → surgical outcomes↓

SLRT (+) → surgical outcomes ↑

Surgical treatment

Microdiscectomy

Laminotomy and discectomy

Open approach with retractors

Approach with Tubular retractor


Endoscopic discectomy


Additional approaches

Hemilaminectomy, facectectomy, paraspinal approach

Tubular VS conventional

Randomized clinical trial (n=325)

Conventional microdiscectomy (n=159)

Tubular discectomy (n=166)


5 years f/u

RDQ, VAS for leg pain and low back pain, self-perceived recovery and re-OP incidence

No clinically significant difference at any time point during the 5 years of follow-up

Approach using tubular retractor

Approach using tubular retractor

Approach using tubular retractor

Approach using tubular retractor

Microdiscectomy

Microdiscectomy


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