1. 2013;16;E31-E35Endoscopic Transforaminal Discectomy for an Extruded Lumbar Disc Herniation
   Case Report
   Gabriele P Jasper, MD, Gina M Francisco, BSc, and Albert E Telfeian, MD, PhD.

Microsurgery for lumbar herniated discs that require surgical intervention is a very successful and well-described technique, whether performed through more traditional “open” microsurgical retractors or through minimally-invasive “tube” retractors. Surgery for extruded lumbar disc fragments that migrate caudad or cephalad from the disc origin may typically require modifying the standard hemilaminotomy by removing additional laminar bone to retrieve the migrated fragment. Although midline and paramedian Wiltse approaches have been the standard methods for resecting herniated lumbar disc fragments, advances in neuroendoscopic techniques have expanded the potential targets for transforaminal endoscopic treatment to include extruded lumbar disc fragments. Sequestrations migrated cephalad or caudal to the disc can be removed using specialized flexible instruments. The instruments enable the surgeon to circumnavigate and reach into the epidural space and as far as the mid-vertebral body.

The authors present a case of an endoscopically resected lumbar herniated disc fragment extruded caudad behind the inferior vertebral body through a transforaminal approach in an awake patient using local anesthetic. Radiographic and endoscopic visualization make it possible to access intracanal pathology. Although more traditional lumbar disc surgery is widely performed and is safe and effective, neuroendoscopic procedures may also allow a safe and effective approach for even extruded disc fragments for patients who cannot tolerate general anesthesia or are seeking the most minimally invasive option. Endoscopic discectomy is a minimally invasive alternative to open back surgery. Maintained spinal stability and absence or minimal formation of scar tissue allow for ease of subsequent surgeries, both open and minimally invasive (if needed).