This is a 20-minute video of a 43-year-old male with lumbar radiculopathy from lateral recess and foraminal disc herniation. Tubular lateral recess and foraminal discectomies were performed.
Hi. Uh my name is Doctor Sang Do Kim. I'm an orthopedic spine surgeon at Cedars Sinai. I have a video for you today for a tubular decompression uh surgery. This is an interesting 43 year old male who presents with a lower back pain and pain radiating down the left leg over the thigh, knee and shin with numbness and tingling. He's tried prior conservative treatment without improvement. Um He had uh most of his pain uh was pain shooting down the left leg. He had the minimal back pain. Otherwise, he was a very muscular 6 ft £200 man with uh notable left quadriceps and tibialis anterior weakness. Uh x-rays here demonstrate no scoliosis or spinal the, but he does have some degenerative disc disease at L five S one MRI here uh demonstrates a L 45 disc herniation uh that uh has some migration inferiorly into the uh lateral recess, um as well as a foraminal component at the left L 45 neuro and uh causing uh L four exiting nerve root compression. Initially. Uh We had planned to uh consider doing a uh uh dual portal uh endoscopic uh decompression. Uh But we ultimately decided to uh pursue tubular decompression, both of the lateral recess and the foramen. Here is the uh video of us uh finishing up the uh lateral recess uh decompression. The uh traversing uh L five nerve root is retracted superiorly there. Um And you can see some of the uh disc uh that had extruded um into the uh lateral recess. Uh There's a small fragment that that's coming out. And you can see that there's some more dis uh remaining. The nerve hook is being used uh to try to free up this uh fragment. Whenever the instruments are being passed in and out of the tube, the assistant does aware and uh taking some of the uh pressure off the uh retraction. You can see here. Now the fragments starting to come out, we try to take it out all in one piece. So a fairly large fragment just came out and part of that could have been a, a phenomenal uh extension. Uh Again, another fragment coming out here. So a lot more disc coming out uh than expected based on just the lateral recess uh extrusion, some epidural bleeding here. This is coagulated with the bipolar. So this is a uh surgical view. You can see the um midline incision that was done for the tubular decompression uh for the lateral recess. This is more of a we'll see incision uh over the L 45 segment. Um here we're putting uh the tubular system for dilation. I trying to center this uh over the L 45 for Amon. Yeah, I believe this was a 16 by 50 millimeter tube. Uh This is being mounted to the table and you can use the dilators as the joystick to make sure that you have the tube in the right place and fine adjustments are being made uh with the largest dilator. Now, we have the microscope uh brought in for magnification and illumination here, I'm using a cop to just scrape off some of the tissue, uh overlying the parts and the facet joint, the tube is centered over the corner of the inferior parts of L four and the superior aspect of the joint, this is a safe spot but because it almost gives you access to the Kamens triangle here, um just boving the muscle over the uh parts, your nerve root is going to be underneath the um inter um transverse uh membrane. Um So here I'm using the bipolar just to make sure that I'm not transmitting too much heat. Um Here, I'm feeling for the lateral edge of the parse. And so really at this point, the important part is to make sure that um right at the corner of the L four inferior pars and the uh facet joint, um you do end up taking a little bit of the uh facet joint. But even if you were doing a lateral recess, decompression you end up doing a partial facetectomy. So the amount of uh joint that you take here, I don't think is significant. Um I've just repositioned the tube so that I can see that inferior margin. So here I'm bowing over the um superior aspect of the joint in the corner where the parts uh becomes the uh inferior articular process. I'm feeling with my uh suction. Uh for the anatomy here again, you're seeing a good view of the uh edge of the pars of L four was bipolar some of the soft tissue and confirming my uh anatomical landmarks. Really, the key here is to um release the intertrans verse ligament. It is a little bit of synovial tissue uh from the top of the joint here, I'm just releasing some of the tissue from the top of the joint as well as the um transverse process. Again, you have to be very careful that you don't uh Bovi uh in between below the transverse uh ligament here. I'm taking about five millimeters of uh the pars. Um This helps to release the um transfers uh ligament. This is taking a little bit at the joint as well. So all the work from here would be mostly done by bipolar just to avoid the injuring the nerve underneath. This, the inter transverse membrane can be quite thick and um you have to uh really just go about it slowly to release it. But once you release it um as you'll see in a little bit, you'll see the nerve root right underneath it. And what I like about this approach is that it's very predictable. Previously, I would put a K wire, um, into the, um, the foramen and try to put a, a dilated tube. It was just never really predictable where the nerve was and it was very nerve wracking. Um, two use a bipolar dissection all the way down here. Once you release the intertrans verse ligament, it is very predictable where the nerve root is. And that corner from 12 o'clock to about three o'clock is a very safe area. Uh And this is where I start the decompression. Um and this is all in an effort to release the intertrans ligament and to identify the, the nerve root, you are using the kero and to release the intertrans ligament uh immediately you may encounter some lateral edge of the um ligamentum flavum. So, again, from 12 to 3 o'clock, uh in this view, uh you are safe um from the nerve. And so most of the work again is starts from this area. There are lots of epidurals in this area that uh can cause some bleeding. You can start to see the disc. I'm just trying to separate out the epidurals and some of the um capsule away from this area. You can start to see the nerve root right next to me uh to the suction there. You'll see it. Uh better in a second. So again, you're seeing some of the intertrans verse ligament being um taken off and you can see the nerve root on the left side don't necessarily have to take off the entire inter transverse ligament. But you can see the nerve root right underneath there and it gives you a much better visualization. It does help to rotate the table a little bit so that you're looking down uh straight rather than at an angle. Again, I really like this approach compared to the um approach that I used to do with the tube coming underneath the facet joint, it aiming directly at the uh foramen just because you end up coming at quite a bit of an angle. And um you, you end up using a much longer tube here, we're getting ready to start the annulotomy. I had the assistant come in with the knife but he couldn't get a good angle. Um And I realized that the disc here um at least this component that's compressing on the nerve is uh uh a little bit calcified. It's possible that we got some of the soft tissue component uh from the uh lateral recess when we were uh aiming towards the Foramen. Um But there is this calcified component and I decided to go ahead and break this down uh with a uh a disk knife. This disk knife is uh a little bit more robust so that you can actually uh mallet it. And uh you'll see me doing that in a minute. In my early training, we were taught. If something is calcified, then you just leave it. But in my mind, if it's compressing, um you know, I try to uh take it down. Uh As long as, you know, I'm not at risk for hurting uh uh the surrounding structures here. So I have the nerve root, L four nerve root nicely retracted uh superiorly uh at nine o'clock here. Um And I'm using the disk knife and a uh a mallet to uh knock away some of this calcified, this fragment which I feel is compressing the nerve. So this is a, a downgoing uh back down Carline Curt which I'm trying to see if I can push away this calcified fragment, hemostasis is achieved with uh bipolar electrocautery and uh gel films soaked uh a thrombin soaked gel foam probing underneath the nerve root for any other loose fragments. You can see here this calcified fragment is compressing on the nerve. And you get a clear view here of why I previously said wanted three o'clock is the safe zone because you have the nerve root coming down obliquely. So here again, I'm using the uh disco knife and a mallet to break down this um calcified disk. So here's a, a fragment of calcified disc coming out. I had elected not to get AC T scan uh on this patient because he was a young man Um but um you know, we may have seen that this disc component was more calcified. Uh Had we gotten the CT scan? Oftentimes these calcified fragments are almost like a bony hook coming off the inferior body of the uh vertebrae uh which causes almost like a lasso over the uh underneath the nerve root. Um especially when I'm doing a list. Um I'm very cognizant of these uh bony hooks coming off uh as you um distract the anterior disk space. Yeah, you can cause nerve roots uh from this uh bony hook. Um some bleeding from the calcified disc as well as the uh epidurals around the this space. Again, you can see the nerve root uh running from around 10 o'clock down to six o'clock obliquely on your left in combination of uh thrombin soap gel foam compression and bipolar electrocautery. Just see a plexus of um epidurals even after you coagulate it, it just keeps bleeding some bone wax to stop the bony bleeding. Once we're done with the uh um a decompression, we're just trying to get some uh hemostasis because we um removed some bone. We're getting some bony bleeding uh which will uh address with uh compression and bipolar electrocautery as well as um um bone wax. Uh Ultimately, the patient did very well. Um He is about six months out. Uh He went back to playing sports. Um his strength uh came back to uh his preoperative uh or preinjury state and he's now back to playing sports again. Um So I thought that this was an interesting case of both uh uh lateral recess and phenomenal disc herniations. Uh This can be done uh endoscopically or uh through a tube. Um In, in this case, we uh originally had planned for doing a tubular decompression. Um but um ended up doing a uh tubular. Um I really don't think it makes huge difference in terms of long term uh outcomes. Uh short term. Uh even, you know, these are done outpatient uh um and uh patients go home the same day.
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