Pros of the contralateral (over-the-top) approach to intra/extraforaminal lumbar disc herniations at the L5-S1 level

Edvin Zekaj; Christian Saleh; Guglielmo Iess; Andrea Ciuffi; Phillip Jaszczuk; Tommaso Francesco Galbiati; Domenico Servello

doi:10.25259/SNI_400_2022

Pros of the contralateral (over-the-top) approach to intra/extraforaminal lumbar disc herniations at the L5-S1 level

Surg Neurol Int. 2022 Jun 10:13:243. doi: 10.25259/SNI_400_2022. eCollection 2022.

Authors

Edvin Zekaj¹, Christian Saleh², Guglielmo Iess³, Andrea Ciuffi¹, Phillip Jaszczuk⁴, Tommaso Francesco Galbiati¹, Domenico Servello¹

Affiliations

¹ Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
² Department of Neurology, REHAB Basel, Basel, Switzerland.
³ Department of Functional Neurosurgery, IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
⁴ Department of Spinal Surgery and Spinal Cord Surgery, Swiss Paraplegic Centre, Nottwil, Switzerland.

Abstract

Background: Minimally invasive approaches to intra/extraforaminal lumbar disc herniations offer the benefit of less bone removal and reduced nerve root manipulation at the L5-S1 level. Moreover, the potential to better preserve stability.

Methods: Here, we summarized the efficacy of the contralateral approach to intraforaminal/extraforaminal lumbar disc herniations particularly focusing on the L5-S1 level. Variables studied included the level of these disc herniations, their locations within the foramina, and the anatomy of the facet joints.

Results: A major "pro" for the contralateral interlaminar procedure at the L5-S1 level is that it does not require facet joint removal, or with a spondylotic facet, <30% joint excision, to directly visualize the intraforaminal/ extraforaminal nerve root. It, therefore, reduces the risk of creating iatrogenic instability, while offering a higher certitude of adequate nerve root visualization, decompression, and safer disc removal.

Conclusion: The contralateral interlaminar approach is more suitable for all types of intra/extraforaminal disc herniations at the L5/S1 level. The most specific benefit of this approach is its avoidance of disruption/significant removal (i.e., <30%) of the facet joint to adequately expose the foraminal L5 nerve root, and more safely remove the intra/extraforaminal disc herniation.

Keywords: Contralateral approach; Crossover technique; Intraforaminal lumbar disc herniation; Minimally invasive spine surgery; Over-the-top access; Spinal stability.