Lumbar Discectomy via Wiltse Approach

Introduction

Most patients with sciatica caused by lumbar disc herniation have a positive natural history and respond well to nonsurgical treatment. Lumbar disc herniation surgery is most commonly performed electively in patients where conservative therapies have failed to achieve improvement in leg/back pain.

Case Presentation and Surgery Technique

A 40‐year‐old female patient with lumbar disc herniation was hospitalized because of low back pain with right sciatica for 6 months and exacerbation in the last two days. A diagnosis of L₅S₁ disc herniation was made based on history and imaging examination. Clinical evaluation included a visual analog scale (VAS) and the Oswestry disability index (ODI). The patient gave informed consent prior to surgery. Routine preoperative tests were performed in order to assess surgical risks. After preoperative discussion, lumbar discectomy via an approach between the multifidus and latissimus dorsi muscles was planned.

After endotracheal intubation and general anesthesia, the patient was placed prone on a spine arched frame with sterile drapes. After identifying the responsible disc by fluoroscopy, a longitudinal incision about 2.5 cm was made 2 cm lateral to the spinous process. After passing between the multifidus and latissimus dorsi muscles, routine fenestration on lamina was performed. The herniation and loose nucleus pulposus was removed and relief of nerve root compression confirmed. The intervertebral space was rinsed with saline, a drainage tube placed outside the vertebral plate and equipment and materials checked before suturing the incision. The patient received standard pre‐ and postoperative management of the patient, including pre‐ and postoperative pain management according to our protocol for achieving freedom from pain, prevention of postoperative infection with a first generation cephalosporin, and administration of mannitol and dexamethasone to relieve nerve root edema. The drainage tube was removed 24–48 hours after surgery and straight leg raising exercises initiated 48 hours postoperatively to prevent nerve root adhesions. The patient was confined to bed for 24–48 hours after surgery. Active lumbodorsal muscles exercises were initiated 2 weeks postoperatively.

The operation time was 35 minutes; blood loss 50 mL and drainage volume 30 mL. There were no postoperative complications. The preoperative VAS score for low back pain was 3 and for the leg 7; the ODI score was 78. The postoperative VAS scores for both low back and leg were 1 and the ODI score 15. At the 3 month follow‐up, the clinical results were satisfactory.

Discussion

Some studies have reported no significant differences in clinical outcome between surgically and non‐surgically treated patients 2 years after surgery1. However, there is reportedly a high short‐term success rate after surgical treatment of symptomatic lumbar disc herniation2. In more recent long‐term follow‐up studies, surgically treated patients have reported being more satisfied with treatment and achieving better relief of leg pain than patients treated conservatively3. This presentation will help to standardize preoperative care and lumbar discectomy via an approach between the multifidus and latissimus dorsi muscles for lumbar disc herniation. Such standardized and systematic treatments would benefit these patients, reducing the incidence of postoperative complications and achieving better clinical efficacy.

Supporting information

Video Clip S1. Lumbar Discectomy with Wiltse Approach.