Srdjan Mirkovic

1. Bowel and bladder dysfunction (absolute)

2. Failure of conservative management (relative)

3. Recurrent sciatica (relative)

4. Duration of symptoms greater than three months (relative)

1. Painless herniated nucleus propulsus (HNP)

2. Ongoing infection

3. Significant nonorganic findings

4. Lack of concordance between clinical presentation, anatomic level, physical examination, and imaging study

5. Low back pain only

1. Anteroposterior (AP) lateral radiographs of the lumbar spine

2. Imaging studies (MRI, CT, CT myelogram)

3. Neurological evaluation, psychological assessment, and sciatic tension signs

4. Medical and anesthetic evaluation

5. Intravenous antibiotics prior to surgery

1. The patient is placed either prone on chest rolls with hips and knees extended or in the 90-degree knee chest position.

2. Antiembolic stockings and/or compression boots are used.

3. Consider inserting a Foley catheter in older individuals.

4. The arms are placed in a 90/90 position to avoid brachial plexus traction.

5. All pressure points are padded, specifically the chest, elbows, and knees.

6. In males, the groin is checked to ensure no compression.

7. The procedure can be done under general, spinal, or local anesthesia. If not medically contraindicated, consider hypotensive anesthesia with a mean pressure of less than 70 mm Hg which helps minimize epidural bleeding.

8. The procedure is performed under microscope or loop magnification and light augmentation. If using loops, a fiber optic head light is used.

9. Basic lumbar spinal instruments: rongeurs, pituitaries, kerrosens, bipolar cautery, Penfield retractors, gelfoam, thrombin, Cobb elevators, special self-retaining retractors, and either a microscope or loops

10. Consider using spinal cord monitoring.

1. Ensure that the abdomen hangs free in order to diminish venous compression and help control epidural bleeding.

2. The patient should be completely paralyzed in order to facilitate paravertebral muscle retraction.

3. Only approach paracentral disc herniations on the affected side, thereby leaving the contralateral musculature intact. Central disc herniations represent an exception to this rule and should be approached bilaterally.

4. During the procedure, the nerve root should be retracted intermittently while instrumentation is within the discs. This avoids battering the nerve root.

5. Review the patient’s history and imaging studies pre-operatively in order to ensure that the surgery is performed at the right level and on the appropriate side. Preoperatively ask the patient to indicate the side of his lower extremity symptoms. Mentally, re-check the level and side prior to making the incision and ensure that you are standing on the appropriate side.

6. In males, the top of the iliac crest approximates the L4-L5 level. Avoid rolling your fingers over the iliac crest, which would place the incision at a higher level. The posterosuperior iliac spines approximate the L5-S1 level.

7. To palpate the midline in obese patients, start at a higher level until the spinous processes are felt and line these up with the intergluteal fold.

8. Check the level intraoperatively by placing a radiopaque marker at the surgical site and obtaining lateral X-rays.

9. Assess the presence of spinal anomalies such as spina bifida or abnormal lumbosacral segmentation.

1. Avoid operating at the wrong level. The tendency is to be too high, particularly in the presence of marked lumbar lordosis.

2. Avoid ignoring a lack of correlation between intraoperative findings and preoperative imaging and physical examination.

3. Avoid missing extruded disc fragments.

1. The majority of patients are discharged within 24 to 48 hours.

2. Patients are discharged once they are ambulating; their preoperative symptoms have resolved or are markedly diminished; they have normal bowel and bladder function, are tolerating oral intake, and are not nauseated.