Step-by-Step Procedure for L4-L5 PIVD Discectomy
Discectomy is the standard surgical treatment for prolapsed intervertebral disc (PIVD) at L4-L5 level when conservative management fails to provide relief. 1
Patient Selection and Preoperative Considerations
- Appropriate candidates include patients with:
- Radicular symptoms corresponding to L4-L5 nerve root compression
- Failed conservative management (including rehabilitation programs)
- Radiological confirmation of disc herniation at L4-L5 level
- Neurological deficits or persistent pain affecting quality of life
Surgical Procedure
1. Anesthesia and Positioning
- General anesthesia is typically administered
- Patient is positioned prone on a radiolucent operating table
- Abdomen should hang free to reduce venous pressure
- Knees and hips flexed to open the interlaminar space
2. Localization and Incision
- Fluoroscopic guidance to identify L4-L5 level
- Midline skin marking over the target level
- Approximately 2-3 cm midline or paramedian incision depending on approach
3. Approach Options
Standard Open Discectomy:
- Midline incision followed by paraspinal muscle dissection
- Retraction of muscles to expose L4-L5 laminae and interlaminar space
Minimally Invasive Options:
- Tubular retractor systems with progressive dilation
- Endoscopic approaches via interlaminar or transforaminal routes 2
4. Exposure and Access
- Removal of ligamentum flavum to expose the dural sac and nerve root
- Careful retraction of the thecal sac and traversing nerve root medially
- Identification of the herniated disc material
5. Discectomy Procedure
- Incision of the annulus fibrosus
- Removal of herniated disc fragment using pituitary rongeurs and curettes
- Exploration of disc space to remove any loose fragments
- Careful inspection to ensure adequate decompression of neural elements
- Meticulous hemostasis throughout the procedure
6. Closure
- Irrigation of the surgical field
- Layered closure of fascia, subcutaneous tissue, and skin
- No drain is typically necessary for standard discectomy
7. Postoperative Care
- Early mobilization (typically within 24 hours)
- Pain management with non-narcotic analgesics when possible
- Gradual return to activities with appropriate rehabilitation
Special Considerations
Intradural Disc Herniation
- Rare but possible finding during surgery 3
- Requires durotomy, removal of intradural disc material, and watertight dural closure
Endoscopic Approaches
- Full-endoscopic discectomy via interlaminar approach shows good outcomes with shorter hospital stays 2
- Mean surgical duration approximately 70 minutes for L4-L5 level
- Lower complication rates compared to open procedures in experienced hands 4
Potential Complications
- Dural tears (cerebrospinal fluid leakage)
- Nerve root injury
- Epidural hematoma
- Infection
- Recurrent disc herniation (approximately 4-5% rate) 4
- Postoperative discal pseudocyst (rare complication) 5
Important Caveats
- Fusion is generally NOT indicated for primary disc herniation with radiculopathy 1
- Adding fusion to discectomy increases surgical complexity, prolongs surgical time, and potentially increases complication rates without proven medical necessity 1
- Studies show no significant difference in outcomes between discectomy alone versus discectomy with fusion for primary disc herniation 1
Remember that proper patient selection and meticulous surgical technique are crucial factors affecting the outcome of discectomy procedures for L4-L5 PIVD.