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Study Design Retrospective study. Objective The interlaminar approach represents the standard procedure for the surgical treatment of lumbar disk herniation (LDH). In the case of disk herniations in the “hidden zone,” it could be necessary to perform laminotomies or laminectomies and partial or total facetectomies to remove the herniated fragment, thus leading to iatrogenic instability. The objective of the study is to evaluate the translaminar approach, in terms of the results, safety, and efficacy compared with the standard approach. Methods Since February 2010, 38 patients (26 men and 12 women; mean age 50.9 years, range 31 to 78 years) with LDH and migration into the hidden zone underwent a microdiskectomy by the translaminar approach. Using a micro-diamond dust-coated burr, a translaminar hole (8 ± 2 mm) was made, with subsequent exposure of the involved root and removal of the fragment. A clinical follow-up was performed at months 1, 3, 6, and 12 using the visual analog scale and the Oswestry Disability Index. All patients were evaluated according to the Spangfort score. Postoperative radiographic evaluations were done at 1, 6, and 12 months (dynamic radiographic studies done at 6 and 12 months). Results In over 60% of cases, L4–L5 was the involved disk. The visualization of the roots was successfully achieved through a translaminar approach. No laminotomies, laminectomies, or partial or total facetectomies were performed. The flavum ligament was always spared. A severe intraoperative bleeding episode occurred in 5% of the cases, due to involvement of the epidural veins, but it did not result in prolonged operative time (mean duration 60 ± 10 minutes). The patients showed a gradual resolution of the back pain and a progressive resolution of the radicular pain and the neurologic deficits. No sign of radiographic instability was documented during the follow-up. No infections, dural tears, or spinal cord injuries occurred. No revision surgery was performed. Conclusion The translaminar approach is the only tissue-sparing technique viable in case of cranially migrated LDH encroaching on the exiting nerve root in the preforaminal zones, for the levels above L2–L3, and in the preforaminal and foraminal zones, for the levels below L3–L4 (L5–S1 included, if a total microdiskectomy is not necessary). The possibility to spare the flavum ligament is one of the main advantages of this technique. According to our experience, the translaminar approach is an effective and safe alternative minimally invasive surgical option.

Introduction Low-back pain syndrome is, up to date, one of the most common cause of inability, especially for young-adult people. In 20% of cases, patients have a degenerative disc disease associated with radiculopathy due to neuroforamen diameter reduction and lumbar soft-stenosis. Interspinous devices were extensively used in the treatment of this pathology, with different outcomes. Material and Methods An observational study was conducted comparing the interspinous device implant only, according to the standard technique, versus the devices implant together with a supraspinous ligament removal. Since April 2012, 81 patients with low-back pain and foraminal “soft” stenosis were enrolled and divided into two groups, homogeneous for age, sex, and disease severity (clinically and instrumentally assessed). Before surgery, all patients were subjected to medical therapy for at least 6 months without any clinical benefit. A total of 39 patients (group A, control) underwent interspinous devices implant only, according to the standard technique and 42 patients (group B) underwent device implant and supraspinous ligament removal. A clinical follow-up was performed at month 1, 3, 6, 12, and 24 by mean of visual analog scale (VAS), neurogenic claudication outcome score (NCOS), and Oswestry low back pain disability questionnaire (OLBPDQ). A radiographic control was obtained at month 1 and 6 (dynamic radiographic studies included). A MRI was done at month 6. The data were analyzed by mean of the Kaplan–Meier curve (results yielding a p value Results Until month 12, slight differences in VAS, NCOS, and OLBPDQ values were noticed between the two groups, but these scores was significantly higher in group B at month 24. Furthermore, radiographic evaluation showed a more significant neural foramina height recovery (mean value: 23 ± 3% vs. 41 ± 3%, respectively, in groups A and B). Although the supraspinous ligament is removed, there is not iatrogenic instability risk, because the device produces an immediate mechanical stability and a consequent intervertebral fusion. At follow-up there were no “fixation failure” and none patient underwent revision surgery. The standard technique provides the intraspinous ligament incision only and the devices positioning in the space between the spinous processes. In our opinion, this approach represents only a partial approach. Although the device implant is useful for radiculopathy resolution, usually low back could decrease, but in many cases only at the beginning. In fact the device may produce a supraspinous ligament extreme elongation, through to the intervertebral distraction. The nociceptors are abnormally stimulated and the back pain can reappear or in some cases persist. Conclusion This approach is able to definitively resolve both radiculopathy and low-back pain. This is an effective technique in terms of safety and efficacy, capable to provide a structural and functional correction, without back pain persistence risk, due to supraspinous ligament extreme elongation.

Introduction The concepts of “tissue-sparing surgery” and “mini-invasiveness” are gradually involving the surgical approach to spine pathologies, both traumatic and degenerative. Patients and Methods The aim of the study is to evaluate the fracture healing model in case of unstable thoracolumbar vertebral fractures surgical treatment, treated by posterior percutaneous transpedicular stabilization (PPTS). Since March 2011, 89 patients with this fracture pattern, without neurologic involvement (according to ASIA classification) were enrolled in the study. Patients were randomly divided into two homogeneous samples. PPTS (with rods and screws) and standard posterior open approach were performed in patients of groups A (46 patients) and B (43 patients, control), respectively. A clinical and radiographical follow-up was performed respectively at months 1, 3, 6, 12 (according to visual analog scale [VAS] and Oswestry Disability Index [ODI]) and at months 1, 6, 12 (dynamic radiographic studies in the last two times). Segmental kyphosis and wedge-shaped deformity amount of the involved vertebral bodies, were measured pre- and postsurgery. At month 12, a CT scan with 3D reconstruction and analysis of chrome-densitometry was obtained. The data were analyzed by mean of the Kaplan–Meier curve (results yielding p Results Clinically, in group A, we have observed a progressive and more rapid VAS and ODI scores improvement. Vertebral body collapse or kyphosis progression was not observed. There were no “fixation failure” and no patient underwent revision surgery. The 3D reconstructions and the chrome-densitometry evaluation at month 12 showed a more homogeneous and organized trabecular architecture recovery in group A (vs. group B). The PPTS acts as an “angular stability” fixation system; it allows a “biological” healing process (according to Wolf law), producing better clinical and radiographical results. Conclusion Unstable thoracolumbar fractures PPTS is an effective alternative to the classic open standard treatment. The advantage of mini-invasive spine surgery and “biological” healing process explain these better results and faster recovery times. This technique represents a safe and effective treatment, in terms of clinical and radiographical findings.

Introduction Interlaminar approach represents the standard procedure for lumbar disc herniation surgical treatment. In case of cranial or lateral fragment migration into the neuroforamen (hidden zone), it is necessary to perform partial or total arterectomy to remove the herniated material, thus leading to iatrogenic vertebral instability risk. Materials and Methods Since January 2010, 40 patients with lumbar disc herniation and with disc fragment migration into the “hidden zone” underwent microdiscectomy by translaminar approach. Using a micro high-speed cutter, a 8 ± 2 mm fenestration at the level of affected side hemilamina was performed, displaying the involved root and removing the disc fragment. A clinical follow-up at months 1, 3, 6, and 12 was performed by mean of the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). A radiographic control at months 1, 6, and 12 was obtained (dynamic radiographic studies in last two times). Results In over 60% of cases, L4-L5 was the disk involved. Roots visualization was successfully achieved through translaminar approach. There was no need to associate neither partial or complete arterectomy nor flavectomy. An intraoperative bleeding occurred only in 5% of cases, as a consequence of an epidural veins involvement, treated through local hemostasis (Avitene) and without surgery time prolongation (mean duration 60 ± 10 minutes). There were no dural injuries. Patients showed an immediate and lasting radicular symptoms resolution. There was no need to perform revision surgery. Dynamic radiographic studies at months 6 and 12 did not detected instabilities. Conclusion Surgical microdiscectomy allowed us to successfully treat patients affected by lumbar disc herniation. Low back pain treatment and disc-root conflict resolution must be done conservatively avoiding iatrogenic instability risk. In case of cranial or lateral fragment migration into the neuroforamen, because a partial or total arterectomy could be requested for herniated disc fragment removal, this is not always possible. A conservative and minimally invasive approach, which allows to resolve disc-root conflict without affecting spine stability, represents a crucial technique. The translaminar approach is an anatomical, effective, and minimally invasive technique, suitable in cases of lumbar disc herniations with disc fragment migration into the hidden zone. It can be performed in all lumbar segments, not involving posterior elements (both bony and ligamentous ones), which are necessary for spine stability. In case of proper indications, this technique is more effective than the standard one because it allows symptoms relief, faster recovery times, less postoperative pain, and reduction in iatrogenic instability risk. Disclosure of Interest None declared References Papavero L, Kothe R. The translaminar approach for cranially extruded lumbar disc herniations. Oper Orthop Traumatol 2013;25(1):6–15 Seiz M, Pechlivanis I, Bag S, Schmieder K, Thome C, Tuettenberg J. [Translaminar fenestration for caudally herniated lumbar discs—a technical note]. Z Orthop Unfall 2009;147(5):597–599 Choi KC, Kim JS, Ryu KS, Kang BU, Ahn Y, Lee SH. Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: transforaminal versus interlaminar approach. Pain Physician 2013;16(6):547–556

Introduction Life expectancy increased, in the last years, have led to a larger proportion of elderly population and consequently to a greater incidence of degenerative arthritic disease. Lumbar spine is one of the most common localization. Therefore, low-back pain syndrome-increased prevalence was noted. In 20% of cases, patients have a degenerative disc disease associated with disc-root conflict and lumbar stenosis. Materials and Methods An observational study was conducted, comparing microdiscectomy and micro-interlaminotomy approaches versus standard open discectomy and laminectomy. Since February 2010, 60 patients with lumbar disc herniation and unilateral root involvement with spinal canal stenosis were enrolled and divided into the two groups, homogeneous for age, sex, and disease severity (clinically and instrumentally assessed). Before surgical operation, all patients had been under medical therapy for at least 6 months without any clinical benefit. Of the 60 patients, 30 patients (group A) underwent microdiscectomy and micro-interlaminotomy and 30 patients (group B, control) underwent standard open approach. A clinical follow-up was performed at 1, 3, 6, and 12 months by mean of visual analog scale, neurogenic claudication outcome score, and oswestry low back pain disability questionnaire. A radiographic control was obtained at 1 and 12 months. Results As time goes by, disc degeneration is associated with intervertebral space reduction, yellow ligament hypertrophy, and calcification. Intervertebral articulations overload and subsequent hypertrophy can lead to arthritis, epidural osteophytes, and spinal stenosis over time; then, disc-root conflict and lumbar stenosis may occur. Open discectomy and laminectomy has been the standard treatment over the last years. This approach allows a wide decompression, leading to good short-term results. This approach is invasive and not anatomic, as it is associated with a significant posterior elements demolition (both bony and ligamentous); then, instability may occur. This surgical technique is also associated with an increased intraoperative bleeding, leading to a dural adhesions great risk, fibrous scar, and recurrences. Conclusion Microdiscectomy and micro-interlaminotomy approaches allow obtaining disc-roots conflict resolution and an effective medullary “recalibrage” in a noninvasive fashion. The minimal and controlled laminae demolition and the paraspinal muscles respect, result in a postoperative pain reduction, in a faster recovery time, in reduction of recurrence's risk, and in best long-term results. Disclosure of Interest None declared References Tharin S, Mayer E, Krishnaney A. Lumbar microdiscectomy and lumbar decompression improve functional outcomes and depression scores. Evid Based Spine Care J 2012;3(4):65–66 Schroeder JE, Dettori JR, Brodt ED, Kaplan L. Disc degeneration after disc herniation: are we accelerating the process? Evid Based Spine Care J 2012;3(4):33–40 Banczerowski P, Bognár L, Rappaport ZH, Veres R, Vajda J. Novel surgical approach in the management of longitudinal pathologies within the spinal canal: the split laminotomy and “archbone” technique: alternative to multilevel laminectomy or laminotomy. Adv Tech Stand Neurosurg 2014;41:47–70 Choi WS, Oh CH, Ji GY, et al. Spinal canal morphology and clinical outcomes of microsurgical bilateral decompression via a unilateral approach for lumbar spinal canal stenosis. Eur Spine J 2013