Ten-Step Minimally Invasive Treatment of Lumbar Giant Disc Herniation via Unilateral Tubular Laminotomy for Bilateral Decompression: 2-Dimensional Operative Video

Giant disc herniation (GDH) is generally defined as a lumbar disc herniation that obstructs 50% or more of the space in the spinal canal.1-3 Common treatment options for GDH include unilateral interlaminar approach, bilateral approach, or open full laminectomy.4,5 Surgical treatment of GDH may be challenging because severe bilateral compression of neural elements in the spinal canal increases the risk of iatrogenic injury to nerve roots and dura. The surgical approach can be further complicated by calcification, hardening, and dehydration of the GDH tissue. The prevailing opinion in the literature is that giant disc herniations cannot safely be treated via tubular minimally invasive approaches.5-7 In this video, we present a case of a 52-yr-old male patient with a history of progressive low back pain that radiates bilaterally from the buttocks toward the posterior legs and knees for 2 yr because of a GDH at the L4-5 level. The patient was treated via a tubular “over-the-top” minimally invasive decompression in order to first provide generous bilateral decompression of neural elements and dura.8,9 After sufficient decompression at the surgical level, the discectomy was performed via an ipsilateral piecemeal resection of the GDH. The “over-the-top” contralateral mobilization of disc herniation was also achieved with this approach, which facilitated the removal of the entire disc fragment. Patient consent was obtained prior to performing the procedure. Therefore, GDH should not be considered as a contraindication for tubular decompression when this modified technique is performed.