Clinical Findings

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  A 48-year-old male presented with right leg pain along the L5 dermatome and right gluteal pain.

  
  
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  The VAS score was 8 to 9/10 for right leg pain and 3/10 for back pain.

  
  
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  Preoperative imaging showed a ruptured and downward-migrated soft disk herniation at the right L4-L5 level ( Fig. 18.66 ).

Preoperative Plan

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  The skin entry point lies at 10 cm from the midline, and the intended needle trajectory is angulated cranial to caudal ~15 degrees ( Fig. 18.67 ).

Surgical Procedures

1. 
   

   Two points are considered during the determination of the proper needle placement:

   
   
   
   
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     The site of annular puncture is at the medial pedicular line for a lower lumbar disk herniation (not the midpedicular line as in cases involving the upper lumbar disks) ( Fig. 18.68A ).

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  The inclination of the needle trajectory is directed downward and reaches the lower part of the disk at the medial pedicular line when the needle tip lies at the posterior vertebral line ( Fig. 18.68B ).

  
  
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  Diskography is essential in this case to stain the migrated fragment. The diskography showed leakage of dye in the region of the ruptured fragment lying inferi-orly ( Fig. 18.69 ).