Extreme lateral and interlaminar approach for intra-canal and foraminal double disc herniation at lumbosacral level

Bae, Jung-Sik; Kim, Ki Joon; Kang, Mun Soo; Jang, Il-Tae

doi:10.1016/j.neucie.2018.07.004

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(C) Determination of the transverse diameter, defined as the distance between the medial borders of the pedicles at the mid-pedicle level." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan Delgado-Fernández, Ricardo Gil Simoes, María Ángeles García Pallero, Juan Ramón Penanes Cuesta, Guillermo Blasco, Paloma Pulido, Rafael G. Sola" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Juan" "apellidos" => "Delgado-Fernández" ] 1 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Gil Simoes" ] 2 => array:2 [ "nombre" => "María Ángeles" "apellidos" => "García Pallero" ] 3 => array:2 [ "nombre" => "Juan Ramón" "apellidos" => "Penanes Cuesta" ] 4 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Blasco" ] 5 => array:2 [ "nombre" => "Paloma" "apellidos" => "Pulido" ] 6 => array:2 [ "nombre" => "Rafael G." 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In these types of disc herniation, the conventional interlaminar approach cannot resolve lesions; instead, the extraspinal intertransvertebral approach is mainly used.<a class="elsevierStyleCrossRefs" href="#bib0150">1–4</a> Although rare, the surgeon may face a double lesion consisting of an intracanal spine lesion broadly involving the foramen or the extraforamen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In such a case, total facetectomy or fusion surgery is performed to address both lesions,<a class="elsevierStyleCrossRefs" href="#bib0170">5–7</a> but a combined interlaminar and paraisthmic approach (CIPA), which is cost-effective and less invasive, may also be utilized.<a class="elsevierStyleCrossRefs" href="#bib0180">7,8</a> Because in most cases at the lumbosacral (lumbar 5 (L5) – sacrum 1 (S1)) level, the isthmus and the facet joint are located in the exterior to the intervertebral foramen, partial facetectomy is often performed in the conventional paraisthmic approach (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In cases with a double lesion, medial facetectomy is performed in parallel, and so the risk of instability is high following CIPA at the L5-S1 level due to facet joint disruption or post-operative spondylolysis. Accordingly, in the present study, the authors aimed to introduce the extreme lateral and interlaminar approach (ELIA), which can minimize facetectomy to prevent postoperative instability in cases with a double disc herniation at the L5-S1 level, and to compare the approach with the conventional CIPA procedure.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Material and methodsThe authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level (lumbar 5-sacral 1) between March 2012 and February 2016 at the study hospital. Only those patients who underwent CIPA or ELIA were selected. The present study was a retrospective study, and was conducted based on patient records, surgical records, and imaging data. For preoperative testing, simple X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans were performed. The presence of spondylolysis and instability was determined using dynamic X-ray, and double disc herniation was diagnosed using MRI (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). CT was performed as a secondary test, and the presence of a limbus fracture or a calcified disc in the endplate was examined using the CT. In addition, patient gender and age, the length of post-operative follow-up, the surgical approach used, and whether a reoperation was performed were considered. For postoperative outcomes, the groups who underwent CIPA and ELIA, respectively, were compared with respect to the Korean version of the Oswestry Disability Index (K-ODI) and Numeric Rating Scale (NRS) at one, two, and three months post-operation. Patients showing spondylolysis, spondylolisthesis, or instability were excluded. All surgeries were performed by one surgeon. The institutional review board approved this study (IRB No. NR-IRB 2016-021).Statistical analysisStatistical analysis was conducted with SPSS 12.0 for Windows (SPSS, Inc., Chicago, IL, USA). Postoperative K-ODI and NRS were compared using Student's t-test, and whether a reoperation was performed in the groups was compared using Fischer's exact test. Statistical significance was noted if the p value was less than 0.05.Surgical techniquePatients were placed with prone position. And the procedure was done under general anesthesia. First, the herniated disc material was removed in the intracanal area using the standard interlaminar approach. To prevent postsurgical spondylolysis that can occur due to excessive laminotomy, laminotomy at L5 was minimized as much as possible. All the procedure of laminotomy and discectomy were performed by using surgical microscope. Decompression at the S1 root was confirmed by performing laminotomy in the upper portion of the sacral laminar. Subsequently, an extreme lateral approach (ELA) was performed to decompress the L5 root pressured in the intervertebral foramen. The angle at which to access the intervertebral foramen without violating the facet joint and the appropriate location for making the skin incision were determined using a preoperative MRI image. The skin incision was performed approximately 7–9cm away from the midline (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>). While the approach angle was roughly estimated, the paraspinal muscle was obliquely dissected and then the facet joints at L4-5 and L5-S1 were examined. Afterwards, a self-retaining Magana retractor was used and the isthmus at L5 was examined by sufficiently dissecting the muscle. In the absence of facet joint hypertrophy, access at an oblique angle enabled the examination of the lower portion of the facet joint, where the root was passing through, via muscle and ligament dissection. The L5 root was immediately examined through a sufficient and careful dissection of the ligaments. To prevent L5 nerve root injury during dissection of the intervertebral ligament, we started dissection at the caudal portion where L5 nerve root did not exist. Upper portion, especially at the junction of L5 transverse process and isthmus, L5 nerve root usually passes through. After finding out perineural fat zone, we did meticulous dissection to check L5 root and L5 pedicle. After the L5 root and L5 pedicle were examined, the root was carefully retracted to examine the herniated disc material and then, the disc material was removed (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). For complete root decompression, the sacral ala was partially removed in the extraforaminal area and finally, the freely moving root was examined. If hypertrophy due to arthropathy in the facet joint was present, only a partial removal of the lower portion of S1 superior facet provided sufficient visibility. In some cases, visibility at the skin incision site was obstructed by the iliac bone, in which case a small portion of the iliac bone was removed to obtain visibility at the site.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>ResultsA total of 35 patients underwent CIPA or ELIA at the study hospital to treat a double disc herniation at the L5-S1 level between March 2012 and February 2016. Of those, 14 patients were male and 21 were female, and the mean age was 63.4 (±13.7) years. In the ELIA group, there were a total of 11 patients (three men and eight women) and the mean age was 63.0 (±13.9) years, while in the CIPA group, there were a total of 24 patients (11 men and 13 women) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The mean follow-up length was 11.1 (±4.7) months in the ELIA group and 18.3 (±10.1) months in the CIPA group. The mean operation time was 88.8min (±14.5) in ELIA and 86.8min (±10.1) (p: 0.652). The preoperative K-ODI score was 34.1 (±3.3) months in the ELIA group and 32.4 (±4.0) months in the CIPA group (p: 0.23). Postoperative K-ODI scores in the ELIA and the CIPA groups were 8.2 (±4.1) and 8.1 (±3.2) (p: 0.97) at month one; 6.4 (±2.1) and 7.1 (±3.5) (p: 0.54) at month two; and 5.3 (±2.4) and 8.4 (±6.4) (p: 0.005) at month three, respectively. Thus, only the postoperative K-ODI scores at month three showed a significant between-group difference. Additionally, the preoperative NRS score was 8 (±0.9) in the ELIA group and 8.6 (±1.0) in the CIPA group (p: 0.1). Postoperative NRS scores in the ELIA and the CIPA groups were 2.4 (±1.5) and 3.3 (±1.4) (p: 0.1) at month one; 2.2 (±1.5) and 3.3 (1.6) (p: 0.063) at month two; and 2.0 (±0.9) and 3.7 (±1.9) (p: 0.001) at month three, respectively. Again, only the postoperative NRS at month three showed a significant between-group difference (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). There were four patients who underwent reoperation, all of whom belonged to the CIPA group. In those cases, the mean time interval was 12.8 months. Three patients suffered from recurred lumbar disc herniation and one patient had foraminal stenosis. All lesions were due to post-operative instability. All patients underwent posterior intervertebral body fusion surgery. The proportion of reoperation was 0% in the ELIA group and 31.4% in the CIPA group, and the p-value was 0.29 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe intracanal and foraminal lumbar disc herniation lesions can cause double radicular compression.<a class="elsevierStyleCrossRefs" href="#bib0180">7,9,10</a> Such lesions are difficult to treat with surgery. Several surgical techniques have been introduced in the treatment of double lumbar disc herniation. The simplest is to remove the intracanal disc material following the interlaminar approach and then to remove the disc material of the foraminal lesion following extended medial facetectomy.<a class="elsevierStyleCrossRefs" href="#bib0175">6,11–13</a> However, in this approach, the extra foraminal lesion is not accessible and, even though an attempt is made to remove the disc material of the foraminal lesion, it is highly likely for some to be left behind. Another disadvantage is that if medial facetectomy is excessively performed, the risk of instability is high due to postoperative spondylolysis or facet disruption.<a class="elsevierStyleCrossRefs" href="#bib0170">5,14–16</a> Accordingly, some authors have recommended performing total facetectomy in parallel.<a class="elsevierStyleCrossRefs" href="#bib0170">5,6,13,16</a> However, this approach has also been criticized because of a high risk of postoperative instability or chronic pain after surgery. Thus, there are authors who recommend performing intervertebral fusion surgery after total facetectomy to treat double lumbar disc herniation.<a class="elsevierStyleCrossRefs" href="#bib0170">5,17</a> Notably, though, fusion surgery takes a relatively long time and causes a large amount of blood loss, increasing the risk for various complications. It is also expensive. For direct access to the foramen, pars interarticularis fenestration has been introduced by Di Lorenzo and colleagues,<a class="elsevierStyleCrossRef" href="#bib0235">18</a> but this approach is disadvantageous in that only limited exposure is possible, and that there is a concern about a postoperative fracture of the pars.<a class="elsevierStyleCrossRef" href="#bib0240">19</a> Hence, the CIPA approach was introduced by some authors, and many advantages of the approach have been highlighted.<a class="elsevierStyleCrossRefs" href="#bib0180">7,8,20,21</a> In CIPA, the transversing root and the exiting root are simultaneously visible, and the lesion can be removed without destroying the facet joint, resulting in a low likelihood of postoperative instability. Particularly, the paraisthmic approach is a very useful surgical technique, as access to the foramen is possible only with a partial removal of the superior-lateral portion of the facet joint.<a class="elsevierStyleCrossRefs" href="#bib0255">22–25</a> However, the problem is that when this approach is used at the L5-S1 level, excessive facetectomy or excessive removal of isthmus can happen.<a class="elsevierStyleCrossRefs" href="#bib0275">26–28</a> The lateral pars at L5 are located up to the outer portion of the intervertebral foramen, unlike those at other levels, and thus, an excessive removal of isthmus is necessary to completely expose the foramen.<a class="elsevierStyleCrossRefs" href="#bib0285">28,29</a> In contrast, in the paraisthmic approach, a foramen lesion can easily be resolved without removing isthmus because at upper lumbar levels such as at L2-3 or L3-4, isthmuses are located further in relative to the intervertebral foramen (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). However, this is not the case in some lesions at L4-5 and most lesions at L5-S1. Accordingly, for lesions at the L5-S1 level, the authors attempted to remove foraminal or extraforaminal disc materials without performing lateral facetectomy or removing isthmus by using an extreme lateral approach. With the ELIA approach, it was possible to resolve most lesions without involving the facet joint, and excellent outcomes on pain and K-ODI was observed during the follow-up in comparison with following the CIPA approach. Even in cases with facet arthropathy, access was possible through minimal superior facet undercutting, and the facet joint was never involved. With respect to reoperation, 31.4% of patients in the CIPA group underwent reoperation, whereas none did so in the ELIA group. Of course, the follow-up period was relatively short and statistical significance was not obtained, but the authors believe that the statistics are meaningful in their own right. The study has limitations in that it was a retrospective study, and its sample size was relatively small. And the total follow-up period was relatively short. And there were not exact records about last follow-up outcome. It was because of retrospective study. In the future, an effort should be made to derive more meaningful outcomes by using a larger sample and by observing patients for a longer follow-up period.In the treatment of L5-S1 double disc herniation, the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation.FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1155841" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1083183" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1083181" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres1155840" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1083182" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgical technique" ] ] ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-30" "fechaAceptado" => "2018-07-29" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1083183" "palabras" => array:4 [ 0 => "Combined approach" 1 => "Disc herniation" 2 => "Lumbosacral junction" 3 => "Lumbar" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1083181" "palabras" => array:6 [ 0 => "ELIA" 1 => "CIPA" 2 => "CT" 3 => "MRI" 4 => "K-ODI" 5 => "NRS" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1083182" "palabras" => array:4 [ 0 => "Abordaje combinado" 1 => "Hernia discal" 2 => "Unión lumbosacra" 3 => "Lumbar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and objectivesThere are several approaches for double disc herniation consisting of an intracanal and foraminal lesion. Of several approaches, we introduced extreme lateral and interlaminar approach (ELIA). And we aimed to compare the approach with the conventional combined interlaminar and paraisthmic approach (CIPA). Patients and methodsThe authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level between March 2012 and February 2016 and patients who underwent CIPA or ELIA were selected. For preoperative testing, simple X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans were performed. For postoperative outcomes, the Korean version of the Oswestry Disability Index (K-ODI) and Numeric Rating Scale (NRS) at one, two, and three months post-operation were checked. ResultsEleven patients were given ELIA and twenty-four patients were involved in CIPA. The mean pre K-ODI was 34.1 (±13.9) and 32.4 (±4.0) at each group. 1st, 2nd and 3rd month post-operative K-ODI was 8.2 (±4.1), 6.4 (±2.1) and 5.3 (±2.4) in ELIA and 8.1 (±3.2), 7.1 (±3.5) and 8.4 (±6.4) in CIPA. Post-operative 3rd month K-ODI showed significant difference between two groups (p: 0.005). The mean pre NRS was 8 (±0.9) and 8.6 (±1.0). 1st, 2nd and 3rd month post-operative NRS was 2.4 (±1.5), 2.2 (±1.5) and 2.0 (±0.9) in ELIA and 3.3 (±1.4), 3.3 (±1.6) and 3.7 (±1.9). Post-operative 3rd month NRS showed significant difference between two groups as well (p: 0.001). There were four (19.0%) recurrence cases in CIPA patients group, otherwise there was no recurrence case in ELIA group. ConclusionsIn the treatment of L5-S1 double disc herniation, the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Introducción y ObjetivosExisten varios tipos de abordajes para la hernia discal doble formada por una lesión intracanal y foraminal. Hemos elegido el Abordaje Extremo Lateral e Interlaminar (ELIA, por su sigla en inglés) con el objetivo de compararlo con el Abordaje Interlaminar y Paraístmico Convencional combinado (CIPA, por su sigla en inglés). Pacientes y MétodosLos autores revisaron los cuadros médicos de pacientes que se vieron sometidos a un procedimiento para una hernia discal doble a nivel lumbosacro entre marzo del 2012 y febrero del 2016, y se seleccionaron los pacientes que se sometieron a CIPA o a ELIA. Como pruebas preoperatorias, se realizaron radiografías simples, tomografías computarizadas (CT, por su sigla en inglés), y escaneos de imágenes de resonancia magnética (MRI, por su sigla en inglés). Para resultados postoperatorios, se revisó la versión coreana del Índice de Discapacidad Owestry (K-ODI, por su sigla en inglés) y la Escala de Estimación Numérica (NRS, por su sigla en inglés) a intervalos postoperatorios de uno, dos y tres meses. ResultadosOnce pacientes fueron sometidos a ELIA y veinticuatro pacientes a CIPA. La media antes de K-ODI fue 34,1 (±13,9) y 32,4 (±4,0) en cada grupo. El resultado K-ODI para el 1°, 2° y 3° mes postoperatorio fue de 8,2 (±4,1), 6,4 (±2,1) y 5,3 (±2,4) en ELIA y 8,1 (±3,2), 7,1 (±3,5) y 8,4 (±6,4) en CIPA. El resultado postoperatorio K-ODI del 3° mes mostró una diferencia significativa entre los dos grupos (p: 0,005). La media antes del NRS fue de 8 (±0,9) y 8,6 (±1,0). El resultado del NRS del 1°, 2° y 3° mes postoperatorio fue de 2,4 (±1,5), 2,2 (±1,5) y 2,0 (±0,9) en ELIA y 3,3 (±1,4), 3,3 (±1,6) y 3,7 (±1,9). El resultado del NRS para el 3° mes postoperatorio también mostró una diferencia significativa entre los dos grupos (p: 0,001). Hubo cuatro casos de recurrencia en el grupo de pacientes sometidos a CIPA (19,0%), mientras que, por el contrario, no existió recurrencia en el grupo de pacientes sometidos a ELIA. ConclusionesEn el tratamiento de hernia discal doble L5-S1, el abordaje quirúrgico ELIA mostró mejores resultados que el abordaje quirúrgico CIPA con respecto a dolor y resultados de K-ODI durante los exámenes de seguimiento a intermedio conducidos durante los tres meses posteriores a la cirugía." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 870 "Ancho" => 900 "Tamanyo" => 95100 ] ] "descripcion" => array:1 [ "en" => "Double disc lesion consisting of an intracanal (blue arrow) spine lesion broadly involving the foramen (red arrow) at L5-S1 level." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 758 "Ancho" => 950 "Tamanyo" => 56974 ] ] "descripcion" => array:1 [ "en" => "The isthmus (A) of L5 is located in the exterior to the intervertebral foramen (B)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 784 "Ancho" => 900 "Tamanyo" => 97696 ] ] "descripcion" => array:1 [ "en" => "Complete removal of disc material and preservation of lateral side facet joint. Yellow arrow: the direction of extreme lateral approach; blue arrow: the direction of conventional paraisthmic approach." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 628 "Ancho" => 950 "Tamanyo" => 87272 ] ] "descripcion" => array:1 [ "en" => "A schematic figure for extreme lateral approach." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1686 "Ancho" => 1249 "Tamanyo" => 231913 ] ] "descripcion" => array:1 [ "en" => "Pre (A: sagittal, B: axial) and post (C: sagittal, D: axial) MR image. Yellow arrow: the lesion of disc herniation; yellow ring: the removal site of disc material; red arrow: skin incision site." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ELIA: extreme lateral and interlaminar approach; CIPA: combined interlaminar and paraisthmic approach." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ELIA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CIPA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (male:female) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3:8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11:13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63.0 (±13.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63.6 (±13.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.62 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean duration of complaints (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.8 (±2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.5 (± 3.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1973117.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patients group." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ELIA: extreme lateral and interlaminar approach; CIPA: combined interlaminar and paraisthmic approach; K-ODI: Korean Version of the Oswestry Disability Index; NRS: Numeric Rating Scale." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ELIA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CIPA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre K-ODI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.1 (±3.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.4 (±4.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 1st month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.2 (±4.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.1 (±3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 2nd month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.4 (±2.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.1 (±3.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 3rd month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.3 (±2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.4 (±6.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre NRS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (±0.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.6 (±1.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 1st month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.4 (±1.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.3 (±1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 2nd month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.2 (±1.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.3 (±1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.063 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 3rd month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.0 (±0.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.7 (±1.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1973116.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparing of outcome scale." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "HNP: herniation of nucleus pulposus; CIPA: combined interlaminar and paraisthmic approach; PLIF: posterior lumbar interbody fusion; TLIF: transforaminal lumbar interbody fusion." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Approach \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Revision operation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Time interval (months) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reason of re-operation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CIPA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PLIF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recurred HNP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CIPA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PLIF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recurred HNP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CIPA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TLIF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Foraminal stenosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CIPA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PLIF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recurred HNP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean value \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1973115.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Re-operation cases." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Frequency and specific surgical management of far lateral lumbar disc herniations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.R. 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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Of several types of intervertebral disc herniation occurring in the lumbosacral spine&#44; the most universal is intracanal paramedian disc herniation&#44; which constitutes 93&#37; of the total cases&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> Additional types include disc herniations that can occur in the neuroforamen or the extra-foramen&#46; In these types of disc herniation&#44; the conventional interlaminar approach cannot resolve lesions&#59; instead&#44; the extraspinal intertransvertebral approach is mainly used&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#8211;4</span></a> Although rare&#44; the surgeon may face a double lesion consisting of an intracanal spine lesion broadly involving the foramen or the extraforamen &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In such a case&#44; total facetectomy or fusion surgery is performed to address both lesions&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#8211;7</span></a> but a combined interlaminar and paraisthmic approach &#40;CIPA&#41;&#44; which is cost-effective and less invasive&#44; may also be utilized&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a> Because in most cases at the lumbosacral &#40;lumbar 5 &#40;L5&#41; &#8211; sacrum 1 &#40;S1&#41;&#41; level&#44; the isthmus and the facet joint are located in the exterior to the intervertebral foramen&#44; partial facetectomy is often performed in the conventional paraisthmic approach &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In cases with a double lesion&#44; medial facetectomy is performed in parallel&#44; and so the risk of instability is high following CIPA at the L5-S1 level due to facet joint disruption or post-operative spondylolysis&#46; Accordingly&#44; in the present study&#44; the authors aimed to introduce the extreme lateral and interlaminar approach &#40;ELIA&#41;&#44; which can minimize facetectomy to prevent postoperative instability in cases with a double disc herniation at the L5-S1 level&#44; and to compare the approach with the conventional CIPA procedure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">The authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level &#40;lumbar 5-sacral 1&#41; between March 2012 and February 2016 at the study hospital&#46; Only those patients who underwent CIPA or ELIA were selected&#46; The present study was a retrospective study&#44; and was conducted based on patient records&#44; surgical records&#44; and imaging data&#46; For preoperative testing&#44; simple X-ray&#44; computed tomography &#40;CT&#41;&#44; and magnetic resonance imaging &#40;MRI&#41; scans were performed&#46; The presence of spondylolysis and instability was determined using dynamic X-ray&#44; and double disc herniation was diagnosed using MRI &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; CT was performed as a secondary test&#44; and the presence of a limbus fracture or a calcified disc in the endplate was examined using the CT&#46; In addition&#44; patient gender and age&#44; the length of post-operative follow-up&#44; the surgical approach used&#44; and whether a reoperation was performed were considered&#46; For postoperative outcomes&#44; the groups who underwent CIPA and ELIA&#44; respectively&#44; were compared with respect to the Korean version of the Oswestry Disability Index &#40;K-ODI&#41; and Numeric Rating Scale &#40;NRS&#41; at one&#44; two&#44; and three months post-operation&#46; Patients showing spondylolysis&#44; spondylolisthesis&#44; or instability were excluded&#46; All surgeries were performed by one surgeon&#46; The institutional review board approved this study &#40;IRB No&#46; NR-IRB 2016-021&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Statistical analysis was conducted with SPSS 12&#46;0 for Windows &#40;SPSS&#44; Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; Postoperative K-ODI and NRS were compared using Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; and whether a reoperation was performed in the groups was compared using Fischer&#39;s exact test&#46; Statistical significance was noted if the <span class="elsevierStyleItalic">p</span> value was less than 0&#46;05&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patients were placed with prone position&#46; And the procedure was done under general anesthesia&#46; First&#44; the herniated disc material was removed in the intracanal area using the standard interlaminar approach&#46; To prevent postsurgical spondylolysis that can occur due to excessive laminotomy&#44; laminotomy at L5 was minimized as much as possible&#46; All the procedure of laminotomy and discectomy were performed by using surgical microscope&#46; Decompression at the S1 root was confirmed by performing laminotomy in the upper portion of the sacral laminar&#46; Subsequently&#44; an extreme lateral approach &#40;ELA&#41; was performed to decompress the L5 root pressured in the intervertebral foramen&#46; The angle at which to access the intervertebral foramen without violating the facet joint and the appropriate location for making the skin incision were determined using a preoperative MRI image&#46; The skin incision was performed approximately 7&#8211;9<span class="elsevierStyleHsp" style=""></span>cm away from the midline &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; While the approach angle was roughly estimated&#44; the paraspinal muscle was obliquely dissected and then the facet joints at L4-5 and L5-S1 were examined&#46; Afterwards&#44; a self-retaining Magana retractor was used and the isthmus at L5 was examined by sufficiently dissecting the muscle&#46; In the absence of facet joint hypertrophy&#44; access at an oblique angle enabled the examination of the lower portion of the facet joint&#44; where the root was passing through&#44; via muscle and ligament dissection&#46; The L5 root was immediately examined through a sufficient and careful dissection of the ligaments&#46; To prevent L5 nerve root injury during dissection of the intervertebral ligament&#44; we started dissection at the caudal portion where L5 nerve root did not exist&#46; Upper portion&#44; especially at the junction of L5 transverse process and isthmus&#44; L5 nerve root usually passes through&#46; After finding out perineural fat zone&#44; we did meticulous dissection to check L5 root and L5 pedicle&#46; After the L5 root and L5 pedicle were examined&#44; the root was carefully retracted to examine the herniated disc material and then&#44; the disc material was removed &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; For complete root decompression&#44; the sacral ala was partially removed in the extraforaminal area and finally&#44; the freely moving root was examined&#46; If hypertrophy due to arthropathy in the facet joint was present&#44; only a partial removal of the lower portion of S1 superior facet provided sufficient visibility&#46; In some cases&#44; visibility at the skin incision site was obstructed by the iliac bone&#44; in which case a small portion of the iliac bone was removed to obtain visibility at the site&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 35 patients underwent CIPA or ELIA at the study hospital to treat a double disc herniation at the L5-S1 level between March 2012 and February 2016&#46; Of those&#44; 14 patients were male and 21 were female&#44; and the mean age was 63&#46;4 &#40;&#177;13&#46;7&#41; years&#46; In the ELIA group&#44; there were a total of 11 patients &#40;three men and eight women&#41; and the mean age was 63&#46;0 &#40;&#177;13&#46;9&#41; years&#44; while in the CIPA group&#44; there were a total of 24 patients &#40;11 men and 13 women&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The mean follow-up length was 11&#46;1 &#40;&#177;4&#46;7&#41; months in the ELIA group and 18&#46;3 &#40;&#177;10&#46;1&#41; months in the CIPA group&#46; The mean operation time was 88&#46;8<span class="elsevierStyleHsp" style=""></span>min &#40;&#177;14&#46;5&#41; in ELIA and 86&#46;8<span class="elsevierStyleHsp" style=""></span>min &#40;&#177;10&#46;1&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;652&#41;&#46; The preoperative K-ODI score was 34&#46;1 &#40;&#177;3&#46;3&#41; months in the ELIA group and 32&#46;4 &#40;&#177;4&#46;0&#41; months in the CIPA group &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;23&#41;&#46; Postoperative K-ODI scores in the ELIA and the CIPA groups were 8&#46;2 &#40;&#177;4&#46;1&#41; and 8&#46;1 &#40;&#177;3&#46;2&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;97&#41; at month one&#59; 6&#46;4 &#40;&#177;2&#46;1&#41; and 7&#46;1 &#40;&#177;3&#46;5&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;54&#41; at month two&#59; and 5&#46;3 &#40;&#177;2&#46;4&#41; and 8&#46;4 &#40;&#177;6&#46;4&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;005&#41; at month three&#44; respectively&#46; Thus&#44; only the postoperative K-ODI scores at month three showed a significant between-group difference&#46; Additionally&#44; the preoperative NRS score was 8 &#40;&#177;0&#46;9&#41; in the ELIA group and 8&#46;6 &#40;&#177;1&#46;0&#41; in the CIPA group &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;1&#41;&#46; Postoperative NRS scores in the ELIA and the CIPA groups were 2&#46;4 &#40;&#177;1&#46;5&#41; and 3&#46;3 &#40;&#177;1&#46;4&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;1&#41; at month one&#59; 2&#46;2 &#40;&#177;1&#46;5&#41; and 3&#46;3 &#40;1&#46;6&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;063&#41; at month two&#59; and 2&#46;0 &#40;&#177;0&#46;9&#41; and 3&#46;7 &#40;&#177;1&#46;9&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;001&#41; at month three&#44; respectively&#46; Again&#44; only the postoperative NRS at month three showed a significant between-group difference &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There were four patients who underwent reoperation&#44; all of whom belonged to the CIPA group&#46; In those cases&#44; the mean time interval was 12&#46;8 months&#46; Three patients suffered from recurred lumbar disc herniation and one patient had foraminal stenosis&#46; All lesions were due to post-operative instability&#46; All patients underwent posterior intervertebral body fusion surgery&#46; The proportion of reoperation was 0&#37; in the ELIA group and 31&#46;4&#37; in the CIPA group&#44; and the <span class="elsevierStyleItalic">p</span>-value was 0&#46;29 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The intracanal and foraminal lumbar disc herniation lesions can cause double radicular compression&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;9&#44;10</span></a> Such lesions are difficult to treat with surgery&#46; Several surgical techniques have been introduced in the treatment of double lumbar disc herniation&#46; The simplest is to remove the intracanal disc material following the interlaminar approach and then to remove the disc material of the foraminal lesion following extended medial facetectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;11&#8211;13</span></a> However&#44; in this approach&#44; the extra foraminal lesion is not accessible and&#44; even though an attempt is made to remove the disc material of the foraminal lesion&#44; it is highly likely for some to be left behind&#46; Another disadvantage is that if medial facetectomy is excessively performed&#44; the risk of instability is high due to postoperative spondylolysis or facet disruption&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;14&#8211;16</span></a> Accordingly&#44; some authors have recommended performing total facetectomy in parallel&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;6&#44;13&#44;16</span></a> However&#44; this approach has also been criticized because of a high risk of postoperative instability or chronic pain after surgery&#46; Thus&#44; there are authors who recommend performing intervertebral fusion surgery after total facetectomy to treat double lumbar disc herniation&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;17</span></a> Notably&#44; though&#44; fusion surgery takes a relatively long time and causes a large amount of blood loss&#44; increasing the risk for various complications&#46; It is also expensive&#46; For direct access to the foramen&#44; pars interarticularis fenestration has been introduced by Di Lorenzo and colleagues&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> but this approach is disadvantageous in that only limited exposure is possible&#44; and that there is a concern about a postoperative fracture of the pars&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Hence&#44; the CIPA approach was introduced by some authors&#44; and many advantages of the approach have been highlighted&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8&#44;20&#44;21</span></a> In CIPA&#44; the transversing root and the exiting root are simultaneously visible&#44; and the lesion can be removed without destroying the facet joint&#44; resulting in a low likelihood of postoperative instability&#46; Particularly&#44; the paraisthmic approach is a very useful surgical technique&#44; as access to the foramen is possible only with a partial removal of the superior-lateral portion of the facet joint&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">22&#8211;25</span></a> However&#44; the problem is that when this approach is used at the L5-S1 level&#44; excessive facetectomy or excessive removal of isthmus can happen&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26&#8211;28</span></a> The lateral pars at L5 are located up to the outer portion of the intervertebral foramen&#44; unlike those at other levels&#44; and thus&#44; an excessive removal of isthmus is necessary to completely expose the foramen&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28&#44;29</span></a> In contrast&#44; in the paraisthmic approach&#44; a foramen lesion can easily be resolved without removing isthmus because at upper lumbar levels such as at L2-3 or L3-4&#44; isthmuses are located further in relative to the intervertebral foramen &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; However&#44; this is not the case in some lesions at L4-5 and most lesions at L5-S1&#46; Accordingly&#44; for lesions at the L5-S1 level&#44; the authors attempted to remove foraminal or extraforaminal disc materials without performing lateral facetectomy or removing isthmus by using an extreme lateral approach&#46; With the ELIA approach&#44; it was possible to resolve most lesions without involving the facet joint&#44; and excellent outcomes on pain and K-ODI was observed during the follow-up in comparison with following the CIPA approach&#46; Even in cases with facet arthropathy&#44; access was possible through minimal superior facet undercutting&#44; and the facet joint was never involved&#46; With respect to reoperation&#44; 31&#46;4&#37; of patients in the CIPA group underwent reoperation&#44; whereas none did so in the ELIA group&#46; Of course&#44; the follow-up period was relatively short and statistical significance was not obtained&#44; but the authors believe that the statistics are meaningful in their own right&#46; The study has limitations in that it was a retrospective study&#44; and its sample size was relatively small&#46; And the total follow-up period was relatively short&#46; And there were not exact records about last follow-up outcome&#46; It was because of retrospective study&#46; In the future&#44; an effort should be made to derive more meaningful outcomes by using a larger sample and by observing patients for a longer follow-up period&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the treatment of L5-S1 double disc herniation&#44; the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Combined approach"
            1 => "Disc herniation"
            2 => "Lumbosacral junction"
            3 => "Lumbar"
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        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1083181"
          "palabras" => array:6 [
            0 => "ELIA"
            1 => "CIPA"
            2 => "CT"
            3 => "MRI"
            4 => "K-ODI"
            5 => "NRS"
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          "palabras" => array:4 [
            0 => "Abordaje combinado"
            1 => "Hernia discal"
            2 => "Uni&#243;n lumbosacra"
            3 => "Lumbar"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There are several approaches for double disc herniation consisting of an intracanal and foraminal lesion&#46; Of several approaches&#44; we introduced extreme lateral and interlaminar approach &#40;ELIA&#41;&#46; And we aimed to compare the approach with the conventional combined interlaminar and paraisthmic approach &#40;CIPA&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level between March 2012 and February 2016 and patients who underwent CIPA or ELIA were selected&#46; For preoperative testing&#44; simple X-ray&#44; computed tomography &#40;CT&#41;&#44; and magnetic resonance imaging &#40;MRI&#41; scans were performed&#46; For postoperative outcomes&#44; the Korean version of the Oswestry Disability Index &#40;K-ODI&#41; and Numeric Rating Scale &#40;NRS&#41; at one&#44; two&#44; and three months post-operation were checked&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eleven patients were given ELIA and twenty-four patients were involved in CIPA&#46; The mean pre K-ODI was 34&#46;1 &#40;&#177;13&#46;9&#41; and 32&#46;4 &#40;&#177;4&#46;0&#41; at each group&#46; 1st&#44; 2nd and 3rd month post-operative K-ODI was 8&#46;2 &#40;&#177;4&#46;1&#41;&#44; 6&#46;4 &#40;&#177;2&#46;1&#41; and 5&#46;3 &#40;&#177;2&#46;4&#41; in ELIA and 8&#46;1 &#40;&#177;3&#46;2&#41;&#44; 7&#46;1 &#40;&#177;3&#46;5&#41; and 8&#46;4 &#40;&#177;6&#46;4&#41; in CIPA&#46; Post-operative 3rd month K-ODI showed significant difference between two groups &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;005&#41;&#46; The mean pre NRS was 8 &#40;&#177;0&#46;9&#41; and 8&#46;6 &#40;&#177;1&#46;0&#41;&#46; 1st&#44; 2nd and 3rd month post-operative NRS was 2&#46;4 &#40;&#177;1&#46;5&#41;&#44; 2&#46;2 &#40;&#177;1&#46;5&#41; and 2&#46;0 &#40;&#177;0&#46;9&#41; in ELIA and 3&#46;3 &#40;&#177;1&#46;4&#41;&#44; 3&#46;3 &#40;&#177;1&#46;6&#41; and 3&#46;7 &#40;&#177;1&#46;9&#41;&#46; Post-operative 3rd month NRS showed significant difference between two groups as well &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;001&#41;&#46; There were four &#40;19&#46;0&#37;&#41; recurrence cases in CIPA patients group&#44; otherwise there was no recurrence case in ELIA group&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In the treatment of L5-S1 double disc herniation&#44; the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Existen varios tipos de abordajes para la hernia discal doble formada por una lesi&#243;n intracanal y foraminal&#46; Hemos elegido el Abordaje Extremo Lateral e Interlaminar &#40;ELIA&#44; por su sigla en ingl&#233;s&#41; con el objetivo de compararlo con el Abordaje Interlaminar y Para&#237;stmico Convencional combinado &#40;CIPA&#44; por su sigla en ingl&#233;s&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los autores revisaron los cuadros m&#233;dicos de pacientes que se vieron sometidos a un procedimiento para una hernia discal doble a nivel lumbosacro entre marzo del 2012 y febrero del 2016&#44; y se seleccionaron los pacientes que se sometieron a CIPA o a ELIA&#46; Como pruebas preoperatorias&#44; se realizaron radiograf&#237;as simples&#44; tomograf&#237;as computarizadas &#40;CT&#44; por su sigla en ingl&#233;s&#41;&#44; y escaneos de im&#225;genes de resonancia magn&#233;tica &#40;MRI&#44; por su sigla en ingl&#233;s&#41;&#46; Para resultados postoperatorios&#44; se revis&#243; la versi&#243;n coreana del &#205;ndice de Discapacidad Owestry &#40;K-ODI&#44; por su sigla en ingl&#233;s&#41; y la Escala de Estimaci&#243;n Num&#233;rica &#40;NRS&#44; por su sigla en ingl&#233;s&#41; a intervalos postoperatorios de uno&#44; dos y tres meses&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Once pacientes fueron sometidos a ELIA y veinticuatro pacientes a CIPA&#46; La media antes de K-ODI fue 34&#44;1 &#40;&#177;13&#44;9&#41; y 32&#44;4 &#40;&#177;4&#44;0&#41; en cada grupo&#46; El resultado K-ODI para el 1&#176;&#44; 2&#176; y 3&#176; mes postoperatorio fue de 8&#44;2 &#40;&#177;4&#44;1&#41;&#44; 6&#44;4 &#40;&#177;2&#44;1&#41; y 5&#44;3 &#40;&#177;2&#44;4&#41; en ELIA y 8&#44;1 &#40;&#177;3&#44;2&#41;&#44; 7&#44;1 &#40;&#177;3&#44;5&#41; y 8&#44;4 &#40;&#177;6&#44;4&#41; en CIPA&#46; El resultado postoperatorio K-ODI del 3&#176; mes mostr&#243; una diferencia significativa entre los dos grupos &#40;p&#58; 0&#44;005&#41;&#46; La media antes del NRS fue de 8 &#40;&#177;0&#44;9&#41; y 8&#44;6 &#40;&#177;1&#44;0&#41;&#46; El resultado del NRS del 1&#176;&#44; 2&#176; y 3&#176; mes postoperatorio fue de 2&#44;4 &#40;&#177;1&#44;5&#41;&#44; 2&#44;2 &#40;&#177;1&#44;5&#41; y 2&#44;0 &#40;&#177;0&#44;9&#41; en ELIA y 3&#44;3 &#40;&#177;1&#44;4&#41;&#44; 3&#44;3 &#40;&#177;1&#44;6&#41; y 3&#44;7 &#40;&#177;1&#44;9&#41;&#46; El resultado del NRS para el 3&#176; mes postoperatorio tambi&#233;n mostr&#243; una diferencia significativa entre los dos grupos &#40;p&#58; 0&#44;001&#41;&#46; Hubo cuatro casos de recurrencia en el grupo de pacientes sometidos a CIPA &#40;19&#44;0&#37;&#41;&#44; mientras que&#44; por el contrario&#44; no existi&#243; recurrencia en el grupo de pacientes sometidos a ELIA&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En el tratamiento de hernia discal doble L5-S1&#44; el abordaje quir&#250;rgico ELIA mostr&#243; mejores resultados que el abordaje quir&#250;rgico CIPA con respecto a dolor y resultados de K-ODI durante los ex&#225;menes de seguimiento a intermedio conducidos durante los tres meses posteriores a la cirug&#237;a&#46;</p></span>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pre &#40;A&#58; sagittal&#44; B&#58; axial&#41; and post &#40;C&#58; sagittal&#44; D&#58; axial&#41; MR image&#46; Yellow arrow&#58; the lesion of disc herniation&#59; yellow ring&#58; the removal site of disc material&#59; red arrow&#58; skin incision site&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ELIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex &#40;male&#58;female&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#58;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#58;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;0 &#40;&#177;13&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;6 &#40;&#177;13&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean duration of complaints &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;8 &#40;&#177;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5 &#40;&#177; 3&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 1st month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;2 &#40;&#177;4&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;1 &#40;&#177;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 2nd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;4 &#40;&#177;2&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;1 &#40;&#177;3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 3rd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;3 &#40;&#177;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;4 &#40;&#177;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre NRS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;&#177;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;6 &#40;&#177;1&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 1st month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;4 &#40;&#177;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;3 &#40;&#177;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 2nd month&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 3rd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;0 &#40;&#177;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => """
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Time interval &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Foraminal stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:29 [
            0 => array:3 [
              "identificador" => "bib0150"
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