Neurosurg Focus 25 (2):E20, 2008

Perioperative results following lumbar discectomy:

comparison of minimally invasive discectomy and
standard microdiscectomy

JOHN W. GERMAN, M.D.,1 MATHEW A. ADAMO, M.D.,1 REGIS G. HOPPENOT, M.D.,2

JESSIN H. BLOSSOM, B.S., M.S.,1 AND HENRY A. NAGLE, B.A., M.A.1
Division of Neurosurgery, Albany Medical College, Albany, New York; and 2Department of
1

Neurosurgery, University at Buffalo Neurosurgery, Inc., Buffalo, New York

Object. Minimally invasive lumbar discectomy is a refinement of the standard open microsurgical discectomy
technique. Proponents of the minimally invasive technique suggest that it improves patient outcome, shortens hos-
pital stay, and decreases hospital costs. Despite these claims there is little support in the literature to justify the adop-
tion of minimally invasive discectomy over standard open microsurgical discectomy. In the present study, the
authors address some of these issues by comparing the short-term outcomes in patients who underwent first time,
single-level lumbar discectomy at L3–4, L4–5, or L5–S1 using either a minimally invasive percutaneous, muscle
splitting approach or a standard, open, muscle-stripping microsurgical approach.
Methods. A retrospective chart review of 172 patients who had undergone a first-time, single-level lumbar dis-
cectomy at either L3–4, L4–5, or L5–S1 was performed. Perioperative results were assessed by comparing the fol-
lowing parameters between patients who had undergone minimally invasive discectomy and those who received
standard open microsurgical discectomy: length of stay, operative time, estimated blood loss, rate of cerebrospinal
fluid leak, post-anesthesia care unit narcotic use, need for a physical therapy consultation, and need for admission
to the hospital.
Results. Forty-nine patients underwent minimally invasive discectomy, and 123 patients underwent open micro-
surgical discectomy. At baseline the groups did differ significantly with respect to age, but did not differ with
respect to height, weight, sex, body mass index, level of radiculopathy, side of radiculopathy, insurance status, or
type of preoperative analgesic use. No statistically significant differences were identified in operative time, rate of
cerebrospinal fluid leak, or need for a physical therapy consultation. Statistically significant differences were iden-
tified in length of stay, estimated blood loss, postanesthesia care unit narcotic use, and need for admission to the
hospital.
Conclusions. In this retrospective study, patients who underwent minimally invasive discectomy were found to
have similiar perioperative results as those who underwent open microsurgical discectomy. The differences,
although statistically significant, are of modest clinical significance. (DOI: 10.3171/FOC/2008/25/8/E20)

KEY WORDS • discectomy • hospital stay • lumbar spine • minimally invasive surgery
• narcotic use

UMBAR discectomy was first described in 1934 by Mix- approach-related complications associated with open discec-

L ter and Barr.11 Since the original description, the proce-

dure has undergone continued refinement to limit com-
plications and improve patient outcome.2,4,10,20–22 Most re-
cently, the use of a percutaneous, muscle-splitting, minimally
invasive approach rather than a standard open, muscle-strip-
ping approach has been described in an effort to limit ap-
proach-related complications. This latest refinement was
described by Foley and Smith4 in 1997 as a means to reduce
Abbreviations used in this paper: CSF = cerebrospinal fluid;
PACU = postanesthesia care unit.
tomy. Although proponents of this approach suggest that
patient outcome may be improved over a standard microsur-
gical discectomy,4,14,15 little comparative data has been provid-
ed to show that the differences in clinical outcome are indeed
different.6,8,12,13 To date, the largest studies of minimally inva-
sive discectomy have described an initial surgical experience
without extensive comparison to a standard microsurgical dis-
cectomy group.4,14,15 Given the potentially significant learning
curve associated with the use of a minimally invasive ap-
proach many surgeons have been reluctant to embrace these
techniques without more substantial evidence of clinical ben-
efit. Indeed, the current literature concerning minimally inva-

Neurosurg. Focus / Volume 25 / August 2008 1

Unauthenticated | Downloaded 11/06/21 10:12 PM UTC

FIG. 1. Photograph of the bladed retractor (left), used in the microsurgical group, and the tubular retractor (right), used
in the minimally invasive surgical group.
sive lumbar discectomy has been criticized for not emphasiz-
ing adverse results and complications.3
The present study was undertaken to further clarify the
effects of minimally invasive discectomy on short-term
patient outcome, and includes an analysis of 172 patients
treated by 6 board-certified neurosurgeons over a 3-year
period.
Methods
After institutional review board approval was received,
the divisional financial database at Albany Medical Center
was used to identify all patients who had undergone a lum-
bar discectomy (CPT code 63030) for radiculopathy be-
tween November 1, 2002 and March 1, 2006. One hundred
seventy-two patients who had undergone a first-time, sin-
gle-level discectomy at L3–4, L4–5, or L5–S1 were identi-
fied. These records were then reviewed for patient demo-
graphics (age, sex, height, weight, and body mass index),
type of radiculopathy (level and side), type of preoperative
analgesic use (none, nonsteroidal antiinflammatory, or nar-
cotic), insurance status (workers’ compensation or not),
type of surgical approach (minimally invasive or open mi-
crosurgical), operative time (in minutes), estimated blood
loss (in milliliters), percentage of patients with intraopera-
tive CSF leakage, percentage who required conversion to
an open procedure, postoperative narcotic use (in milligram
morphine equivalents), percentage of patients who required
physical therapy evaluation, percentage who required hos-
pital admission, and length of stay (in days).
2 Neurosurg. Focus / Volume 25 / August 2008
J. W. German et al.
Both groups of patients underwent lumbar discectomy
with either an open2,21,22 or minimally invasive technique4 as
previously described. The main difference between the
techniques lies within the treatment of the paraspinous
muscles and the type of retractor used (Fig. 1). Briefly, pa-
tients in the open group underwent a standard midline inci-
sion ~ 4–5 cm in length with a muscle-stripping approach
to the interspace. A bladed retractor was then inserted to
maintain surgical access. In contrast, the patients in the
minimally invasive group underwent a paramedian incision
~ 1.8 cm in length with a transmuscular approach to the
interspace using serial soft-tissue dilators. A tubular retrac-
tor was then inserted to maintain surgical access. Both
groups received similar perioperative care with respect to
general anesthesia, local anesthetic, postoperative pain
medications, and early mobilization.
The data are presented as means 6 standard errors of the
means. The groups were compared using the Student t-test
for continuous variables and the chi-square test for cate-
gorical variables. A probability value of 0.05 was consid-
ered statistically significant.
Results
Baseline demographics including age, sex, height,
weight, body mass index, insurance status, type of preoper-
ative analgesia, level and side of radiculopathy are present-
ed in Table 1. A statistically significant difference between
the groups was identified with respect to age (minimally
Unauthenticated | Downloaded 11/06/21 10:12 PM UTC
Short-term outcomes after lumbar discectomy

TABLE 1 fied in operative time, rate of CSF leak, or need for physi-
Summary of baseline characteristics of patients in cal therapy consultation. Statistically significant differ-
minimally invasive and standard microsurgical groups ences were identified in length of stay (minimally invasive
group: 0.82 6 0.28 days; open microsurgical group: 1.44 6
Minimally Invasive Standard Microsurgical 0.09 days; p , 0.05), estimated blood loss (minimally inva-
Characteristic Discectomy (49 patients) Discectomy (123 patients)
sive group: 59.3 6 12.0 ml; open microsurgical group: 90.4
age (yrs)* 47.45 ± 1.98 41.75 ± 1.11 6 8.1 ml; p , 0.05), PACU narcotic use (minimally inva-
male sex (%) 44.9 61.0 sive group: 9.1 6 1.56 mg morphine equivalents; open
body mass index 29.60 ± 0.66 29.53 ± 0.59 microsurgical group: 14.2 6 1.1 mg morphine equivalents;
no. on workers’ comp (%) 8.0 7.4 p , 0.05), and the need for hospital admission (minimally
no. w/ preop
medications (%)
invasive group: 34.7% admitted; open microsurgical
narcotics 62 58 group: 90.2% admitted; p , 0.0001).
NSAID 16 17
none 22 25 Discussion
discectomy side (%)
right 56.0 44.3 Criticism of Present Study
left 44.0 55.7
discectomy level (%) The goal of this study was to compare the perioperative
L3–4 12.0 7.4 outcomes after lumbar discectomy among patients who
L4–5 38.0 40.2 have undergone the minimally invasive muscle-splitting
L5–S1 50.0 52.4 approach and those who had the open microsurgical ap-
* Statistically significant difference, p = 0.021. Abbrevitions: comp = proach. The surgical care provided was similar between the
compensation; NSAID = nonsteroidal antiinflammatory drug. groups with the patients in both groups having received
general anesthesia. Postoperative pain was controlled with
local anesthesia at the skin incision and closure, oral nar-
invasive: 47.45 6 1.98 years; open microsurgery: 41.75 6 cotic combinations, and parenteral narcotics. Despite these
1.11 years; p , 0.05). The groups did not differ signifi- generalizations, the present study presents a retrospective
cantly with respect to height, weight, body mass index, review of patients who underwent lumbar laminotomy and
level or side of radiculopathy, insurance status, or type of discectomy over a 3-year period. Accordingly, the results
preoperative analgesic use. should be interpreted in the context of a retrospective
The percentage of patients who incurred a CSF leak was review with the disadvantages that such a study affords.
not statistically different between groups. Two patients who While several large series have described clinical results
underwent a minimally invasive approach required conver- using a minimally invasive approach,4,14,15 there are more
sion to a standard, open microsurgical discectomy. Due to limited clinical data comparing these surgical tech-
insurance issues the first patient remained in the hospital niques.6,8,12,13 It should be emphasized that the patients who
for 6 days before returning to the operating room for an underwent the minimally invasive approach still had the
open microsurgical hemilaminectomy to address a heavily benefit of an intralaminar exposure and were not treated
calcified intradural disc herniation. In the second patient, with an extraforaminal, intradiscal procedure as described
access could not be maintained using a minimally invasive by others.7
approach, and conversion to an open procedure was per- The baseline characteristics between the groups are not
formed at that time. The reason for the conversion was a statistically similar with respect to age. We believe that the
mechanical failure of the reticulated arm, which holds the observed difference in age between the groups is not very
tubular retractor in place. One patient in the minimally in- likely to have a significant effect on the short-term out-
vasive group sustained an iliac vein injury requiring emer- comes observed in this study. The fact that no statistically
gency vascular surgery for repair. significant differences were noted with respect to height,
weight, body mass index, preoperative medication use, or
Perioperative Parameters
workers’ compensation status suggests that the 2 surgeons
Perioperative outcome parameters are summarized in offering the minimally invasive approach were not biased
Table 2. No statistically significant differences were identi- towards younger, leaner, or noncompensation patients.

TABLE 2
Summary of results*
Minimally Invasive Open Microsurgical
Parameter Discectomy (49 patients) Discectomy (123 patients) p Value

operative time (min) 165.5 ± 5.75 169.8 ± 4.37 NS

estimated blood loss (ml) 59.3 ± 12.0 90.4 ± 8.1 ,0.05
CSF leak (%) 8.2 4.9 NS
pain med (mg morphine equivalents) 9.1 ± 1.6 14.2 ± 1.1 ,0.05
PT evaluation (%) 8.2 13.0 NS
LOS (days) 0.82 ± 0.28 1.44 ± 0.09 ,0.005
hospital admission (%) 34.7 90.2 ,0.0001
* LOS = length of stay; med = medicine; PT = physical therapy; NS = not significant.

Neurosurg. Focus / Volume 25 / August 2008 3

Unauthenticated | Downloaded 11/06/21 10:12 PM UTC
 J. W. German et al.

TABLE 3
Literature review of minimally invasive lumbar discectomy*
No. of Patients Analgesia (mg morphine) EBL (ml) OR Time (min) LOS (days)
Authors, Year MI Open MI Open MI Open MI Open MI Open

Smith & Foley, 1997† 43 NR NR NR NR NR NR NR 0.25 NR

Muramatsu et al., 2001‡ 70 15 52% 100% 12.1 59.1 NR NR 8.1 23.8
Grenier-Perth et al., 2002 43 86 NR NR 30 90 69 63 NR NR
Palmer, 2002 135 NR NR NR 22 NR 66 NR 1.0 2.0
Perez-Cruet et al., 2002 150 NR NR NR NR NR 97 NR 0.3 NR
Nakagawa et al., 2003§ 30 30 NR NR 92.9 112.8 74.7 65.8 NR NR
Huang et al., 2005 10 12 NR NR 87.5 190 109 72.1 3.57 5.92
Righesso et al., 2007 21 19 NR NR 50 40 63.7 82.6 1.0 1.08
Ryang et al., 2008 30 30 NR NR 26.2 63.8 92 82 4.0 4.4
current stud 49 123 9.14 14.18 59.3 90.4 166 170 0.84 1.43
* EBL = estimated blood loss; MI = minimally invasive; NR = not reported; OR = operating room.
† All patients were discharged within 6 hours of surgery except the first, who was admitted for 48 hours for a CSF leak
‡ Authors reported percentage who received morphine instead of milligrams of morphine. Estimated blood loss is given in grams.
§ Authors reported no significant difference in analgesic dosage on the day and night postoperatively. The number of patients who did not require analge-
sia postoperatively was significantly greater in the microendoscopic discectomy group.

An important variable that was not controlled in our
study was the attitude of the treating surgeon towards hos-
pital discharge after lumbar discectomy. This attitude is
most often shaped by hospital policies, hospital reimburse-
ment, insurance status, and nursing care than by any actual
clinical data. The effect of the surgeon’s attitude on clinical
outcome is not well-described, but there is some literature
to support its effect on clinical outcome.5
The importance of the present study lies in its size: this
is the largest comparative analysis of minimally invasive
versus open microsurgical discectomy to be presented to
date. Data from 6 board-certified, practicing neurosurgeons
are incorporated. Previous series of minimally invasive dis-
cectomy cases have largely been limited to single- or 2-sur-
geon experience.4,14,15
Complications of Minimally Invasive Spinal Surgery
The present study highlights the fact that the adoption of
minimally invasive techniques does not limit the potential
for complications. Although the percent of patients who
developed a CSF leak was similar between the groups, our
anecdotal experience suggests that most patients who
undergo a minimally invasive approach fare better because
they do not require bed rest, may be discharged home on
the day of surgery, and do not require further intervention
for symptomatic headaches or poor wound healing. This
analysis also demonstrates that the potential for major com-
plications is not avoided with a minimally invasive ap-
proach as 1 patient in this group required surgical repair of
an iliac vein laceration. Longer term complications such as
wound infections, recurrent disc herniation, and sympto-
matic spinal instability were not addressed in the present
study. To date the reported literature regarding minimally
invasive spine surgery has been criticized as being overly
optimistic.3 The continued review and reporting of adverse
events is essential to a full understanding of the effective-
ness of these procedures.
Effect of a Minimally Invasive Approach on Perioperative
Outcome
In our analysis, the minimally invasive approach demon-
strated statistical differences from the standard microsurgi-
cal approach with respect to length of stay, estimated blood
loss, PACU narcotic use, and the need for hospitalization.
Although statistically significant, these differences are of
dubious clinical significance. For example, the observed
difference in estimated blood loss between the groups is
minimal and would seem unlikely to affect the need for a
transfusion (a rare event in lumbar disc surgery). Similarly
the difference in PACU narcotic use is also negligible, and
would not seem to affect the need for more aggressive pain
control such as extended intravenous narcotics or a patient-
controlled analgesic pump. The medicoeconomic impact of
the difference in length of stay and the need for hospital
admission is not the subject of the current study. Such dif-
ferences may have different implications when analyzed
from the perspective of the patient, surgeon, hospital, or
insurance provider. Lorish et al.9 have suggested that, from
the perspective of the insurance provider, the cost savings
of a 1-day versus a 2-day hospitalization after lumbar dis-
cectomy is ~ $781. A prospective, randomized clinical trial
has been proposed to specifically address the issue of cost-
effectiveness.1
The largest benefit of a minimally invasive approach
may rest in the psychological effect afforded some patients
by allowing and encouraging a faster return to normal
activities and deemphasizing sickness behavior. Again this
benefit is not the subject of the current study.
Our results in the present study also demonstrate that a
minimally invasive approach does not add safety to the sur-
gical procedure.16 The rate of CSF leakage was numerical-
ly but not statistically higher in the minimally invasive
group compared to the open microsurgical group. The only
iliac vein injury observed occurred in the minimally inva-
sive group.
Comparison with Other Series of Minimally Invasive
Discectomy
A review of the reported studies of minimally invasive
discectomy is provided in Table 3. Huang et al.,8 Nakagawa
et al.,13 Grenier-Perth et al.,6 and Muramatsu et al.12 have
provided some comparative short-term outcome data using

4 Neurosurg. Focus / Volume 25 / August 2008

Unauthenticated | Downloaded 11/06/21 10:12 PM UTC
Short-term outcomes after lumbar discectomy
historical controls in their studies documenting the effects
of a minimally invasive approach to the spine. None of
these authors attempted to compare the effects of the mini-
mally invasive approach with a concurrent cohort of pa-
tients who underwent standard microsurgical discectomy.
The differences we observed between the groups are in
agreement with the findings of these previously published
studies.
Righesso and colleagues17 and Ryang et al.18 recently re-
ported the results of 2 prospective randomized trials of
minimally invasive versus open microdiscectomy in pa-
tients with first-time lumbar radiculopathy caused by disc
herniation. In both studies the investigators identified no
differences in clinical outcome between the groups at a
mean follow-up of 16 months as determined by Visual
Analog Scale, Oswestry Disability Index, and Short Form-
36 score. It should be noted that a power anlysis was not in-
cluded in either study, and it is possible that these studies
were underpowered to identify small differences between
groups.
The Importance of Minimally Invasive Lumbar Discectomy
The concept of minimally invasive spinal surgery is not
new, and previous attempts at minimally invasive lumbar
discectomy have often been viewed as less optimal than
traditional open microsurgical discectomy.2,19,20 Most re-
cently Foley and Smith4 introduced a percutaneous tubular
retractor system as a means of limiting approach-related
muscle damage during lumbar discectomy.
In the present study all patients in the minimally invasive
lumbar discectomy group underwent the access procedure
as described originally by Smith and Foley to a final diam-
eter of either 16 or 18 mm. After spinal access had been
obtained, a standard lumbar laminotomy and discectomy
were performed using traditional microsurgical techniques.
As a result, all patients in the minimally invasive group had
smaller incisions (16–18 mm in length) and underwent a
muscle-splitting approach. In contrast, the patients in
whom the standard open approach was performed had
slightly larger incisions (25–35 mm in length) and under-
went a muscle-stripping approach to allow placement of a
McCollough retractor. Although the authors of some stud-
ies have suggested that there is a decrease in associated
muscle injury with the use of the minimally invasive ap-
proach,8,19 the effect on patient outcome remains debatable
and, indeed, is the subject of our retrospective review.
It should be emphasized that although this study demon-
strates a very modest benefit of the minimally invasive
approach over the standard open microsurgical approach,
the potential benefits of such an approach should not be
immediately dismissed. For all surgeons attempting to
adopt minimally invasive approaches in clinical practice,
lumbar discectomy remains the most important transition
procedure. More involved procedures such as bilateral lum-
bar decompression, multilevel lumbar decompression, and
instrumented lumbar fusion can all be performed through a
minimally invasive approach. These procedures are techni-
cally more involved, of longer duration, and require more
extensive soft tissue destruction. Accordingly, application
of a minimally invasive approach to these procedures may
very well demonstrate even greater therapeutic gains over
the standard open approaches.
Neurosurg. Focus / Volume 25 / August 2008
Conclusions
Minimally invasive discectomy provides some statistical
advantages over open microsurgical discectomy with
respect to the need for admission, length of stay, estimated
blood loss, and PACU narcotic use. The clinical signifi-
cance of these rather modest differences is unclear. Given
the learning curve associated with the introduction of mini-
mally invasive approaches to clinical practice, these modest
clinical benefits probably do not warrant the transition from
a standard microsurgical approach to a minimally invasive
approach for surgeons whose lumbar spine practice is pre-
dominantly limited to laminotomy and discectomy.
Acknowledgments
We thank Drs. Alan S. Boulos, Joseph F. Emrich, Darryl J.
DiRisio, A. John Popp, and Paul E. Spurgas for contributing cases
to this analysis.
Disclaimer
The authors do not report any conflict of interest concerning the
materials or methods used in this study or the findings specified in
this paper.
References
1. Arts MP, Peul WC, Brand R, Koes BW, Thomeer RT: Cost-effec-
tiveness of microendoscopic discectomy versus conventional
open discectomy in the treatment of lumbar disc herniation: a
prospective randomized controlled trial [ISRCTN5187546.]
BMC Musculoskelet Disord 7:42, 2006
2. Caspar W: A new surgical procedure for lumbar disc herniation
causing less tissue damage through a microsurgical approach, in
Wullenweber R, Brock M, Hamer J (eds): Advances in Neu-
rosurgery. Berlin: Springer-Verlag, 1977, pp 74–77
3. Epstein NE: How often is minimally invasive minimally effective:
what are the complication rates for minimally invasive surgery?
Surg Neurol [epub ahead of print], 2008
4. Foley KT, Smith MM: Microendoscopic discectomy. Tech Neu-
rosurg 3:301–307, 1997
5. Graz B, Wietlisbach V, Porchet F, Vader JP: Prognosis or “curabo
effect?”: physician prediction and patient outcome of surgery for
low back pain and sciatica. Spine 30:1448–1453, 2005
6. Grenier-Perth R, Böhm H, El Saghir H: Microscopically assisted
percutaneous nucleotomy, an alternative minimally invasive pro-
cedure for the operative treatment of lumbar disc herniation: pre-
liminary results. Neurosurg Rev 25:225–227, 2002
7. Hermantin FU, Peters T, Quartararo L, Kambin P: A prospective,
randomized study comparing the results of open discectomy with
those of video-assisted arthroscopic microdiscectomy. J Bone
Joint Surg Am 81:958–965, 1999
8. Huang TJ, Wen-Wei Hsu R, Li YY, Cheng CC: Less systemic
cytokine response in patients following microendoscopic versus
open lumbar discectomy. J Orthop Res 23:406–411, 2005
9. Lorish TR, Tanabe CT, Waller FT, London MR, Lansky DJ:
Correlation between health outcomes and length of hospital stay
in lumbar microdiscectomy. Spine 23:2195–2200, 1994
10. Love JG: Removal of protruded intervertebral disc without lamin-
ectomy. Proc Staff Meet Mayo Clinic 14:800–805, 1939
11. Mixter WJ, Barr JS: Rupture of intervertebral disc with involve-
ment of spinal canal. N Engl J Med 211:210–215, 1934
12. Muramatsu K, Hachiya Y, Morita C: Postoperative magnetic res-
onance imaging of lumbar disc herniation: comparison of micro-
endoscopic discectomy and Love’s method. Spine 26:1599–
1605, 2001
13. Nakagawa H, Kamimura M, Uchiyama S, Takahara K, Itsubo T,
5
Unauthenticated | Downloaded 11/06/21 10:12 PM UTC

Miyasaka T: Microendoscopic discectomy (MED) for lumbar
disc prolapse. J Clin Neurosci 10:231–235, 2003
14. Palmer S: Use of a tubular retractor system in microscopic lumbar
discectomy: 1 year prospective results in 135 patients. Neurosurg
Focus 13(2):E5, 2002
15. Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington
R, Smith MM, et al: Microendoscopic lumbar discectomy: tech-
nical note. Neurosurgery 51 (5 Suppl):S129–S136, 2002
16. Podichetty VK, Spears J, Isaacs RE, Booher J, Biscup RS: Com-
plications associated with minimally invasive decompression for
lumbar stenosis. J Spinal Disord Tech 19:161–166, 2006
17. Righesso O, Falavigna A, Avanzi O: Comparison of open discec-
tomy with microendoscopic discectomy in lumbar disc hernia-
tions: results of a randomized controlled trial. Neurosurgery
61:545–549, 2007
18. Ryang YM, Oertel MF, Mayfrank L, Gilsbach JM, Rohde V:
Standard open microdiscectomy versus minimal access trocar
microdiscectomy: results of a prospective randomized study.
Neurosurgery 61:174–182, 2008
19. Stevens KJ, Spenciner DB, Griffiths KL, Kim KD, Zwienenberg-
6 Neurosurg. Focus / Volume 25 / August 2008
J. W. German et al.
Lee M, Alamin T, et al: Comparison of minimally invasive and
conventional open posterolateral lumbar fusion using magnetic
resonance imaging and retraction pressure studies. J Spinal
Disord Tech 19:77–86, 2006
20. Thomé C, Barth M, Scharf J, Schmiedek P: Outcome after lumbar
sequestrectomy compared with microdiscectomy: a prospective
randomized study. J Neurosurg Spine 2:271–278, 2005
21. Williams RW: Microlumbar discectomy: a conservative surgical
approach to the virgin herniated lumbar disc. Spine 3:175–182,
1978
22. Yaşargil MG: Microsurgical operation for herniated disc, in
Wullenweber R, Brock M, Hamer J, Klinger M, Spoerri O, (eds):
Advances in Neurosurgery. Berlin: Springer-Verlag, 1977, p 81
Manuscript submitted April 11, 2008.
Accepted July 1, 2008.
Address correspondence to: John W. German, M.D., Division of
Neurosurgery, Albany Medical Center, 47 New Scotland Avenue,
Albany, New York 12108. email: jwgerman@hotmail.com.
Unauthenticated | Downloaded 11/06/21 10:12 PM UTC