Above is the nerve root retractor mentioned in part 4. The flexible arm clamps onto the top (right side of this photo). The “bayonet” offset keeps it out of the line of sight. The curved flange at the tip (on the left end in photo) holds the dura and nerve root over. The flange is then pushed down on the floor of the spinal canal so the nerve root won’t slip out and the retractor arm tightened.
The instrument above is used to remove all the loose, protruding pieces of disk cartilage. The “pistol grip’ keeps hands out of the way. It can be straight, up, or down-biting. Sometimes the herniation is in one piece but more often there are several fragments.
A spoon-tipped disc curette, above, is used to dislodge any fragments that may be partially detached, to reduce the chance of recurrence. Then a little antibiotic-containing blood in the exposure (antibiotics are given IV pre-op) is allowed to ooze into the cavity created inside the disc, and clot. The blood clot is a matrix for ingrowth of fibrocartilage to heal the disc defect. It will be as strong as the disc cartilage but not as flexible. Removal of all loose disc material is usually sufficient. At times, the nerve root canal is still too small (stenotic), so the Kerrison ronguer is used to remove more bone and “unroof” it until the nerve root goes through easily, noted by using a curved probe along the nerve after releasing the retractor.
The muscle retractor is then removed and the wound closed in layers. Before that, I inject the muscle and skin with a long-acting local anesthetic and patients usually wake up without incisional pain and, if the nerve root isn’t swollen and/or tight within its exit canal, without persistant leg pain.