Name: Endoscopic Trans-SAP Approach for a Paracentral Disc Herniation at L3-L4
Uploaded: 2026-08-07T13:48:00Z
Channel: Arthrex
Description: Marc Szadkowski, MD (Lyon, France), presents a case of a 51-year-old male with a paracentral disc herniation at L3-L4, treated using an endoscopic trans-SAP decompression approach.

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<p>Marc Szadkowski, MD (Lyon, France), presents a case of a 51-year-old male with a paracentral disc herniation at L3-L4, treated using an endoscopic trans-SAP decompression approach.</p>

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VID1-009874-en-US | A | Endoscopic Trans-SAP Approach for a Paracentral Disc Herniation at L3-L4

Marc Szadkowski

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Endoscopic Trans-SAP Approach for a Paracentral Disc Herniation at L3-L4

Speaker  Hi, I'm Mark Szatkowski. I'm an orthopedic surgeon from the Santee Group from Lyon in France. And today I will show you a trans Sapi approach on l3-l4 level for a paracentral disc herniation. So the trans Sapi approach gives the surgeon the opportunity to increase the power of foraminal techniques to reach difficult anatomical sites by removing extra articular bone from the sap. This approach has many advantages. First, you duck on a highly secure zone far from the exiting nerve. You increase the size of the foramen to explore the canal, and you have a better view on the shoulder of the transversing nerve root. This is the case of a 51 year old gentleman, a heavy worker, and for one month he had a bilateral posterior leg pain. And he came in the emergency to the office because for two days he had weakness in the right leg. On the clinical examination, I had a positive straight leg test, 30 degrees bilateral. And the patient had a motor deficit on the dorsal flexion and on the quadriceps. Here is the MRI. And on the axial view you can see that the dura is severely compressed by your paracentral disc herniation on the level l3 l4. Here you can see in red the disc herniation that is located slightly more on the right side. In green you can see the dural sac that is severely compressed on the sagittal view. Speaker  You can see the level l3 L4 with a disc herniation that goes cranially and caudally. And here you have the same view with the disc in red at the L3 L4 level. The interlaminar window that you see in red is lower than the disc level. So if you want to decompress the dural sac in an open fashion, you have to remove a lot of bony structures, including the ligaments. So the main advantage of the trans sap approach is to leave all the posterior structures intact, and to remove a small extra articular piece of bone to go inside the canal to have a better view on the disc herniation and the dural sac. The planning is to remove a piece of bone that you can see in blue with the dedicated reamers. After docking on the sap here, you see the AP view. First you have to draw a vertical line, which is the midline and a horizontal line, which is the level of the injury. Then you draw the direction you will have to use for this technique, and you will start always with the lateral X-ray. And the aim is to dock more shallow than in a transforaminal approach. On the sap here you can see a lateral view of where you have to dock. Then by using Corona Reamers, you start to create a bony channel in the sap. Speaker  Here you can see the bony channel. You progressively increase the size of the channel in order to put the working channel inside. On the left video, you can see the bony removal and the remaining ligamentum flavum hiding the dura. You can remove this thin layer if you need it with a Kerrison punch. You can also drill the tip of the sap if you want to go more Cranially. On the right video, you start to see the dura that is proceeding. Now as we started to remove the disc herniation, now the dura and the nerve are free. You can see the transversing nerve root and the PLL you can easily reach with this approach to cranial part of the disc. As you can see on the X-ray done with the probe inside for the postoperative period, we ask the patient for four weeks to work and to avoid active physiotherapy at one month post-op. After examination by the surgeon, the patient can return to daily life activities while starting active core training. So this is a great option for patients because you can address multiple conditions like migrated disc herniations, foraminal stenosis, and even recess stenosis combined with disc herniation and without removing any ligament or facet, which ultimately gives the quickest recovery. Thank you.