A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation

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✓ Extreme-lateral lumbar disc herniations present a surgical challenge because the conventional posterior approach requires bone resection for complete visualization of the pathology. The authors have identified constant anatomical landmarks in cadaveric dissections that facilitate access to the intervertebral foramen when combined with a posterolateral approach, as described by Watkins, for lumbar spinal fusion. The authors describe a technique that allows rapid localization and safe excision of these extreme-lateral lumbar disc herniations without the need for bone resection.

Article Information

Address reprint requests to: H. Alan Crockard, F.R.C.S., Department of Surgical Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, England.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: Computerized tomography showing typical appearance of a large extreme-lateral lumbar disc herniation (arrow). Right: A similar disc herniation (arrow) on magnetic resonance imaging. The normal contralateral dorsal root ganglion and nerve root (arrowhead) are shown in an unobstructed root canal.

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    Drawings depicting the posterolateral approach. Left: A transverse section through a left L3–4 lumbar disc herniation. The neurovascular anatomy and the line of surgical approach are shown. The root is displaced dorsally by the herniation. At 30° from horizontal, the approach will identify the transverse process, and the lateral neurovascular branch which, when followed, will direct to the root canal. Center: The skin incision for a left L3–4 approach. The skin incision is 10 cm from the midline; the deep investing fascia is incised to expose the iliocostalis. Right: Further access is at 30° from the horizontal. Having separated the fibers of the iliocostalis, the transverse process is palpated and the taut lateral neurovascular bundle noted.

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    Drawings depicting the operating microscope view of the outlet of the root canal containing a sequestered disc fragment that distorts the root. Upper: The lateral neurovascular bundles are seen crossing the transverse processes, and the most medial bundle wraps around the pedicle. The root ganglion and ventral and dorsal rami are usually easily identified. Lower: After microdissection, the sequestered fragment can usually be extricated by microrongeurs, allowing the root to “fall back” into its normal anatomical position.

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