Different Surgical Approaches to Far Lateral Lumbar Disc Herniations

In far lateral disk surgery, although total facetectomy provides the best exposure and allows for removal of medial and far lateral extruded disk fragments, the risk of instability is increased as a result of excision of the pars interarticularis, Medial facetectomy uncovers the lateral and subarticular recess and preserves stability but does not allow for proper visualization of the far lateral compartment. The isolated extraforaminal approach provides access only to far lateral sequestrated fragments and does not allow access for more medial diskectomy or decompression of associated stenosis. Combining the extraforaminal exposure with a laminotomy, hemilaminectomy, or laminectomy complements the intertransverse (ITT) approach and affords access both to lateral and to medial disk lesions and stenotic abnormalities. The advantages and disadvantages of the less popular extraforaminal, transpars, percutaneous, and anterior decompressive techniques are also assessed. No one technique of far lateral disk excision is applicable for the management of all lesions. It is more appropriate to choose the right operation for the right patient.