17 Minimally Invasive Far Lateral Diskectomy Tips and Pearls Before You Begin Far lateral disk herniations affect the nerve root exiting lateral to the neuroforamen Therefore, a standard hemilaminotomy will not allow for visualization of the disk herniation without excessive or complete resection of the facet joint L5–S1 disk herniations pose an additional anatomic challenge because the sacral ala and iliac wing will often prevent a far lateral approach L4 L5 • Lateral fluoroscopic visualization is essential to confirm the appropriate level 93 IV Lumbar Spine L5 ing t ers e roo v tra erv n L3–L4 facet joint L5–S1 facet joint e ne xit r v ing e L ro ot L4–L5 facet joint L5 tr pr ansv oc er es se s disk space L4 transverse process • The incision is typically made cm lateral to the midline The tube is docked onto the lateral aspect of the pars interarticularis and the inferior transverse process disk space e ne xit rv ing e L ro ot L5–S1 facet joint L5 ng rsi root e v tra erve n L4–L5 facet joint L5 tr pr ansv oc er es se s 94 intertransverse septum • The tube is docked lateral to the L4–L5 facet joint L3–L4 facet joint L4 transverse process 17 Minimally Invasive Far Lateral Diskectomy gL sin t ver e roo a r t er v n L4–L5 disk herniation L4–L5 facet joint L5–S1 facet joint L4 transverse process L5 transverse process exiting L4 nerve root • The intertransverse septum is exposed and is detached from the inferior transverse process with a curved curette ro ne rv e L4 transverse process L4 L5 transverse process herniated disk ot L4–L5 facet joint L5–S1 facet joint • The nerve root is typically displaced such that it is dorsal and lateral to the disk herniation 95 96 IV Lumbar Spine L4–L5 facet joint L5–S1 facet joint L4 transverse process herniated disk space L5 transverse process ng iti ex ot ro L4 • The nerve root should be gently mobilized superiorly to expose the underlying disk space L4–L5 facet joint L5 transverse process disk material L er 4n r ve t oo • A pituitary rongeur is used to remove the disk fragments 17 Minimally Invasive Far Lateral Diskectomy oo t t oo 5r L ng rsi L4–L5 ve facet joint tra ne rv er L5–S1 facet joint L5 transverse process L4 L4 disk space r rve ne t oo • A curette is placed into the site of the disk herniation L4–L5 facet joint L5–S1 facet joint disk space L5 transverse process L4 ne o er rv ot L4 transverse process • If there is any foraminal stenosis, a Kerrison rongeur can be passed into the neuroforaminal space from the outside in, thereby resecting any foraminal or extraforaminal osteophytes 97 98 IV Lumbar Spine Potential Pitfalls Meticulous dissection is necessary to obtain hemostasis, particularly when the intertransverse septum is resected Bleeding, if not controlled, will result in poor visualization of the disk herniation, with a resultant inadequate decompression