This document discusses the surgical management of extreme lateral disc herniations. It defines extreme lateral disc herniations as occurring outside the spinal canal but lateral to the facet joints. The document reviews different surgical approaches for these herniations including midline, paramedian, retroperitoneal, and endoscopic approaches. It then presents a case study of a 43-year-old patient who underwent a minimally invasive extreme lateral trans psoas approach to remove an L2-L3 disc herniation. The patient experienced good postoperative improvement in their leg and back pain. The document concludes this approach is a good option for extreme lateral disc herniations as it is fast, safe, and causes minimal blood loss or disruption

1. Dott. Nicola Zullo
UF Neurochirurgia
Clinica Eporediese Policlinico di Monza
Responsabile: Dott. C. Musso
Extreme lateral disc herniation causing
lumbar and radicular pain: surgical
management
IV Italian XLIF Consensus Meeting
13-14 September 2013
SantaVittoria (Cn)

2. • Herniated disc lateral to a line drawn between two adiacent
pedicles
• Herniation located at the outer upper corner of the intervertebral
disk
• Usually extends from the foramen laterally
• Completely free or contained within a minimal covering of the
anulus
• Unusual: 10-12% of disk herniations
• Most common in L4-L5 and in L3-L4
• Usually compress the root exiting around the pedicle, causing
painful ganglion irritation
Far Lateral disc herniation: definition

3. • Midline with medial facetectomy
• Midline with total facetectomy
• Paramedian/intertransverse process
• Endoscopic diskectomy
• Retroperitoneal diskectomy
• Controlateral approach to intraforaminal disk herniation (Berra et
al. SpineVolume 25, Number 6, pp 709-713, 2010)
Far Lateral disc herniation: surgical
approaches

4. Surgical approaches to far lateral HNP
Controlateral approache Extra-articular
intertransverse
Median approache

5. • In most articles far lateral and extreme lateral disc herniation are
synonymous
• Clinical presentation, diagnosis, surgical treatments are the same
previously reported
• Only one article by Madhok and Kanter describes a minimally
invasive extreme lateral trans psoas approach in two cases of far
lateral LDH
• Dezawa et al. described a retroperitoneal laparoscopic lateral
approach for far lateral disc herniation at L5-S1 or L1-L2 levels
Extreme lateral disc herniation:
review of the Literature

6. M.P. female, 43YO, no previous history of back or radicular pain
In November 2012 the patient lifted a load; one month later sudden onset of
mild lumbar back pain and severe radicular pain descending on the antero-
medial aspect of left thigh and leg, not responsive to drugs and physical
therapy
MRI: no intracanalicular, intra or extra-foraminal DH at L1-S1 levels; L2-L3
right lateral disc prolapse; no evidence of lesions of lumbar nerve roots
TC: confirmed the L2-L3 right disc prolapse extending between the muscular
fibers of psoas muscle
Case Report

7. • Disc herniation removed via extreme lateral trans psoas approach
• Minimal blo0d loss
• Short operative time (about an hour)
• Interbody fusion with Co-Roent XL 22x50x10 mm minimize the
risk of recurrency
• No disruption or removal of bone structures
• For a pure lateral disc herniation, traditional postero-lateral
approaches to intra-extraforaminal disc prolapses are not helpful
Surgical Management

8. • Clinical evaluation + LS X-Ray one month later, VAS Back/Leg and ODI
questionnaire + Lumbo-Sacral X-Ray at three months
• Clinical evaluation one month later: improvement of the left inferior limb
pain, no back pain
• LS X-Ray at three months: no subsidence, no evidence of fusion.
Follow Up
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ODI VAS B VAS L
Pre
Post

9. • X-Lif approach can be an option for the treatment of far lateral and
extreme lateral disc herniations
• In far lateral disc herniation help to avoid bone removal and articular
disruption (Madhok and Kanter)
• In extreme lateral disc herniation retroperitoneal access is
mandatory, because the lateral aspect of the disc lie below the transverse
processes; minimally invasive trans psoas approach with MaXcess
retractor is a good option: fast, safe, minimal blood loss, well known by
Orthopedic and Neurosurgeons
CONCLUSION