Endoscopic transforaminal discectomy for far lateral disc herniation at L3-L4: A 2-dimensional operative video

Far lateral disc herniations (FLDHs) comprise approximately 7-12% of all lumbar disc herniations and involve protrusion of disc material within or lateral to the intervertebral foramen. Compression of the exiting nerve root and dorsal root ganglion at the same intervertebral level may result in more severe, acute, and refractory radicular pain when compared to paramedian disc herniations, often necessitating surgical management. Due to their lateral location, FLDHs limit direct posterior access and often require off-midline approaches to avoid excessive bony resection. These technical challenges motivate the use of endoscopic techniques, which enable targeted decompression of the exiting nerve root.

This report describes a 49-year-old male with progressive worsening lumbar radiculopathy in the setting of a right FLDH at the Lumbar 3 - Lumbar 4 level. Given the single-level extraforaminal pathology causing progressive, refractory radicular symptoms despite conservative management, endoscopic far lateral discectomy was recommended. To begin, a paramedian incision was made over the right L3-L4 foramen, after which dilators were advanced down to the facet complex and a tubular retractor was positioned over the lateral aspect of the lamina and facet. Using the endoscope, soft tissue was cleared from the lateral facet and transverse process with electrocautery and pituitary rongeurs. We then performed a laminotomy and partial lateral facetectomy to mobilize the exiting L3 nerve root. The herniated disc was removed with pituitary rongeurs, and closure was performed in a layered fashion.

The patient had an uncomplicated postoperative hospital course and recovery. At 2 weeks, he reported significant improvement in right lower extremity pain with minor residual pain in the right knee and shin. By 4 months, the patient reported continued improvement in preoperative symptoms with no ongoing pain or discomfort. The patient consented to the procedure, and Institutional Review Board approval was not required for this single-case observational surgical video.