Clinical Findings

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  A 27-year-old male presented with complaints of right radicular pain and paresthesia along the right lateral calf having lasted 3 months.

  
  
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  On clinical examination, weakness of the ankle and great toe was observed on dorsiflexion.

  
  
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  Preoperative imaging showed a right-sided sequestrated extraforaminal disk herniation at the L5-S1 level with slight upward migration. Spondylolysis of the L5 vertebra was observed, but with no significant instability ( Fig. 18.87 ).

Surgical Procedure

1. 
   

   The cannula tip is positioned at the midpedicular line as seen in the AP fluoroscopic view ( Fig. 18.88A ).

   
   
2. 
   

   The cannula tip is at the outer surface of the posterior annulus in the lateral fluoroscopic view ( Fig. 18.88B ).

   
   
3. 
   

   In the targeted fragmentectomy using the extraforaminal approach for extraforaminal herniations, it is not necessary to insert the working cannula into the disk space because there is no need for central debulking of the disk to create a working space.

Endoscopic Findings

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  In extraforaminal disk herniations, the first view on introduction of the scope is usually the blue-stained herniated mass with some periannular fat. The fat and vessels are cleared with a high-radiofrequency bipolar triggerflex probe. Because the fat tissue usually contains small blood vessels, one should always coagulate it first with a radiofrequency probe and then proceed to the removal of the fragment with endoscopic forceps. Otherwise, troublesome bleeding may start that would be difficult to control ( Fig. 18.89A ).

  
  
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  The blue-stained fragment is grasped and removed with forceps ( Fig. 18.89B ).

  
  
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  Some remnant disk fragments lie within the axilla of the exiting nerve root ( Fig. 18.89C ).

  
  
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  These remnant disk fragments in the axilla of the L5 nerve root are removed with forceps. Note that the tail of the fragment can be grasped and removed completely even when the whole fragment cannot be seen. This avoids unnecessary manipulation of the inflamed nerve root and dorsal root ganglion ( Fig. 18.89D ).

  
  
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  After complete removal of the sequestrated fragments, the exiting nerve root is decompressed and coursing freely all along its course. However, the root appears to be inflamed ( Fig. 18.89E ). In such cases, injection of steroid (20 mg triamcinolone mixed with 1% lidocaine) around the nerve root at the end of the procedure can be useful to reduce postoperative discomfort and dysesthesia.