Wiltse Approach for Lumbar Microdiscectomy and Foraminotomy: 2-Dimensional Operative Video.

Far lateral disc herniations account for between 7% and 12% of all disk herniations and occur predominantly at L3/4 and L4/5.1,2 They can cause severe radicular pain due to dorsal root ganglion involvement and are exacerbated by lateral bending to the side of the lesion. Back pain is less of a feature with this pathology.3 The Wiltse approach was first described in the 1960s as an approach to L5/S1 noninstrumented fusion for isthmic spondylolisthesis4; its use in pedicle screws and far lateral discs was described in 1988.5 It has been shown to reduce muscle atrophy, wound infection, and blood loss.6,7 The Wiltse approach for a far lateral disc herniation provides a direct route to the disc pathology and as such is useful in cases with this isolated pathology. It confers less extensive muscle dissection and therefore less postoperative pain, minimal bone resection with preservation of the integrity of the facet joint, and it does not rely on endoscopy (rather the traditional operating microscope). It can also be used where endoscopy is contraindicated such as in revision cases. Here we present the case of a 53-year-old woman who presented with several weeks of back pain and right L3 radiculopathy, as well as right hip flexion and knee extension weakness. A Wiltse approach microdiscectomy was proposed for her far lateral disk herniation, and the patient consented to the procedure. At 6 weeks of follow-up, her radicular pain had resolved and there was improvement in hip flexion and knee extension. Image at 5:50 of Surgical Video is used with permissions from the Wiltse, L, Bateman, JD, Hutchinson, RH, and Nelson, WE. The Paraspinal Sacrospinalis-Splitting Approach to the Lumbar Spine. J Bone Joint Surg Am. 1968;50(5):919-926. Copyright © 1968 by The Journal of Bone and Joint Surgery, Inc.