Midline sequestrectomy for far lateral lumbar disc herniation: a case series and technique description

Background: Far lateral lumbar disc herniation (FLLDH) accounts for a small proportion of lumbar disc pathologies and often requires surgical intervention when conservative management fails. Although minimally invasive tubular approaches are widely adopted, access to advanced microsurgical equipment remains limited in many centers. This study evaluates the clinical outcomes and feasibility of midline fragment-only sequestrectomy for FLLDH in a resource-limited setting. Methods: This retrospective single-surgeon case series included 35 patients with MRI-confirmed FLLDH treated by midline fragment-only sequestrectomy between 2018 and 2023. Patients with persistent radicular leg pain refractory to conservative treatment for at least 3 weeks and without spinal instability were included, whereas those with prior lumbar surgery, infection, or malignancy were excluded. All procedures were performed through a midline incision under microscopic visualization, using limited bone removal without formal hemilaminectomy or facetectomy to access the far lateral zone. Clinical outcomes were assessed using the Visual Analog Scale (VAS) preoperatively and at 12-month follow-up, and the Macnab criteria at final follow-up. Pre- and postoperative VAS scores were compared using the Wilcoxon signed-rank test. Results: The mean age was 45 years (range: 30-60). Herniation levels were identified as follows: L2-L3 (2.8%), L3-L4 (14.3%), L4-L5 (68.6%), and L5-S1 (14.3%). The mean operative time was 30 ± 10 minutes, and the mean blood loss was 40 ± 10 ml. All patients were discharged within 16 hours post-surgery. During the 24-month follow-up period, no recurrences or instability were observed. At the final follow-up, 82.8% of the patients reported excellent outcomes, while 17.2% reported good outcomes. Conclusion: Midline sequestrectomy yields favorable short- and long-term outcomes consistent with previously reported series and is a safe, cost-effective option in resource-limited settings.