How I do it: microsurgical extraforaminal sequestrectomy through a midline intertransverse approach.

BACKGROUND: Several surgical approaches exist for extraforaminal (far lateral) lumbar disc herniations, including paraspinal Wiltse-type, interlaminar, lateral intertransverse, and combined medial-lateral techniques. METHOD: We present microsurgical extraforaminal sequestrectomy through a midline intertransverse approach, chosen for familiar anatomy, minimal facet joint resection, and avoidance of a muscle-splitting trajectory. Unilateral subperiosteal dissection exposes the isthmus, facet margin, and transverse processes with the intertransverse ligament; the facet margin is removed with a straight osteotome, the ligament resected, the intertransverse artery coagulated, and the nerve root and disc space exposed for sequestrectomy. CONCLUSION: This approach provides effective sequestrectomy while preserving spinal stability using familiar midline anatomy.