Another special patient population for which APLD should be the first procedure chosen consists of patients whose herniations occur in the far lateral location beyond the intervertebral foramen. Such patients are difficult to treat with a traditional interlaminar approach of mi-crodiscetomy, which sometimes requires the removal of all or a large portion of the facet (Figure 8.4). Our excellent results with APLD in this patient population are understandable, since the percutaneous disc-ectomy instrumentation essentially drives over the herniation itself.13 Special care is needed in performing the procedure in these patients, however, for if the nerve is pushed into a more posterior position, and placement of the instrumentation becomes more problematic.
Figure 8.4. Axial CT scan showing far lateral HNP on the right side (black arrow). The nerve (straight, white arrow) is displaced by the herniation posteriorly and laterally, possibly making placement of the instruments more difficult. The normal nerve on the left is noted (curved arrow).
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