Which approach would you recommend for a posterolateral herniated disc at L4-5?
A 35-year-old healthy active woman presents with a three-month history of progressive right-sided leg pain. The pain is directed along the right-sided L5 dermatome and is associated with some numbness along the lateral leg and into the first dorsal web space. There is some weakness of the extensor hallicus longus (EHL) muscle on the right side with strength graded at 4/5. There is no back pain.
The patient has tried physical therapy and anti-inflammatory medications which helped a little initially, but the pain recurred when she resumed her daily activities after one week of rest. The patient had a transforaminal epidural steroid injection at L5-S1 that gave her four days of complete relief of her leg pain, but it has now returned. She has had two further epidural injections with temporary relief. Currently the pain is almost constant; she rates it as 7 out of 10. She is currently working but has difficulty throughout the day and is interested in a long-term solution.
Plain radiographs demonstrate mild narrowing of the disc space height at L4-5 compared to the adjacent levels. Magnetic resonance imaging (MRI) demonstrates a large rightsided posterolateral disc herniation at L4-5 which compresses the right-sided L5 nerve root and extends slightly into the foramen.
The patient is interested in surgery. How would you proceed with treatment at this point?