Surgical management of symptomatic retroperitoneal migratory disc herniation anterior to the sacral ala causing L5 radiculopathy using direct decompression and fusion: illustrative case

Imaging can be unreliable in distinguishing migratory disc herniation from tumors. Although MRI and PET/CT are standard tools, they can show features that overlap with neoplastic processes. Histopathological evaluation remains crucial for accurate diagnosis. The pararectus approach provides excellent access for biopsy and direct decompression in cases of atypical herniations, minimizing recurrence risk while addressing concurrent disc degeneration. This case highlights the importance of comprehensive imaging and interdisciplinary discussions when diagnosing and treating rare disc herniations, with the pararectus approach offering a viable surgical solution for these challenging cases. Surgeons should consider atypical herniation locations when diagnosing lumbar radiculopathy, especially in cases where imaging is inconclusive. For retroperitoneal herniations, the pararectus approach allows for both diagnostic biopsy and effective surgical management, including decompression and fusion in a single procedure. https://thejns.org/doi/10.3171/CASE24866.