Transforaminal Endoscopic Lumbar Foraminotomy/Foraminoplasty

Abstract

Lumbar spinal stenosis (LSS) is a disease that refers to a condition in which the spinal canal is narrowed and causes compression of the nerve root and thecal sac. LSS is usually encountered in patients aged 60 years or older and is the most common cause of back pain. The condition of this disease was first described by Antonie Patel in 1803. In the 1950s, Verbiest first named the term spinal stenosis, and also described the factors associated with this disease.

Anatomically, LSS is classified into lateral recess or subarticular, foraminal, and extraforaminal stenosis, including the central, depending on the area being compressed. Foraminal stenosis (FS) is caused by a decrease in the intervertebral disc space, the formation of osteophytes of vertebral endplate and facet joint, and herniation of the disc.

In the case of minimally invasive surgery such as endoscopic surgery, it has been confirmed that postoperative muscle damage can be reduced depending on the wound size and approach direction and method. As a treatment for FS using this endoscopic approach, TELF/TELD (Transforaminal endoscopic lumbar foraminotomy/discectomy) is a technique that enables the selective removal of neural compromising structure that causes the patient’s symptoms within the range that guarantees the stability of the facet joint without damaging the muscles around the spine. While the first endoscopic foraminotomy was reported in the early 2000s, technical and technological advances allowed a safer and more efficient procedure, adopting an “outside-in” approach to the stenotic foramen.

When considering endoscopic foraminotomy, the site of stenosis can come in various forms, and the technique requires decompression in two main directions in technical aspects. The first half consists of superior articular process (SAP) decompression and lateral recess decompression. The second half consists of 3C (central, caudal, and cranial) technique, osteophyte resection, and disc fragmentectomy in that order. Afterwards, when a patient is encountered in the treatment room, it is necessary to classify it into one of eight subtypes, identify important points, and then establish a surgical strategy. And then, the endoscopic surgery method suitable for each case can be selected and performed.

Endoscopic decompression (Lateral recess decompression/Foraminotomy) may be an excellent tool for alleviating the pain. It offers a more powerful and less morbid alternative approach to spinal pathology that ultimately elevates the standard of care. This technique may be an excellent procedure for patients who are not willing to get lumbar fusion.