Endoscopic Foraminoplasty: Key to Understanding the Sources of Back Pain and Sciatica and Their Treatment

Abstract

Since 1990, I have been practicing aware-state surgery and have regularly found that the exiting nerve is being irritated or compressed by facet joint osteophytes, the superior foraminal ligament (SFL), and/or shoulder osteophytes and tethering of the exiting nerve to the billowing or inflamed disc. These features are grossly underdemonstrated by magnetic resonance imaging (MRI) and computed tomography (CT) scans. In addition, these investigative tools fail to account for neural anomalies. The key finding however is that pressure on the medial border of the irritated nerve produces back pain, while the core of the nerve produces oft-atypical dermatomal pain and the disc wall seldom produces back pain. Consequently, endoscopic minimally invasive spine surgery involving transforaminal decompression and foraminoplasty offers a paradigm shift in the treatment of chronic lumbar spondylosis and back pain, degenerative disc disease, and failed back surgery by treating the causal factors, mobilizing the nerve and the dorsal root ganglion. This surgery is performed in the aware state, thus allowing accurate determination of the single most relevant foraminal level, avoiding open surgery, retaining segmental movement, and maintaining the options for the patient as new techniques such as keyhole nuclear replacement become established.