Name: Transforaminal Full-Endoscopic Lumbar Foraminotomy Under Local Anesthesia for L5/S1 Adjacent Segment Foraminal Stenosis (Video) | JoVE Journal
Uploaded: 2025-10-17T14:05:00.000+00:00
Duration: 7 min 44 s
Description: Learn transforaminal full-endoscopic foraminotomy under local anesthesia for treating L5/S1 adjacent segment foraminal stenosis. This motion-preserving technique offers a minimally invasive alternative to spinal fusion surgery.

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<li>Park, P., Garton, H. J., Gala, V. C., Hoff, J. T., McGillicuddy, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Adjacent+segment+disease+after+lumbar+or+lumbosacral+fusion%3A+review+of+the+literature%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature.</a> Spine. 29 (17), 1938-1944 (2004).</li>
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<li>Ahn, Y., Kim, H. S., Lee, J. H., Kim, J. S., Jang, I. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Radiographic+assessment+on+magnetic+resonance+imaging+after+percutaneous+endoscopic+lumbar+foraminotomy%5BTitle%5D)+AND+%22Neurol+Med+Chir+%28Tokyo%29%22%5BJournal%5D)">Radiographic assessment on magnetic resonance imaging after percutaneous endoscopic lumbar foraminotomy.</a> Neurol Med Chir (Tokyo). 57 (12), 649-657 (2017).</li>
<li>Song, Q. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Full-endoscopic+foraminotomy+with+a+novel+large+endoscopic+trephine+for+severe+degenerative+lumbar+foraminal+stenosis+at+L5-S1+level%3A+An+advanced+surgical+technique%5BTitle%5D)+AND+%22Orthop+Surg%22%5BJournal%5D)">Full-endoscopic foraminotomy with a novel large endoscopic trephine for severe degenerative lumbar foraminal stenosis at L5-S1 level: An advanced surgical technique.</a> Orthop Surg. 13 (2), 659-668 (2021).</li>
<li>Sairyo, K., Chikawa, T., Nagamachi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Strengths+and+merits+of+transforaminal+full-endoscopic+lumbar+spine+surgery+under+the+local+anesthesia%3A+A+review+article%5BTitle%5D)+AND+%22J+Minim+Invasive+Spine+Surg+Tech%22%5BJournal%5D)">Strengths and merits of transforaminal full-endoscopic lumbar spine surgery under the local anesthesia: A review article.</a> J Minim Invasive Spine Surg Tech. 9 (Suppl 2), S143-S151 (2024).</li>
<li>Matsumura, T., Chikawa, T., Nishidono, K., Sairyo, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Step-by-step+explanation+of+full-endoscopic+lumbar+foraminotomy+at+the+L5%2FS1+level+under+local+anesthesia%3A+An+editorial+technical+note%5BTitle%5D)+AND+%22EC+Orthop%22%5BJournal%5D)">Step-by-step explanation of full-endoscopic lumbar foraminotomy at the L5/S1 level under local anesthesia: An editorial technical note.</a> EC Orthop. 14 (7), 47-53 (2023).</li>
<li>Ahn, Y., Song, S. -K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transforaminal+endoscopic+lumbar+foraminotomy+for+octogenarian+patients%5BTitle%5D)+AND+%22Front+Surg%22%5BJournal%5D)">Transforaminal endoscopic lumbar foraminotomy for octogenarian patients.</a> Front Surg. 11, 1324843(2024).</li>
<li>Zheng, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anesthesia+methods+for+full-endoscopic+lumbar+discectomy%5BTitle%5D)+AND+%22Front+Med%22%5BJournal%5D)">Anesthesia methods for full-endoscopic lumbar discectomy.</a> Front Med. 10, 1193311(2023).</li>
<li>Yamashita, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+full+endoscopic+lumbar+foraminoplasty+for+adjacent+level+foraminal+stenosis+following+vertebral+intersegmental+fusion+in+an+awake+and+aware+patient+under+local+anesthesia%3A+A+case+report%5BTitle%5D)+AND+%22J+Med+Invest%22%5BJournal%5D)">Percutaneous full endoscopic lumbar foraminoplasty for adjacent level foraminal stenosis following vertebral intersegmental fusion in an awake and aware patient under local anesthesia: A case report.</a> J Med Invest. 64 (3-4), 291-295 (2017).</li>
<li>Zhang, C., Berven, S. H., Fortin, M., Weber, M. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Adjacent+segment+degeneration+versus+disease+after+lumbar+spine+fusion+for+degenerative+pathology%3A+A+systematic+review+with+meta-analysis+of+the+literature%5BTitle%5D)+AND+%22Clin+Spine+Surg%22%5BJournal%5D)">Adjacent segment degeneration versus disease after lumbar spine fusion for degenerative pathology: A systematic review with meta-analysis of the literature.</a> Clin Spine Surg. 29 (1), 21-29 (2016).</li>
<li>Okuda, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgical+complications+of+posterior+lumbar+interbody+fusion+with+total+facetectomy+in+251+patients%5BTitle%5D)+AND+%22J+Neurosurg+Spine%22%5BJournal%5D)">Surgical complications of posterior lumbar interbody fusion with total facetectomy in 251 patients.</a> J Neurosurg Spine. 4 (4), 304-309 (2006).</li>
<li>Guo, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparative+advantages+of+transforaminal+percutaneous+endoscopic+lumbar+decompression+versus+traditional+revision+surgery+for+degenerative+adjacent+segment+degeneration+following+lumbar+fusion%3A+A+retrospective+propensity+score+matching+study%5BTitle%5D)+AND+%22BMC+Surg%22%5BJournal%5D)">Comparative advantages of transforaminal percutaneous endoscopic lumbar decompression versus traditional revision surgery for degenerative adjacent segment degeneration following lumbar fusion: A retrospective propensity score matching study.</a> BMC Surg. 24 (1), 177(2024).</li>
<li>Hashimoto, K., Aizawa, T., Kanno, H., Itoi, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Adjacent+segment+degeneration+after+fusion+spinal+surgery%3A+A+systematic+review%5BTitle%5D)+AND+%22Int+Orthop%22%5BJournal%5D)">Adjacent segment degeneration after fusion spinal surgery: A systematic review.</a> Int Orthop. 43 (4), 987-993 (2019).</li>
<li>Gore, S., Yeung, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+%26%2334%3Binside+out%26%2334%3B+transforaminal+technique+to+treat+lumbar+spinal+pain+in+an+awake+and+aware+patient+under+local+anesthesia%3A+Results+and+a+review+of+the+literature%5BTitle%5D)+AND+%22Int+J+Spine+Surg%22%5BJournal%5D)">The &#34;inside out&#34; transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: Results and a review of the literature.</a> Int J Spine Surg. 8, 28(2014).</li>
<li>Findlay, M. C., Hamrick, F. A., Kim, R. B., Twitchell, S., Mahan, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Hospital+cost+differences+between+open+and+endoscopic+lumbar+procedures%5BTitle%5D)+AND+%22J+Neurosurg+Spine%22%5BJournal%5D)">Hospital cost differences between open and endoscopic lumbar procedures.</a> J Neurosurg Spine. 40 (1), 77-83 (2023).</li>
<li>Hsu, H. T., Chang, S. J., Yang, S. S., Chai, C. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Learning+curve+of+full-endoscopic+lumbar+discectomy%5BTitle%5D)+AND+%22Eur+Spine+J%22%5BJournal%5D)">Learning curve of full-endoscopic lumbar discectomy.</a> Eur Spine J. 22 (4), 727-733 (2013).</li>
</ol>

The authors have no conflicts of interest to declare.

Transforaminal full-endoscopic foraminotomy under local anesthesia for L5/S1 foraminal stenosis adjacent to previous fusion is a valuable motion-preserving technique. It directly addresses the neural compression while avoiding the morbidity of fusion extension or extensive posterior revision surgery. This discussion will elaborate on the advantages of this method, key technical considerations for its success, and its limitations and future directions.
Advantages of the transforaminal endoscopic approach in ASD 
ASD, particularly foraminal stenosis at a level adjacent to a previous lumbar fusion, presents a significant clinical challenge4,14. Conventional management for symptomatic ASD often involves extending the fusion to include the affected segment , which necessitates sacrificing the motion of an additional segment and is associated with increased surgical morbidity5,15. Revision surgery via a traditional posterior approach is also technically difficult due to postsurgical scarring, altered anatomical landmarks, and potential adherence of neural structures, which can increase the risk of complications, such as dural tears or nerve root injury15.
In contrast, the TF-FESS technique offers distinct advantages. The transforaminal approach accesses the foramen via a posterolateral corridor that typically remains undisturbed by prior posterior fusion surgery. Accessing the target through native tissue planes significantly reduces the risks associated with dissecting through scar tissue and has been shown to reduce operative time and blood loss compared with traditional posterior revision16. Furthermore, this technique directly addresses the stenosis without requiring additional fixation, thus preserving motion at the affected segment and potentially mitigating or delaying further degeneration of adjacent segments17.
Performing this procedure under local anesthesia with conscious sedation further enhances its usability and efficiency, particularly for the elderly or those with comorbidities who may be poor candidates for general anesthesia11,12. This approach not only minimizes physiological insult but also provides a crucial safety feature: real-time patient feedback, which helps prevent neural irritation1,18. The minimally invasive nature of the procedure contributes to shorter hospital stays, reduced postoperative pain, and a faster return to daily activities, potentially lowering overall healthcare costs when compared to revision fusion surgery19.
Key technical considerations and troubleshooting 
The success of this technique hinges on several critical protocol steps. First, meticulous preoperative trajectory planning is paramount to navigate the narrow corridor, which is often obstructed by a high iliac crest. Second, strict adherence to the &#34;bone is my friend&#34; principle ensures the safety of the exiting nerve root by maintaining contact with the SAP as a reliable landmark. Finally, the &#34;detach technique&#34; for ligamentum flavum removal is a cornerstone of achieving complete decompression, as it allows the thickened ligament to be fully mobilized before removal, minimizing dural traction.
Common intraoperative challenges can be effectively managed. A high iliac crest can be addressed by adjusting patient positioning or planning a slightly steeper trajectory. Intraoperative bleeding is typically controlled by increasing irrigation pressure and using a radiofrequency probe. In revision cases with unclear landmarks, relying on fluoroscopy and carefully exposing the bony anatomy of the SAP is the safest approach.
Limitations and scope of the technique 
Despite its advantages, the described method has important limitations and a specific scope. It is crucial to acknowledge that ASD presents in various forms, including central stenosis, degenerative spondylolisthesis, or frank instability. The technique detailed herein is specifically indicated for radiculopathy caused by foraminal stenosis without significant instability. Patients with other forms of ASD may require different treatment strategies, such as interlaminar decompression for central stenosis or fusion extension for instability.
Furthermore, this protocol focuses on caudal ASD at the L5/S1 level. While the principles of endoscopic foraminotomy can be applied to cranial adjacent segments, the surgical trajectory and anatomical challenges differ, and were not the focus of this article. A significant limitation of this case report is the lack of long-term follow-up and dynamic radiographic evaluation. As such, the potential for delayed instability at the operated segment after this motion-preserving decompression remains a valid concern that requires further investigation. Finally, as with all advanced endoscopic procedures, a steep learning curve must be considered to minimize operative risks such as dural tears or incomplete decompression20.
Future directions 
The limitations of this study highlight clear directions for future research. A prospective, long-term study including dynamic radiographs is essential to evaluate the durability of clinical outcomes and the incidence of postoperative instability. To establish the definitive role of this technique, a randomized controlled trial comparing endoscopic foraminotomy with revision fusion surgery for foraminal stenosis in ASD is warranted. Such a trial should assess clinical outcomes, radiographic changes at the index and adjacent levels, and cost-effectiveness. Additionally, future studies could focus on adapting and evaluating this technique for cranial-level ASD and investigating the use of advanced technologies like intraoperative navigation to improve safety and accuracy.
Conclusion 
Transforaminal full-endoscopic foraminotomy under local anesthesia for L5/S1 foraminal stenosis adjacent to previous fusion is a valuable technique that directly addresses the neural compression while avoiding the morbidity of fusion extension or extensive posterior revision surgery. Its minimally invasive nature, coupled with the benefit of local anesthesia, makes it an attractive option for a challenging patient population.

Lumbar spinal stenosis is a common condition with a significant impact on quality of life, and foraminal stenosis is a frequent subtype causing radicular symptoms due to nerve root compression1,2. A particularly challenging scenario arises in patients with Adjacent Segment Disease (ASD), a long-term complication following lumbar fusion surgery. ASD frequently manifests as new-onset foraminal stenosis at levels adjacent to the fused segments, with a reported incidence of up to 30% within five years post-surgery3.
Traditionally, revision surgeries for symptomatic ASD have involved open decompression with fusion extension4,5. However, this approach is associated with considerable surgical morbidity, increased blood loss, and prolonged recovery, especially in elderly patients with comorbidities6. Consequently, minimally invasive spine surgery (MISS) techniques have gained traction. Among these, full-endoscopic spine surgery (FESS) offers the potential for adequate neural decompression with minimal tissue disruption, reduced postoperative pain, and faster recovery, often with shorter operative times7,8. The transforaminal endoscopic approach, in particular, provides direct access to the foramen, making it suitable for treating foraminal stenosis9. Despite its benefits, addressing L5/S1 foraminal stenosis via a transforaminal endoscopic approach presents unique anatomical challenges, primarily due to the presence of a high iliac crest, a narrow foramen, and in cases with ASD, altered anatomy or scar tissue from previous surgeries1,10. Performing such procedures under local anesthesia further enhances patient safety by allowing for intraoperative patient feedback, and is particularly beneficial for patients who are poor candidates for general anesthesia11,12.
This article provides a comprehensive, step-by-step demonstration of our updated transforaminal full-endoscopic lumbar foraminotomy technique. This method is specifically indicated for patients with unilateral radiculopathy due to L5/S1 foraminal stenosis adjacent to a prior lumbar fusion, who do not present with significant segmental instability. Our protocol highlights key surgical maneuvers, including precise superior articular process (SAP) resection and use of the &#34;detach technique&#34; for safe and complete ligamentum flavum removal, to achieve thorough neural decompression in these challenging revision scenarios13.

<table><tbody><tr><td>10K Arthroscope tube set</td><td>Zimmer Biomet</td><td>LC-10K0-100-00</td><td>Irrigation system console</td></tr><tr><td>10K Irrigation console&amp;nbsp;</td><td>Zimmer Biomet</td><td>LC-10K0-000-00</td><td>Irrigation system console</td></tr><tr><td>1-Coarse Diamond Bur SPL (3.5)&amp;nbsp;</td><td>Nakanishi</td><td>PDS-1CD330-35</td><td>High-speed drill&amp;nbsp;</td></tr><tr><td>21G PTCD needle, 200 mm</td><td>Hakko Shoji</td><td>U5099-MM</td><td>Needle for local anesthesia</td></tr><tr><td>23G Catelan needle</td><td>NIPRO</td><td>2022</td><td>Needle for local anesthesia</td></tr><tr><td>32-inch 4K LCD monitor&amp;nbsp;</td><td>Sony</td><td>LMD-X3200MD</td><td>Monitor</td></tr><tr><td>Aquarius NET Server</td><td>TeraRecon</td><td>N/A</td><td>CT reconstruction and analysis software</td></tr><tr><td>Atarax-P</td><td>Pfizer</td><td>N/A</td><td>Hydroxyzine hydrochloride</td></tr><tr><td>Centricity Universal Viewer Zero Footprint Client</td><td>GE Healthcare</td><td>Version 6.0 SP11.2.2</td><td>MRI visualization and analysis software</td></tr><tr><td>CLICKLINE grasping forceps&amp;nbsp;</td><td>Karl Storz</td><td>28163FSI</td><td>Intervertebral disc rongeur</td></tr><tr><td>Curved rongeur, WL 360 mm, &amp;phi;2.5 mm</td><td>RIWOspine</td><td>89240.1044</td><td>Soft tissue rongeur</td></tr><tr><td>Dilator, &amp;Oslash;7.0 mm, effective length 225 mm (2 holes)</td><td>Elliquence</td><td>11-2311</td><td>Dilator</td></tr><tr><td>ENDOCAM Logic 4K camera controller</td><td>Richard Wolf GmbH</td><td>55253011 86-103</td><td>Camera</td></tr><tr><td>ENDOCAM Logic 4K camera head</td><td>Richard Wolf GmbH</td><td>85525942 86-104</td><td>Camera</td></tr><tr><td>Fiber light cable (&amp;phi;3.5 mm/3.0 mm)</td><td>Richard Wolf GmbH</td><td>806635301 86-124</td><td>Camera</td></tr><tr><td>Flexible probe (&amp;Phi;2.5 mm, WL 350 mm)</td><td>RIWOspine</td><td>892501925</td><td>Flexible probe</td></tr><tr><td>Floseal Hemostatic Matrix</td><td>Baxter</td><td>ADS201844 5mL Kit</td><td>Hemostatic agent</td></tr><tr><td>Guide wire&amp;nbsp;</td><td>Nihon MDM</td><td>28163GWT</td><td>Dilator</td></tr><tr><td>Kerrison punch handle&amp;nbsp;</td><td>Elliquence</td><td>12-1947</td><td>Kerrison&amp;nbsp;</td></tr><tr><td>Kerrison punch, angled type, &amp;Oslash;3.5 mm, effective length 360 mm&amp;nbsp;</td><td>Elliquence</td><td>12-1938</td><td>Kerrison&amp;nbsp;</td></tr><tr><td>Kerrison punch, angled type, &amp;Oslash;4.0 mm, effective length 360 mm&amp;nbsp;</td><td>Elliquence</td><td>12-1940</td><td>Kerrison&amp;nbsp;</td></tr><tr><td>LED light source unit for endoscopy (LED 1.2 set)</td><td>Richard Wolf GmbH</td><td>51610011 86-164</td><td>Camera</td></tr><tr><td>Primado2 Drill System</td><td>Nakanishi</td><td>P200-CU-100</td><td>High-speed drill&amp;nbsp;</td></tr><tr><td>Primado2 Foot Controler</td><td>Nakanishi</td><td>FC-73</td><td>High-speed drill&amp;nbsp;</td></tr><tr><td>Primado2 Slim motor handpiece&amp;nbsp;</td><td>Nakanishi</td><td>P200-SMH-HS</td><td>High-speed drill&amp;nbsp;</td></tr><tr><td>PTC needle type B, 18G &amp;times; 200 mm&amp;nbsp;</td><td>Hakkou Shoji</td><td>22411830</td><td>Dilator</td></tr><tr><td>Rongeur, WL 360 mm, &amp;phi;3.0 mm</td><td>RIWOspine</td><td>89240.1003</td><td>Soft tissue rongeur</td></tr><tr><td>Sosegon&amp;nbsp;</td><td>Maruishi Pharma</td><td>N/A</td><td>Pentazocine</td></tr><tr><td>Step dilator set (5 pieces)</td><td>Elliquence</td><td>CSD-5</td><td>Dilator</td></tr><tr><td>Super Slim attachment 200&amp;nbsp;</td><td>Nakanishi</td><td>P200-RA330-L</td><td>High-speed drill&amp;nbsp;</td></tr><tr><td>Surgi-Max Air</td><td>Elliquence</td><td>IEC4-SP</td><td>Bipolar device</td></tr><tr><td>Trigger-Flex&amp;nbsp;</td><td>Elliquence</td><td>DTF-40</td><td>Bipolar device</td></tr><tr><td>VERTEBRIS lumbar, 25&amp;deg;, 6.9 mm, WL 207 mm</td><td>RIWOspine GmbH</td><td>89210.1254</td><td>Rigid endoscope</td></tr><tr><td>Working channel, duckbill type, &amp;Oslash;8.0 mm, length 165 mm</td><td>Richard Wolf GmbH</td><td>11-2910</td><td>Duckbill cannula</td></tr><tr><td>Working channel, elevator type, &amp;Oslash;8.0 mm, length 165 mm</td><td>Richard Wolf GmbH</td><td>11-2916</td><td>Oblique cannula</td></tr></tbody></table>

transforaminal full-endoscopic lumbar foraminotomy under local anesthesia for l5/s1 adjacent segment foraminal stenosis

Transforaminal Full-Endoscopic Lumbar Foraminotomy Under Local Anesthesia for L5/S1 Adjacent Segment Foraminal Stenosis

Foraminal stenosis in patients with L5/S1 adjacent segment disease (ASD) presents a significant clinical challenge, as conventional treatment often requires fusion extension surgery. This approach sacrifices spinal mobility and is associated with considerable surgical morbidity. This video article describes a motion-preserving surgical alternative, namely, transforaminal full-endoscopic foraminotomy performed under local anesthesia, detailing a step-by-step protocol to navigate the challenges of these revision cases. The technique utilizes a posterolateral corridor, avoiding prior surgical scarring. Key procedural steps include meticulous preoperative trajectory planning, foraminoplasty via resection of the superior articular process (SAP), and partial resection of the inferior articular process to fully expose the ligamentum flavum (LF). A specific "detach" technique is then demonstrated, involving undercutting the ventral rim of the S1 SAP to release the LF before its removal. Representative results demonstrate successful osseous decompression confirmed by postoperative computed tomography. The procedure resulted in immediate improvement in radicular pain and motor weakness, with the patient's visual analog scale score decreasing from 9/10 to 1/10 at the one-month follow-up. This minimally invasive technique provides effective neural decompression and facilitates rapid recovery, offering a valuable alternative to more extensive surgery for this challenging patient population.

A patient with a history of L4/L5 fusion surgery performed 16 years earlier presented with ASD at the L5/S1 level. The chief complaint was chronic pain in the right lower extremity in the sciatic nerve distribution. Physical examination revealed motor weakness of the right extensor hallucis longus, graded as 4/5 on manual muscle testing. The straight leg raise test was positive at 80° on the right. The preoperative visual analog scale score (VAS score) for pain was 8 to 9/10. Preoperative imaging studies confirmed right-sided L5/S1 foraminal stenosis with a herniated nucleus pulposus compressing the exiting L5 nerve root (Figure 7).
The patient underwent a transforaminal full-endoscopic lumbar foraminotomy on the right at L5/S1 under local anesthesia, following the detailed protocol. The surgical procedure involved meticulous foraminoplasty via resection of the hypertrophied SAP (as demonstrated in Figure 3), exposure and detachment of the ligamentum flavum using the 'detach' technique (Figure 4 and Figure 5), and complete removal of the compressive ligamentous and herniated disc material. Final inspection confirmed a fully decompressed and pulsating L5 nerve root (Figure 6).
Postoperative CT scans, when compared with preoperative images, confirmed adequate osseous decompression of the foramen (Figure 8). In this case, the postoperative course was excellent. Immediately following surgery, the motor strength in the extensor hallucis longus improved to 5-/5 with no new neurological deficits. The patient was discharged on postoperative day 5. At the one-month follow-up, there was a significant reduction in both pain and numbness. The VAS score for pain improved from 8 to 9/10 preoperatively to 1/10 during daily activities with a corset. Furthermore, functional outcomes measured by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) demonstrated remarkable improvement at the one-month follow-up. Scores improved across all five domains: pain-related disorders (from 43 to 8), lumbar spine dysfunction (from 92 to 20), gait disturbance (from 7 to 2), social life dysfunction (from 32 to 7), and psychological disturbance (from 46 to 12). The surgical wound healed cleanly without any signs of infection.
<img alt="CT scan diagram showing pelvic anatomy; labeled points a and b for anatomical reference." class="xfigimg" src="/files/ftp_upload/69059/69059fig1.jpg" data-altupdatedat="1783396841000" data-alt="Figure 1"> 
Figure 1: Determination of the skin entry point and needle trajectory. The path is planned based on the target point (a) and the superior articular process. <a href="https://www.jove.com/files/ftp_upload/69059/69059fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Diagram of spinal anatomy, L5-S1 vertebrae, endoscopic portal." class="xfigimg" src="/files/ftp_upload/69059/69059fig2.jpg" data-altupdatedat="1783396841000" data-alt="Figure 2"> 
Figure 2: Preoperative skin marking. The skin entry point is marked under direct fluoroscopic visualization, ensuring the trajectory avoids the iliac crest. SAP, superior articular process. <a href="https://www.jove.com/files/ftp_upload/69059/69059fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="S1 SAP drilling process, endoscopic view, diagram with S1 pedicle, spinal surgical procedure." class="xfigimg" src="/files/ftp_upload/69059/69059fig3.jpg" data-altupdatedat="1783396841000" data-alt="Figure 3"> 
Figure 3: Endoscopic view: Foraminoplasty of the S1 SAP. The left panel shows the initial endoscopic orientation after placement of the cannula, with the lateral aspect of the S1 SAP identified as the primary bony landmark. The right panel demonstrates the commencement of the foraminoplasty, with a high-speed endoscopic drill resecting the caudal base of the S1 SAP at its junction with the S1 pedicle. SAP, superior articular process. <a href="https://www.jove.com/files/ftp_upload/69059/69059fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="S1 SAP tip, L5 IAP anatomy; endoscopic surgical view and drilling diagram for spinal decompression." class="xfigimg" src="/files/ftp_upload/69059/69059fig4.jpg" data-altupdatedat="1783396841000" data-alt="Figure 4"> 
Figure 4: Endoscopic view: Exposure of the LF via L5 IAP resection. The left panel shows the SAP tip and its articulation with the L5 IAP. The right panel demonstrates the results after partial resection of the L5 IAP with a high-speed drill, which has now fully exposed the underlying foraminal LF. IAP, inferior articular process; LF, ligamentum flavum; SAP, superior articular process. <a href="https://www.jove.com/files/ftp_upload/69059/69059fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="LF detachment diagram and endoscopic images showing S1 SAP drilling process in spinal anatomy study." class="xfigimg" src="/files/ftp_upload/69059/69059fig5.jpg" data-altupdatedat="1783396841000" data-alt="Figure 5"> 
Figure 5: Endoscopic view: Release of the LF from the S1 SAP using the "detach" technique. The left panel demonstrates the detach technique, where the ventral rim of the remaining S1 SAP is undercut with a drill to release the caudal attachment of the LF. The right panel shows the LF in a "floating" state, completely mobilized after being detached from the S1 SAP. LF, ligamentum flavum; SAP, superior articular process. <a href="https://www.jove.com/files/ftp_upload/69059/69059fig5large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Lumbar decompression procedure; endoscopic images, L5 ENR, LF, IAP, final diagram." class="xfigimg" src="/files/ftp_upload/69059/69059fig6.jpg" data-altupdatedat="1783396841000" data-alt="Figure 6"> 
Figure 6: Endoscopic view: Final decompression. The left panel shows the removal of the detached floating LF using an endoscopic Kerrison punch. The right panel shows the final view after all compressive elements have been removed, revealing a fully decompressed, relaxed, and pulsating L5 ENR, which indicates successful decompression. ENR, exiting nerve root; IAP, inferior articular process; LF, ligamentum flavum. <a href="https://www.jove.com/files/ftp_upload/69059/69059fig6large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Lumbar spine imaging: lateral radiograph, T2-weighted MRI para-sagittal and axial views, diagnosis." class="xfigimg" src="/files/ftp_upload/69059/69059fig7.jpg" data-altupdatedat="1783396841000" data-alt="Figure 7"> 
Figure 7: Radiological findings in a patient with adjacent segment disease following L4/5 PLIF. The left panel is a standing lateral radiograph of the lumbar spine that reveals instrumentation at L4/5 and degenerative changes at the adjacent level. The middle panel is a right para-sagittal T2-weighted MRI scan showing disc degeneration and foraminal narrowing at L5/S1. The right panel is an axial T2-weighted MRI scan showing nerve root compression within the right L5/S1 foramen. PLIF, posterior lumbar interbody fusion; MRI, magnetic resonance imaging. <a href="https://www.jove.com/files/ftp_upload/69059/69059fig7large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="CT scan comparison of spinal surgery, before and after, highlighting structural changes." class="xfigimg" src="/files/ftp_upload/69059/69059fig8.jpg" data-altupdatedat="1783396841000" data-alt="Figure 8"> 
Figure 8: Pre- and postoperative CT images demonstrating successful osseous decompression. Left panels: Preoperative sagittal and axial CT images show severe right-sided L5/S1 foraminal stenosis. The hypertrophied superior articular process (SAP, yellow arrow) is compressing the neural foramen (dotted outline). Right panels: Corresponding postoperative images confirm adequate decompression, showing significant enlargement of the foramen (dotted outline) after resection of the ventral-cranial portion of the SAP (white arrow). <a href="https://www.jove.com/files/ftp_upload/69059/69059fig8large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

This protocol provides a step-by-step guide for performing transforaminal full-endoscopic foraminotomy under local anesthesia. This motion-preserving technique is presented as a minimally invasive surgical alternative to fusion extension for treating L5/S1 foraminal stenosis in patients with adjacent segment disease.

Foraminal stenosis in patients with L5/S1 adjacent segment disease (ASD) presents a significant clinical challenge, as conventional treatment often ...

In this paper, we described adjacent level foraminal stenosis, and we treat the problem using an endoscope. The most problematic pathology is alpha spondylolisthesis with past fracture. That is very difficult case.So basically we need the fusion, but finally, using the endoscope, we developed the most novel technique, criss-cross compression. For adjacent segment foraminal stenosis, at L five S one, fusion extension was often the only option. Our protocol offers a motion preserving, reproducible endoscopic alternative.Our protocol enables consistent reproducible decompression with minimal fluoroscopy and reduce patient burden, compared to conventional techniques. To begin, establish an intermittent antero posterior and lateral fluoroscopic view at the desired site, and advance the 23 gauge needle along the planned trajectory toward the S one superior articular process. Incrementally infiltrate approximately seven milliliters of 1%lidocaine solution into the paraspinal muscles and soft tissues along this pathway, then switch to an 18 gauge 200 millimeter needle for targeted deep infiltration of anesthesia.Under continued intermittent fluoroscopic guidance, advance the needle to the next anatomical targets. Inject two milliliters of 1%lidocaine into the L five S one facet joint capsule. Next, inject two milliliters into the tip of the S one superior articular process, and two milliliters into the middle portion of the S one superior articular process.Then inject two milliliters of lidocaine onto the S one superior end plate if safely accessible. Advance the needle tip to the surface of the L five S one annulus fibrosis. Confirm satisfactory needle positioning with an AP fluoroscopic view, then inject approximately two milliliters of lidocaine onto the annular surface.Further advance the needle into the L five S one disc space and inject an additional two milliliters of lidocaine. Now inject one to two milliliters of indigo Carmine solution into the disc space for staining, if disc material identification is anticipated to be critical. Insert the initial blood tip serial dilator through the eight millimeter skin incision along the anesthetized trajectory.Under intermittent AP and lateral C-arm fluoroscopic guidance, sequentially advance the serial dilators with gentle rotating movements toward the lateral aspect of the S one superior articular process. Confirm that the tip of each dilator is accurately positioned on the bony surface of the S one superior articular process, ideally at the junction of the SAP and pedicle. Next, advance the beveled working cannula with eight millimeters inner diameter, and 165 millimeters length over the final dilator until it is firmly docked on the lateral aspect of the S one superior articular process.Confirm the final cannula position using AP and lateral fluoroscopy. On the AP view, dock the cannula on the lateral aspect of the superior articular process. On the lateral view, position the cannula tip at the posterior aspect of the foramen, directly overlying the SAP.Now carefully remove the final dilator, leaving the working cannula in place as the operative portal. With the lateral aspect of the S one superior articular process clearly visualized, commence the foraminoplasty using a high speed, endoscopic drill. Start drilling at the coddle base of the S one superior articular process, at its junction with the S one pedicle.Then systematically resect the ventral and cranial portions of the S one superior articular process. Drill in a coddle to cranial direction, gradually shaving the superior articular process from its base towards its tip. Unroof the L five S one foramen dorsally and laterally to expose the underlying ligamentum flavum, and decompress the exiting L five nerve root.Continue drilling until approximately 80 to 90%of the hypertrophied portion of the superior articular process is resected, and the foraminal ligamentum flavum and the shoulder of the L five exiting nerve root are sufficiently exposed. Using the high speed endoscopic drill, carefully resect a portion of the ventral aspect of the L five inferior articular process. To perform the detached technique, press the cranial half of a spherical bur tip against the bony edge of the S one superior articular process at the ligament's insertion point.Employ a rotational shaving motion to resect this bone, while simultaneously pulling the drill proximally to direct the resection away from the thecal sac and safely release the ligamentum flavum. Observe the detached ligamentum flavum for pulsation. Finally, grasp the free floating detached ligamentum flavum with a 3.5 millimeter carisin punch or endoscopic ronjurs.Carefully remove the ligament from the foramen, and observe the decompressed nerve root. Preoperative magnetic resonance imaging confirmed right-sided L five S one foraminal stenosis with compression of the exiting L five nerve root due to a herniated nucleus pulposus. Preoperative computed tomography scans showed severe foraminal narrowing at L five S one caused by a hypertrophied superior articular process.Postoperative computed tomography images demonstrated successful decompression with resection of the ventral cranial portion of the superior articular process, and visible enlargement of the L five S one foramen.

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Research

JoVE Journal

Neuroscience

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A Rat Model of Mild Intrauterine Hypoperfusion with Microcoil Stenosis

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Diffuse Reflectance Spectroscopy: Getting the Capillary Refill Test Under One's Thumb

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Adaptation of Microelectrode Array Technology for the Study of Anesthesia-induced Neurotoxicity in the Intact Piglet Brain

Here we present a protocol for Ca2+ imaging in neurons and glial cells, which enables the dissection of Ca2+ signals at subcellular resolution. This process is applicable to all cell types that allow the expression of genetically encoded Ca2+ indicators.

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Learn transforaminal full-endoscopic foraminotomy under local anesthesia for treating L5/S1 adjacent segment foraminal stenosis. This motion-preserving technique offers a minimally invasive alternative to spinal fusion surgery.

Transforaminal Full-Endoscopic Lumbar Foraminotomy Under Local Anesthesia for L5/S1 Adjacent Segment Foraminal Stenosis

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