Clinical and cost-effectiveness of PCF versus ACD in the treatment of cervical brachialgia (FORVAD trial).

BACKGROUND: Cervical radiculopathy occurs when a nerve root is compressed in the spine, if symptoms fail to resolve after 6 weeks surgery may be indicated. Anterior Cervical Discectomy (ACD) is the commonest procedure, Posterior Cervical Foraminotomy (PCF) is an alternative that avoids the risk of damage to anterior neck structures. This prospective, Phase III, UK multicentre, open, individually randomised controlled trial was performed to determine whether PCF is superior to ACD in terms of improving clinical outcome as measured by the Neck Disability Index (NDI) 52 weeks post-surgery. METHOD: Following consent to participate and collection of baseline data, subjects with cervical brachialgia were randomised to ACD or PCF in a 1:1 ratio on the day of surgery. Clinical outcomes were assessed on day 1 and patient reported outcomes on day 1 and weeks 6, 12, 26, 39 and 52 post-operation. A total of 252 participants were planned to be randomised. Statistical analysis was limited to descriptive statistics. Health economic outcomes were also described. RESULTS: The trial was closed early (n = 23). Compared to baseline, the median (interquartile range (IQR)) NDI score at 52 weeks reduced from 44.0 (36.0, 62.0) to 25.3 (20.0, 42.0) in the PCF group and increased from 35.6 (34.0, 44.0) to 45.0 (20.0, 57.0) in the ACD group. ACD may be associated with more swallowing, voice and other complications and was more expensive; neck and arm pain scores were similar. CONCLUSIONS: The trial was closed early, therefore no definitive conclusions on clinical or cost-effectiveness could be made.

Channel-assisted cervical key hole technology combined with ultrasonic bone osteotome versus posterior percutaneous endoscopic cervical foraminotomy: a clinical retrospective study.

PURPOSE: The search for more effective and safe treatment methods for cervical spondylotic radiculopathy (CSR) has led to the rapid development and increasing popularity of minimally invasive posterior cervical foraminotomy (MI-PCF). This study aims to compare two important approaches for MI-PCF surgery: the channel-assisted cervical key hole technology combined with ultrasonic bone osteotome (CKH-UBO) and posterior percutaneous endoscopic cervical foraminotomy (PPECF). METHODS: Data from patients treated with single-level CKH-UBO (n = 35) or PPECF (n = 40) were analyzed. Clinical outcomes, including visual analogue scale (VAS) scores for neck and arm pain, Neck Disability Index (NDI), and modified Macnab criteria, were assessed preoperatively, as well as at three days, three months, and one year postoperatively. RESULTS: The percentages of patients with excellent and good outcomes were 97.14% and 92.5%, respectively. The average surgical time in the CKH-UBO group was significantly shorter than in the PPECF group (p < 0.001), while the average incision length in the PPECF group was significantly smaller than in the CKH-UBO group. There were no significant differences between the two groups in terms of blood loss, hospital stay, and clinical outcomes at three days, three months, and 12 months postoperatively. CONCLUSION: CKH-UBO can achieve the same surgical outcomes as PPECF for the treatment of CSR. However, CKH-UBO saves more time but requires patients to undergo larger incisions.

Learning curve for endoscopic posterior cervical foraminotomy.

PURPOSE: While anterior cervical discectomy and fusion as well as cervical disk arthroplasty are gold standard treatments for the surgical treatment of cervical radiculopathy, posterior endoscopic cervical foraminotomy (PECF) as a substitute procedure is gaining popularity. To date, studies investigating the number of surgeries needed to achieve proficiency in this procedure are lacking. The purpose of the study is to examine the learning curve for PECF. METHODS: The learning curve in operative time for two fellowship-trained spine surgeons at independent institutions was retrospectively assessed for 90 uniportal PECF procedures (PBD: n = 26, CPH: n = 64) performed from 2015 to 2022. Operative time was assessed across consecutive cases using a nonparametric monotone regression, and a plateau in operative time was used as a proxy to define the learning curve. Secondary outcomes assessing achievement of endoscopic prowess before and after the initial learning curve included number of fluoroscopy images, visual analog scale (VAS) for neck and arm, Neck Disability Index (NDI), and the need for reoperation. RESULTS: There was no significant difference in operative time between surgeons (p = 0.420). The start of a plateau for Surgeon 1 occurred at 9 cases and 111.6 min. The start of a plateau for Surgeon 2 occurred at 29 cases and 114.7 min. A second plateau for Surgeon 2 occurred at 49 cases and 91.8 min. Fluoroscopy use did not significantly change before and after surmounting the learning curve. The majority of patients achieved minimally clinically important differences in VAS and NDI after PECF, but postoperative VAS and NDI did not significantly differ before and after achieving the learning curve. There were no significant differences in revisions or postoperative cervical injections before and after reaching a steady state in the learning curve. CONCLUSION: PECF is an advanced endoscopic technique with an initial improvement in operative time that occurred after as few as 8 cases to as many as 28 cases in this series. A second learning curve may occur with additional cases. Patient-reported outcomes improve following surgery, and these outcomes are independent of the surgeon's position on the learning curve. Fluoroscopy use does not change significantly along the learning curve. PECF is a safe and effective technique that current and future spine surgeons should consider as part of their armamentarium.

Is navigation beneficial for transforaminal endoscopic lumbar foraminotomy? A preliminary comparison study with fluoroscopic guidance.

PURPOSE: The primary purpose of this study was to determine radiation exposure of the surgeon during transforaminal endoscopic lumbar foraminotomy (TELF). Secondary purpose of this study was to compare clinical and radiologic outcomes between TELF under C-arm fluoroscopic guidance (C-TELF) and O-arm navigation-guided TELF (O-TELF). METHODS: The author reviewed patients' medical records who underwent TELF at our institute from June 2015 to November 2022. A total of 40 patients were included (18 patients with C-TELF and 22 with O-TELF). Basic demographic data were collected. Preoperative/postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) were recorded at the outpatient clinic. Radiologic features were compared on X-rays at each follow-up. The degree of foraminal expansion was measured/compared through MRI. In the C-TELF group, the amount of exposure was calculated with a dosimeter. RESULTS: Average surgeon's effective dose in the C-TELF group was 0.036 mSv. In the case of the O-TELF group, there was no radiation exposure during operation. However, the operation time in the O-TELF group was about 37 min longer than that in the C-TELF group. There were significant improvements in VAS/ODI after operation in both groups. Complications were identified in three patients. CONCLUSION: O-TELF showed similarly favorable clinical and radiologic outcomes to C-TELF in lumbar foraminal stenosis, including complication rate. Compared to C-TELF, O-TELF has an advantage of not wearing a lead apron since the operator is not exposed to radiation. However, the operation time was longer with O-TELF due to O-arm setting time. Because there are pros and cons, the choice of surgical method depends on the surgeon's preference.

Full-endoscopic foraminotomy in low-grade degenerative and isthmic spondylolisthesis: a patient-specific tailored approach.

PURPOSE: To describe the surgical technique and methodology to successfully plan and execute an endoscopic foraminotomy in patients with isthmic or degenerative spondylolisthesis, according to each patient's unique characteristics. METHODS: Thirty patients with degenerative or isthmic spondylolisthesis (SL) with radicular symptoms were included from March 2019 to September 2022. Treating physician registered patients' baseline and imaging characteristics, as well as preoperative back pain VAS, leg pain VAS and ODI. Subsequently, authors treated the included patients with an endoscopic foraminotomy according to a "patient-specific" tailored approach. RESULTS: Nineteen patients (63.33%) had isthmic SL and 11 patients (36.67%) had degenerative SL. 75.86% of the cases had a Meyerding Grade 1 listhesis. One of the transforaminal foraminotomies with lateral recess decompression in degenerative SL had to be aborted because of intense osseous bleeding. Of the remaining 29 patients, one patient experienced recurrence of the sciatica pain that required subsequent reintervention and fusion. No other intraoperative or post-operative complications were observed. None of the patients developed post-operative dysesthesia. In 86.67% of the patients, the foraminotomy was implemented using a transforaminal approach. In the remaining 13.33% of the cases, an interlaminar contralateral approach was used. Lateral recess decompression was performed in half of the cases. Mean follow-up time was 12.69 months, reaching a maximum of 40 months in some patients. Outcome variables such as VAS for leg and back pain, as well as ODI, showed statistically significant reduction since the 3-month follow-up visit. CONCLUSION: In the presented case series, endoscopic foraminotomy achieved satisfactory outcomes without sacrificing segmental stability. The proposed patient-specific "tailored" approach allowed to successfully design and execute the surgical strategy to perform an endoscopic foraminotomy through transforaminal or interlaminar contralateral approaches.

Incidence of complications associated with cervical spine surgery and post-operative physical therapy and implications for timing of initiation of post-operative physical therapy: a retrospective database study.

PURPOSE: To describe the incidence of complications associated with cervical spine surgery and post-operative physical therapy (PT), and to identify if the timing of initiation of post-operative PT impacts the incidence rates. METHODS: MOrtho PearlDiver database was queried using billing codes to identify patients who had undergone Anterior Cervical Discectomy and Fusion (ACDF), Posterior Cervical Fusion (PCF), or Cervical Foraminotomy and post-operative PT from 2010-2019. For each surgical procedure, patients were divided into three 12-week increments for post-operative PT (starting at post-operative weeks 2, 8, 12) and then matched based upon age, gender, and Charlson Comorbidity Index score. Each group was queried to determine complication rates and chi-square analysis with adjusted odds ratios, 95% confidence intervals, and p-values were used. RESULTS: Following matching, 3,609 patients who underwent cervical spine surgery at one or more levels and had post-operative PT (ACDF:1784, PCF:1593, and cervical foraminotomy:232). The most frequent complications were new onset cervicalgia (2-14 weeks, 8-20 weeks, 12-24 weeks): ACDF (15.0%, 14.0%, 13.0%), PCF (18.8%, 18.0%, 19.9%), cervical foraminotomy (16.8%, 16.4%, 19.4%); revision: ADCF (7.9%, 8.2%, 7.4%), PCF (9.3%, 10.6%, 10.2%), cervical foraminotomy (11.6%, 10.8% and 13.4%); wound infection: ACDF (3.3%, 3.4%, 3.1%), PCF (8.3%, 8.0%,7.7%), cervical foraminotomy (5.2%, 6.5%, < 4.7%). None of the comparisons were statistically significant. CONCLUSION: The most common post-operative complications included new onset cervicalgia, revision and wound infection. Complications rates were not impacted by the timing of initiation of PT whether at 2, 8, or 12 weeks post-operatively.

Limitations of minimally invasive posterior cervical foraminotomy-a decompression method of posteriorly shifting the nerve root-in cases of large anterior osteophytes in cervical radiculopathy: A retrospective multicenter cohort study.

BACKGROUND: Posterior cervical foraminotomy against anterior osteophyte is an indirect decompression procedure but less invasive compared to anterior cervical discectomy and fusion. Residual compression to the nerve root may lead to poor surgical outcomes. Although clinical results of posterior cervical foraminotomy for osteophytes are not considered better than those of disk herniation, osteophyte size and the association of the decompression area with poor surgical outcomes remain unclear. This study aimed to identify the limitations of minimally invasive posterior cervical foraminotomy for cervical radiculopathy and discuss the methods to improve surgical outcomes. METHODS: We analyzed 55 consecutive patients with degenerative cervical radiculopathy who underwent minimally invasive posterior cervical foraminotomy. Minimum postoperative follow-up duration was 1 year. We divided the patients into nonimproved and improved groups. The cutoff value between preoperative and postoperative Neck Disability Index scores was 30% improvement. Preoperative imaging data comprised disk height, local kyphosis, spinal cord compression, anterior osteophytes in the foramen, and anterior osteophytes of >50% of the intervertebral foramen diameter. Postoperative imaging data comprised craniocaudal length and lateral width of decompressed lamina, preserved superior facet width, and area of decompressed lamina. RESULTS: Fifty-five patients were divided into two groups: nonimproved (n = 19) and improved (n = 36). The presence of osteophytes itself was not significant; however, the presence of osteophytes of >50% of the foramen diameter increased in the nonimproved group (P = 0.004). Mean lateral width and mean area of decompressed lamina after surgery significantly increased in the improved group (P = 0.001, P = 0.03). CONCLUSION: The presence of anterior osteophytes >50% of the diameter of the foramen led to poor improvement of clinical outcomes in minimally invasive posterior cervical foraminotomy. However, the larger the lateral width and area of the decompressed lamina, the better the surgical outcome.

Morphometric change in intervertebral foramen after percutaneous endoscopic lumbar foraminotomy: an in vivo radiographic study based on three-dimensional foramen reconstruction.

PURPOSE: This study aimed to perform in vivo three-dimensional (3D) quantitative measurements of morphometric changes in the foramen in patients with lumbar foraminal stenosis (LFS) undergoing percutaneous endoscopic lumbar foraminotomy (PELF) and investigate the relationship between anatomical changes in the foramen and clinical outcomes. METHODS: We retrospectively reviewed consecutive patients with LFS treated with PELF between January 2016 and September 2020 at our centre. Clinical outcomes were evaluated. Foraminal volume (FV) and foraminal minimal area (FMA) were calculated using a novel vertebral and foramen segmentation method. A comparison of the anatomical parameters of the foramen were conducted between the satisfied and unsatisfied groups divided based on the modified MacNab criteria. RESULTS: A total of 26 eligible patients with a mean follow-up of 3.6 years were enrolled. A significant increase was found in overall FV (71.5%) from 1.436 ± 0.396 to 2.464 ± 0.719 cm3 (P < 0.001) and FMA (109.5%) from 0.849 ± 0.207 to 1.780 ± 0.524 cm2. All clinical outcomes were significantly improved (P < 0.001) after PELF. No significant difference was found in changes in neither FV nor FMA between the two groups. CONCLUSION: Clinical results and foraminal dimensions improved significantly after PELF, indicating that PELF was a prominent technique suitable for LFS because of the direct decompression at impingement structures. No relationship was found between morphometric changes and clinical outcomes, revealing that full-scale endoscopic decompression is necessary and adequate for LFS, and unsatisfactory outcomes are less likely to result from decompression procedure.

Minimally invasive posterior cervical foraminotomy versus anterior cervical discectomy and fusion for cervical radiculopathy: a meta-analysis.

With the recent development of minimally invasive techniques, minimally invasive posterior cervical foraminotomy (MIS-PCF) has become increasingly popular as a minimally invasive method to treat cervical radiculopathy. However, there are still controversies about whether MIS-PCF is superior to anterior cervical discectomy and fusion (ACDF). The purpose of this study is to evaluate the therapeutic effects of MIS-PCF and ACDF on unilateral cervical radiculopathy without myelopathy. We searched PubMed, Embase, the Cochrane Library, and Scopus comprehensively using the terms related to MIS-PCF. Two reviewers independently evaluated the potential studies, and extracted and analyzed the data of operation time, hospital stay, neck disability index (NDI) score, visual analog scale for neck pain (VAS-neck) and arm pain (VAS-arm) scores, reoperation rate, and complications. Seven studies with 1175 patients were included. The study population was 53.5% male, with a mean age of 48.9. MIS-PCF presented a significantly shorter postoperative hospitalization time compared to ACDF, while the operation time, complication/reoperation rate, and VAS-arm, VAS-neck, and NDI scores were comparable between the two cohorts. In North America, the average cost of MIS-PCF is lower than ACDF. Thus, we suggest that MIS-PCF is an alternative to ACDF for selected patients.

Percutaneous endoscopic lumbar foraminotomy: how I do it.

BACKGROUND: Percutaneous endoscopic lumbar foraminotomy (PELF) is a good alternative for foraminal stenosis. The steep learning curve and lack of a practical manual can make this technique challenging. METHOD: We describe a step-by-step technique based on the literature review and our experience in actual practice: (1) posterolateral foraminal landing, (2) bony unroofing of the superior articular process, and (3) full-scale soft tissue decompression. Technical tips for preventing complications are also discussed. CONCLUSION: PELF may be effective and minimally invasive. Standardized surgical techniques are essential for clinical success.

Surgery for diaphragma sellae meningioma: how I do it.

BACKGROUND: Surgery for diaphragma sellae meningiomas (DSM) remains challenging due to the intimate neurovascular relationships of the tumor. Excision of DSM along with a decompression of the optic apparatus requires a good knowledge of the skull base anatomy and a precise preoperative evaluation of the tumor extensions. METHOD: We describe the key steps of transcranial approach for DSM with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. CONCLUSIONS: The transcranial approach allows a safe tumor excision with an early and adequate control of the neurovascular structures, while minimizing postoperative CSF rhinorrhea.

Cervical posterior foraminotomy: how i do it.

BACKGROUND: Cervical pathologies are addressed through a variety of anterior and posterior approaches and minimally invasive procedures have been successfully applied during the last decades. Posterior cervical foraminotomy (PCF) should be proposed with isolated foraminal stenosis. METHOD: We provide a step-by-step description of PCF through the use of tubular retractors. Its advantages and limitations were detailed. CONCLUSION: PCF performed with tubular retractors represent a safe and efficient alternative to address an isolated level disease with unilateral radiculopathy. The risk of mechanical instability is limited when only the medial third of the facet is drilled. Patients present rapid functional recovery.

How I do it? Interlaminar contralateral endoscopic lumbar foraminotomy assisted with the O-arm navigation.

BACKGROUND: The interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) provides access to the foraminal pathology with less violation to facet than the ipsilateral approach. However, it is technically challenging even for an experienced surgeon. METHODS: We introduce the step-by-step workflow of the interlaminar contralateral endoscopic lumbar foraminotomy assisted with O-arm navigation system. CONCLUSION: The ICELF assisted with O-arm navigation is safe, accurate, and efficient for the treatment of lumbar foraminal stenosis. The CT-based navigation reshapes the learning curve of the advanced endoscopic technique, reducing the risk of facet joint violation, and minimizes radiation exposure to surgeons.

Minimally invasive anterior foraminotomy for cervical radiculopathy: how I do it.

BACKGROUND: The standard treatment for cervical radiculopathy is anterior discectomy and fusion. The authors describe a minimally invasive anterior cervical foraminotomy as a surgical option for direct nerve root decompression in cervical radiculopathy. METHOD: Through a modified Smith-Robinson approach, the prevertebral fascia is mobilized laterally, displacing the sympathetic chain with it. A thumbnail size portion of the longus colli muscle is removed. A tubular retractor is placed, centered over the index uncovertebral joint. The lateral part of the joint is progressively drilled towards the foramen. After exposure of the intervertebral foramen, the perivascular ligamentous tissue is opened. Removal of disc fragments and osteophytes allows direct visualization and direct decompression of the nerve root. CONCLUSION: Anterior cervical foraminotomy is a safe "motion preserving" procedure for direct nerve decompression in selected patients with cervical radiculopathy that does not require cervical fusion.

Endoscopic posterior cervical foraminotomy via a single stab incision for contiguous two-level cervical radiculopathy.

BACKGROUND: Endoscopic posterior cervical foraminotomy (EPCF) is an effective surgical treatment method for single-level cervical radiculopathy. However, only few studies have used the technique for two-level EPCF via a single stab incision. METHOD: In this study, the minimally invasive surgical method was used for two-level cervical radiculopathy, and useful information regarding perioperative care was presented. CONCLUSION: EPCF is an alternative treatment for patients with symptoms of adjacent two-level lesions of the cervical spine, and such procedure is advantageous as it can be performed with a small access.

Laser-assisted endoscopic lumbar foraminotomy for failed back surgery syndrome in elderly patients.

Elderly patients with failed back surgery syndrome (FBSS) or post-laminectomy foraminal stenosis have a higher risk of perioperative morbidity with extensive revision surgery. Thus, there is a need for safer and less invasive surgical options, such as laser-assisted endoscopic lumbar foraminotomy (ELF). A pin-point laser beam can allow precise tissue ablation and dissection in fibrotic adhesion tissues while preventing normal tissue injury. The present study aimed to describe the surgical technique of laser-assisted ELF and to evaluate the clinical outcomes of elderly patients with FBSS. Two-year follow-up data were collected from 26 consecutive patients aged 65 years or older who were treated with laser-assisted ELF for FBSS. Full-endoscopic foraminal decompression was performed using a side-firing laser and mechanical instruments. The average age of the patients was 70.2 years (range, 65-83 years). The mean visual analog pain score for leg pain improved from 8.58 at baseline to 3.35 at 6 weeks, 2.19 at 1 year, and 2.35 at 2 years after ELF (P < 0.001). The mean Oswestry disability index improved from 65.93 at baseline to 31.41 at 6 weeks, 21.77 at 1 year, and 20.64 at 2 years after ELF (P < 0.001). Based on the modified Macnab criteria, excellent or good results were obtained in 84.6% patients and symptomatic improvements were obtained in 92.3%. Extensive revision surgery in elderly patients might cause significant surgical morbidities. Laser-assisted ELF under local anesthesia could be a safe and effective surgical alternative for such patients at risk.

Comparison of clinical outcomes in anterior cervical discectomy versus foraminotomy for brachialgia.

AIM: The choice between anterior cervical discectomy & fusion (ACD) or posterior cervical foraminotomy (PCF) for the treatment of cervical brachialgia is controversial. This study aimes to compare clinical outcomes between these two operative inteventions for brachialgia. METHODS: Retrospective review of prospectively collected data was performed. Patients receiving a primary ACD or PCF to treat brachialgia, in a single tertiary neurosurgical unit were included. Surgical details, and patient reported outcomes (COMI-Neck questionnaire) were extracted from a prospectively maintained spinal procedure database. Minimum clinically important difference (MCID) was defined as a change in COMI score of -2 at 12 months. The student t-test, Chi-square test, and linear regression were used to compare groups. RESULTS: Between June 2011 ad February 2016 there were 634 ACD procedures (Median age 49; 321 Male), and 54 PCF procedures (Median age 50; 37 Male) perfomed for brachialgia. Age, ASA and pre-operative COMI were similar between the groups (p > .05). Complete outcome data was recorded at twelve months in 312 ACD and 36 PCF patients. Both ACD and PCF were associated with an improvement in COMI at 3 and 12 months (all p < .01). Mean change in COMI at 3 months was -2.38 for ACD, versus -2.31 for PCF (p = .88); at twelve months it was -2.94 for ACD, versus -2.67 for PCF (p = .55). MCID was seen in 59% of ACD cases, versus 58% of PCF cases at twelve months (p = .91). CONCLUSION: There was no significant difference between outcomes in the ACD and PCF groups. This is supportive of published literature. The proposed multicenter RCTs may inform further.

Factors related to subjective satisfaction following microendoscopic foraminotomy for cervical radiculopathy.

BACKGROUND: Microendoscopic foraminotomy has been reported to be effective for the treatment of cervical radiculopathy, using outcome measurement scores such as the neck disability index (NDI) and numerical rating scale (NRS). However, the scores for spine surgery do not always reflect the true subjective satisfaction of the patient. The purpose of this study was to evaluate factors related to subjective satisfaction following microendoscopic foraminotomy for cervical radiculopathy. METHODS: The subjects consisted of consecutive patients who underwent microendoscopic foraminotomy for cervical radiculopathy. Patient background information and operative data were collected. The NDI, the NRS score for the neck, upper back, and arm, and the EuroQOL-5D (EQ-5D) were assessed preoperatively and 1 year postoperatively. Postoperative subjective satisfaction was also assessed as a direct evaluation of satisfaction, and willingness to undergo the same operation if needed was assessed as an indirect evaluation. RESULTS: A total of 42 patients were included in this study. The mean age was 52.9 ± 11.8 years; 19.0% were female and 81.0% were male. The operation time for one level was 57.7 min and the estimated blood loss was minimal in most cases. All NDI, NRS, and EQ-5D scores improved significantly postoperatively. Univariate analyses revealed that the factors related to subjective satisfaction were younger age, non-smoking status, high preoperative NDI score, and low postoperative NRS score for the arm. Factors related to the willingness to undergo the same operation if needed were high preoperative NDI scores, high preoperative NRS scores for the arm, and low preoperative EQ-5D scores. CONCLUSIONS: Factors related to subjective satisfaction following microendoscopic foraminotomy include younger age, non-smoking status, high preoperative NDI score, high preoperative NRS score for the arm, low preoperative EQ-5D score, and a low postoperative NRS score for the arm.

How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation.

BACKGROUND: Percutaneous transforaminal endoscopic discectomy (PTED) has emerged as a less invasive technique to treat symptomatic lumbar disk herniation (LDH). PTED is performed under local anesthesia with the advantage of immediate intraoperative feedback of the patient. In this paper, the technique is described as conducted in our hospital. METHODS: PTED is performed under local anesthesia in prone position on thoracopelvic supports. The procedure is explained stepwise: e.g. marking, incision, introduction of the 18-gauge needle and guidewire to the superior articular process, introduction of the TomShidi needle and foraminotomy up to 9 mm, with subsequently removal of disk material through the endoscope. Scar size is around 8 mm. CONCLUSION: PTED seems a promising alternative to conventional discectomy in patients with LDH and can be performed safely.

State-of-the-art transforaminal percutaneous endoscopic lumbar surgery under local anesthesia: Discectomy, foraminoplasty, and ventral facetectomy.

Transforaminal (TF) percutaneous endoscopic surgery for the lumbar spine under the local anesthesia was initiated in 2003 in Japan. Since it requires only an 8-mm skin incision and damage of the paravertebral muscles would be minimum, it would be the least invasive spinal surgery at present. At the beginning, the technique was used for discectomy; thus, the procedure was called PELD (percutaneous endoscopic lumbar discectomy). TF approach can be done under the local anesthesia, there are great benefits. During the surgery patients would be in awake and aware condition; thus, severe nerve root damage can be avoided. Furthermore, the procedure is possible for the elderly patients with poor general condition, which does not allow the general anesthesia. Historically, the technique was first applied for the herniated nucleus pulposus. Then, foraminoplasty, which is the enlargement surgery of the narrow foramen, became possible thanks to the development of the high speed drill. It was called the percutaneous endoscopic lumbar foraminoplasty (PELF). More recently, this technique was applied to decompress the lateral recess stenosis, and the technique was named percutaneous endoscopic ventral facetectomy (PEVF). In this review article, we explain in detail the development of the surgical technique of with time with showing our typical cases.