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TYPE Original Research

PUBLISHED 10 November 2022
DOI 10.3389/fsurg.2022.1042184

Endoscopic lumbar
foraminotomy for foraminal
EDITED BY
Yong Yu,
Fudan University, China
stenosis in stable
REVIEWED BY
Xilei Li,
spondylolisthesis
Fudan University, China
Youzhuan Xie, Yong Ahn*, Han Byeol Park, Byung Rhae Yoo and
Jiao Tong University, China
Tae Seok Jeong
*CORRESPONDENCE
Yong Ahn Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon,
South Korea
ns-ay@[Link]

SPECIALTY SECTION
This article was submitted to Orthopedic Background: Open decompression with fusion is the gold-standard surgical
Surgery, a section of the journal Frontiers in technique for spondylolisthesis. However, it may be too extensive for
Surgery patients with foraminal stenosis with stable spondylolisthesis. The
RECEIVED 12 September 2022 endoscopic lumbar foraminotomy (ELF) technique was developed as a
ACCEPTED 24 October 2022 minimally invasive surgical option for foraminal stenosis. Some authors have
PUBLISHED 10 November 2022
reported the outcomes of ELF for various spondylolistheses. However, few
CITATION
studies have demonstrated foraminal stenosis in advanced stable
Ahn Y, Park HB, Yoo BR and Jeong TS (2022)
spondylolisthesis. This study aimed to describe the surgical technique and
Endoscopic lumbar foraminotomy for foraminal
stenosis in stable spondylolisthesis. results of ELF for radiculopathy due to foraminal stenosis in patients with
Front. Surg. 9:1042184. stable spondylolisthesis.
doi: 10.3389/fsurg.2022.1042184 Methods: Consecutive 22 patients who suffered from radiculopathy with
COPYRIGHT spondylolisthesis underwent ELF. The inclusion criterion was unilateral
© 2022 Ahn, Park, Yoo and Jeong. This is an radicular leg pain due to foraminal stenosis in stable spondylolisthesis. After
open-access article distributed under the terms
of the Creative Commons Attribution License
the percutaneous transforaminal approach, foraminal decompression was
(CC BY). The use, distribution or reproduction in performed using various surgical devices under endoscopic visualization.
other forums is permitted, provided the original Surgical outcomes were measured using the visual analog pain score,
author(s) and the copyright owner(s) are
credited and that the original publication in this
Oswestry disability index, and modified MacNab criteria.
journal is cited, in accordance with accepted Results: Pain scores and functional outcomes improved significantly during the
academic practice. No use, distribution or 12-month follow-up periods. The rate of clinical improvement was 95.5% (21 of
reproduction is permitted which does not
comply with these terms.
22 patients). One patient experienced a dural tear and subsequent open
surgery.
Conclusion: ELF can be effective in foraminal stenosis in stable
spondylolisthesis. Technical points specializing in foraminal decompression
in spondylolisthesis are required for clinical success.

KEYWORDS

endoscopic, foraminal stenosis, foraminoplasty, foraminotomy, lumbar, percutaneous,

spondylolisthesis

Abbreviations
endoscopic lumbar foraminotomy, (ELF); visual analog pain score, (VAS); oswestry disability index,
(ODI); superior articular process, (SAP); exiting nerve root, (ENR); ligamentum flavum, (LF)

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Introduction spondylolisthesis demonstrated on magnetic resonance

imaging (MRI) and computed tomography (CT) scans, 3)
The gold standard surgical technique for lumbar spondylolisthesis without definitive hypermobility on dynamic
spondylolisthesis with foraminal stenosis is decompression x-rays, and 4) foraminal stenosis documented as the source of
and fusion surgery, which may be performed using different radiculopathy by imaging studies, neurologic examination,
methods. However, this surgery may result in considerable and selective nerve root block.
morbidity or sequelae, particularly in older patients. The exclusion criteria were low back pain alone, acute
In cases of foraminal stenosis with fixed or stable lumbar disc herniation, severe central stenosis, segmental
spondylolisthesis, adequate foraminal decompression may be a instability or hypermobility, and other pathological conditions
good solution while avoiding the surgical risk of extensive such as inflammation, infection, trauma, or tumor.
fusion surgery. Therefore, a minimally invasive decompression Changes in clinical status were assessed using the visual
technique is required for cases with stable stenosis. analog pain score (VAS) and Oswestry disability index (ODI).
The endoscopic lumbar foraminotomy (ELF) or The global outcome was evaluated using the modified
foraminoplasty technique was developed for effective MacNab criteria. Follow-up data were obtained through
foraminal decompression under a working channel regular outpatient clinic visits or telephone interviews.
endoscopic view (1–4). The foraminal decompression
technique has evolved using different surgical tools such as
microforceps, lasers, bone trephines, and endoscopic burrs. Surgical technique
Moreover, the advanced ELF technique is as effective as open
foraminotomy (4). However, this technique is unfamiliar to The surgical procedure was performed according to a
standard spine surgeons and challenging for endoscopic previously described method of ELF (4, 13). It consists of
surgeons. three processes: 1) the transforaminal approach under
Some studies have been published on transforaminal fluoroscopic view, 2) bone resection using endoscopic burrs,
endoscopic decompression for spondylolisthesis with lumbar and 3) soft tissue removal using micropunches.
stenosis (5–12). However, most studies have described this Intramuscular midazolam (0.05 mg/kg) and intravenous
technique for lumbar intracanal stenosis or disc herniation in fentanyl (0.8 μg/kg) were administered on call. The patient
spondylolisthesis. Furthermore, few studies have demonstrated was placed in a prone position on a radiolucent spine table.
transforaminal endoscopic decompression procedures specific
to severe foraminal stenosis in patients with stable and
advanced spondylolisthesis. Therefore, we believe this study Transforaminal approach (outside-in technique)
will help aspiring endoscopic spine surgeons understand the This step was performed to ensure the safe docking of the
endoscopic foraminal decompression procedure and apply this working sheath at the foraminal zone. The skin entry point
technique in exceptional cases such as spondylolisthesis. and approach angle were determined according to the target
This study aimed to demonstrate the clinical outcomes of point and body size on preoperative MRI, CT scan, and x-rays.
ELF for foraminal stenosis in stable spondylolisthesis and An 18-gauged needle was introduced into the foraminal
describe a practical and technical approach to achieving good zone in the posterolateral direction under fluoroscopic
clinical outcomes with ELF. guidance (lateral and anteroposterior projections). The typical
approach angle is approximately 45° for foraminal
decompression and can be adjusted to become steeper when
the pathologic point is located in the extraforaminal zone.
Materials and methods The needle tip was deeply inserted into the foraminal disc or
on the vertebral body, along the surface of the superior
Patients and evaluation articular process (SAP). The needle was replaced with a
guidewire, and an obturator was introduced along the
Twenty-two consecutive patients with foraminal stenosis in guidewire until the head of the obturator was fitted into the
spondylolisthesis were treated with ELF between January 2019 foramen without any access pain. The beveled final working
and January 2021. Cases were prospectively registered in the sheath was advanced along the obturator by gently tapping
database, and records were retrospectively analyzed. The with a mallet and placed firmly in the foraminal zone with its
institutional review board approved the study, and written sharp end away from the exiting nerve root (ENR). The
informed consent was obtained from all participants. surgical field was created outside the foramen, and
The inclusion criteria for ELF were as follows: 1) chronic decompression proceeded into the foramen (outside-in
unilateral radicular leg pain despite more than 3 months of approach). Thus, the ENR was protected during the entire
nonoperative treatment, 2) foraminal stenosis in procedure (Figures 1A, 2A).

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FIGURE 1
Conceptual illustrations depicting the surgical procedure of endoscopic lumbar foraminotomy for spondylolisthesis. (A) Foraminal docking of the
working sheath viewing the foraminal surgical field protecting the exiting nerve root (outside-in approach). (B) Foraminal unroofing using
endoscopic burrs for resecting the upper pedicle and lower vertebral endplate. (C) Soft tissue decompression with removal of the ligamentum
flavum. (D) Final point of the full-scale foraminal decompression from the axillary side to the lateral exit zone.

Endoscopic bone work be decompressed by resecting these bony structures. Bone

Endoscopic foraminal decompression was initiated after a resection is an essential and critical process of
working channel endoscope was inserted. The initial view foraminal decompression specific to spondylolisthesis cases
included the ENR with perineural fat and disc surface. These (Figures 1B, 2B).
structures helped the surgeon maintain the correct orientation
during the entire procedure. Next, the surface of the SAP was Endoscopic soft tissue work
exposed by rotating the working sheath and the endoscope. After sufficient bone work, delicate soft tissue removal was
The tip of the SAP was then drilled using various endoscopic performed, and the ENR was released. The decompression
burrs along the ENR until the ligamentum flavum (LF) and process was directed toward the proximal side, and the nerve
foraminal ligaments at the axillary zone were sufficiently root course was traced to the axillary epidural zone. The
exposed. Finally, any bone or venous bleeding was coagulated hypertrophied LF and protruding disc material were removed
using radiofrequency tips and hemostatic agents. In cases of gradually using micropunches, forceps, and radiofrequency
advanced spondylolisthesis, the ENR is usually pinched by a tips (Figure 1C). Although minor, bleeding may seriously
narrow space between the upper pedicle and lower vertebral interfere in the endoscopic surgical field. Therefore,
endplates rather than by the SAP. Therefore, the ENR should meticulous hemostasis was essential to ensure a clear vision

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FIGURE 2
Intraoperative endoscopic views. Foraminal unroofing with the removal of the upper pedicle (A) and lower vertebral endplate (B) compressing the
exiting nerve root (ENR). After the full-scale decompression, the ENR was freely released from the proximal axillary zone to the lateral exit zone (C).

during the procedure. The ENR became exposed and released as L3–4 in 2 (9.1%). The mean operative time was 63.6 min
soft tissue work proceeded. Surgeons were careful not to damage (range, 35–115). The mean postoperative hospital stay
the dural membrane. The tissue debris was cleared with duration was 1.9 days (range, 1–5).
radiofrequency, and the neural tissues were separated from The mean preoperative VAS score for the lumbar
the offending tissues. The axillary epidural zone is a key radiculopathy was 7.91 ± 0.75, which improved to 2.73 ± 0.94,
landmark for foraminal decompression. Exposure of the dural 2.05 ± 0.79, and 1.64 ± 0.95 at 6 weeks, 6 months, and 1 year
sac to the starting point of the ENR indicated successful postoperatively, respectively (P < 0.001) (Figure 5A). The
foraminal decompression. Once the proximal axillary zone mean preoperative ODI was 74.82 ± 8.34%, which improved to
was released, the nerve root was examined from the proximal 29.24 ± 6.08%, 23.35 ± 7.24%, and 18.18 ± 7.73% at 6 weeks, 6
side to the lateral exit zone. Any remaining ligament or disc months, and 1 year postoperatively, respectively (P < 0.001)
tissue was trimmed during full-scale foraminal decompression. (Figure 5B). The global results based on the modified
Finally, determining the definitive finishing point is MacNab criteria were rated as follows: excellent in 6 patients
mandatory to prevent an incomplete decompression. The (27. 3%), good in 14 (63.6%), fair in 1 (4.5%), and poor in 1
endpoint of ELF was determined by sufficient exposure and (4.5%). Therefore, the success rate was 90.9%, and the clinical
strong pulsation of the neural tissue (Figures 1D, 2C). improvement rate was 95.5% (Figure 6).
Postoperatively, the surgeon checked each patient’s status for During the procedure, one patient experienced a dural tear
3 h. The patient was discharged within 24 h in the absence of in the axillary zone at the L3–4 level. The patient complained of
complications (Figures 3, 4). severe pain and underwent subsequent open surgery
(transforaminal lumbar interbody fusion with dural repair).
Otherwise, no other significant perioperative complications
Statistical analysis were observed. No newly developed back pain or radiological
signs of further instability were noted during the follow-up
Statistical analysis was performed between the pre- and period.
postoperative clinical results using repeated-measures analysis
of variance and a paired t-test. Statistical significance was set
at P < 0.05. Discussion
Surgical data and clinical outcome
Results
The ELF technique is usually suitable for geriatric patients
The mean age of the patients (14 females and 8 males) was because of its minimal invasiveness. However, the average age
69.2 years (range, 53–83). The mean BMI was 22.94 ± 2.59 kg/ of the surgical candidates in this study was higher than that
m2. The degrees of spondylolisthesis were grade 1 in 20 of other case series of ELF. The disease entity appears to be
patients (90.9%) and grade 2 in 2 (9.1%). The operating levels chronic radiculopathy due to long-standing or advanced
were L5-S1 in 12 (54.5%) patients, L4–5 in 8 (36.4%), and spondylolisthesis. Therefore, most patients may be older

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FIGURE 3
An illustrative case of a 62-year-old Male patient. (A) Preoperative computed tomography (CT) images showing foraminal stenosis with
spondylolisthesis at the L4-5 level. (B) Postoperative CT images showing foraminal decompression with resection of a part of the upper pedicle
(arrow) and lower vertebral endplate (arrowheads).

individuals or long-suffering. Additionally, older patients do not efficacious in ENR decompression and results in significant
prefer extensive fusion surgery for perioperative morbidities. functional improvement.
The operative data showed the typical benefits of minimally The success rate (excellent or good) based on the modified
invasive spine surgery. The mean operative time was 63.6 min, MacNab criteria was 90.9%, with a clinical improvement rate of
which was shorter than that of open fusion surgery (14–17). 95.5%. These findings are comparable to those of published
Blood loss was negligible, and postoperative hospital stays open foraminotomy procedures (21–27).
were fairly straightforward. These findings can facilitate a Our series had no significant complications except for one
patient’s earlier return to ordinary life. dural tear and conversion to open surgery. None of the
The patient outcomes significantly improved in both the patients experienced any further clinical or radiological
VAS and ODI scores. The mean VAS score of radiculopathy segmental instability during the follow-up period. Although
decreased by 6.327 at the final evaluation (P < 0.001). some bony structures were removed to decompress the nerve
Conversely, the mean ODI improved by 56.64 at the final root, the ELF technique did not cause the development of
assessment (P < 0.001). A reduction of more than 50% in the further instability in any of the patients in our study.
VAS score (18) or an improvement of more than 20%–30% in Given the innate characteristics of ELF, the clinical success
the ODI is clinically relevant (19, 20). Therefore, our data and complication rates may depend on the surgeon’s skill.
indicate that the ELF technique for spondylolisthesis is However, once technical proficiency is achieved, surgeons can

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FIGURE 4
An illustrative case of a 75-year-old Male patient. (A) Preoperative magnetic resonance image (MRI) showing foraminal stenosis with spondylolisthesis
at the L5-S1 level (arrow). (B) Postoperative MRI showing foraminal decompression with removal of the protruded disc and surrounding bony tissues
(arrowheads).

produce relevant and reliable results. Therefore, an extensive procedure employed in this study was achieved with the
and systematic learning process is required to implement this third-generation technique, in which spine surgeons applied
procedure. endoscopic burrs and punches. Specially designed surgical
tools enable precise, full-scale foraminal decompression as
effective as open foraminotomy (1, 30–32).
History of ELF/foraminoplasty

Owing to the development of decompression devices, ELF Current studies and theoretical benefits
has become a practical foraminal decompression technique.
The first-generation procedure uses a laser for foraminal Since Knight et al. published endoscopic lumbar laser
decompression. Knight et al. (1, 28) introduced an endoscopic foraminoplasty for isthmic spondylolisthesis (5), some authors
laser foraminoplasty technique. The central concept of laser have published transforaminal endoscopic decompression
foraminoplasty is sculpting the foramen by ablating the techniques for lumbar stenosis or disc herniation in
hypertrophic foraminal ligaments using a side-firing laser spondylolisthesis (6–12). They decompressed the spinal canal
under an endoscopic view. Although the soft tissues and or herniated disc using various surgical devices, such as lasers,
fibrotic adhesion could evaporate, the hard tissue or trephines, forceps, and burrs. However, few studies have
hypertrophic bone could not be effectively removed with the described precise techniques specific to foraminal stenosis in
laser beam. The second-generation technique uses bone stable and advanced spondylolisthesis. Moreover, in stable
trephine or reamer. Ahn et al. (2) reported an endoscopic spondylolisthesis, open decompression and fusion surgery
foraminotomy technique using a bone trephine and Ho: under general anesthesia may be too extensive in foraminal
YAG side-firing lasers. Schubert and Hoogland (29) stenosis without intracanalicular stenosis.
described a foraminoplasty method using a bone trephine Without open fusion surgery, ELF can resolve chronic and
to remove the migrated lumbar disc herniation. Being a intractable radiculopathy caused by spondylolisthesis. In
blind percutaneous technique under fluoroscopic view, the addition, this minimally invasive technique may be efficient
use of bone trephine has inherent limitations, such as for patients who refuse fusion surgery or medically
possible bone bleeding and neural injury. The ELF compromised older patients because the procedure can be

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FIGURE 5
Clinical outcomes. (A) Visual analog pain score for radicular leg pain preoperatively and at 6 weeks, 6 months, and 1 year after surgery. (B) Oswestry
disability index scores preoperatively and at 6 weeks, 6 months, and 1 year after surgery.

performed percutaneously under local anesthesia. Technical keys specific to foraminal

Consequently, the surgical complications of extensive fusion stenosis with spondylolisthesis
surgery can be reduced, and the patient can return to normal
life earlier. Hypertrophic SAP and thickened LF compressing the ENR
However, this minimally invasive procedure has a steep are the primary pathologies of foraminal stenosis. Therefore, the
learning curve and limited indications. Therefore, the clinical basic ELF technique consists of bone resection of the SAP and
application of ELF in spondylolisthesis should be carefully removal of the LF by endoscopic burrs and other surgical
considered. devices. The final landmark of the decompression process is

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FIGURE 6
The global outcome according to the modified macNab criteria: excellent in 6 patients (27. 3%), good in 14 (63.6%), fair in 1 (4.5%), and poor in 1
(4.5%). Therefore, the success rate was 90.9%, and the clinical improvement rate was 95.5%.

the axillary epidural space, which is the starting point of the drawing a conclusive result because the spondylolisthesis
ENR. status or segmental stability may change with time, even after
However, the foraminal anatomy of advanced successful decompression. Therefore, a long-term follow-up
spondylolisthesis is different. Unlike the usual foraminal stenosis study with a larger number of cases is required to verify the
cases, the main offending structure may be the lower vertebral effectiveness of ELF for foraminal stenosis in spondylolisthesis.
endplate rather than the SAP. In the foraminal zone of
spondylolisthesis, the SAP is away from the ENR because of
slippage of the upper vertebral body. Therefore, the ENR may Conclusion
impinge between the upper pedicle and lower vertebral body.
To achieve sufficient foraminal decompression, the surgeon The advanced ELF technique is effective in adequately selected
should target the lower vertebral endplate rather than the SAP cases of lumbar spondylolisthesis. In addition, ELF may be suitable
during the initial approach. Once the working sheath and for intractable radiculopathy due to foraminal stenosis with fixed
endoscope are ensured to be in the foraminal working zone, the spondylolisthesis without segmental hypermobility—a specialized
surgeon should confirm the route of the ENR and disc between technique is required for the clinical success of foraminal
the upper pedicle and lower vertebral endplate. Next, the upper decompression in spondylolisthesis. Moreover, it may provide an
pedicle and lower vertebral endplate should be sculptured using excellent minimally invasive alternative to extensive fusion
an endoscopic burr and punch. Finally, the ENR is released surgery in older or medically compromised patients.
between the two resected bony walls after bone work.

Data availability statement

Limitation of the study
The raw data supporting the conclusions of this article will
This study had some limitations. First, the study was be made available by the authors, without undue reservation.
conducted retrospectively without a control group. Therefore,
selection bias in the inclusion criteria may have been present.
Therefore, a prospective randomized trial or comparative Ethics statement
cohort study comparing ELF and open fusion surgery for
foraminal stenosis with spondylolisthesis is warranted. Second, The studies involving human participants were reviewed
the one-year follow-up period may be relatively short for and approved by Gachon University Gil Medical Center. The

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patients/participants provided their written informed consent to Conflict of interest

participate in this study.
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
Author contributions be construed as a potential conflict of interest.

AY provided ideas and the design of the study and was a major
contributor to the data analysis and paper writing. PHB collected
the data and participated in the data analysis and paper writing.
YBR also participated in the data analysis and paper writing. JTS Publisher’s note
supervised the study and revised the paper. All authors
contributed to the article and approved the submitted version. All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their
affiliated organizations, or those of the publisher, the
Acknowledgments editors and the reviewers. Any product that may be
evaluated in this article, or claim that may be made by its
The authors would like to thank Jin Young Choi and Jae manufacturer, is not guaranteed or endorsed by the
Min Son for their support and assistance with this manuscript. publisher.

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