Editor-in-Chief: Kenneth D. Candido, MD

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  1. IPMReports2017;1;4;167-173 Technical Considerations in using a Modified Outside-in Transforaminal Endoscopic Discectomy Approach in Overcoming Lateral Recess Stenosis: A Case Study
    Case Report
    Matthew Skoblar, DO, Gabriele P. Jasper, MD, and Matthias H. Wiederholz, MD.

Microsurgery is a well-established and definitive surgical intervention performed for symptomatic radiculopathy secondary to lumbar disk herniation. While midline and paramedian Wiltse approaches have been the standard for lumbar nerve decompression, advances in neuroendoscopic instrumentation and visualization have broadened the ability of transforaminal endoscopic treatment to resect pathology in more challenging locations. Flexible instruments can be used to reach herniations in the epidural space as far centrally as the mid-vertebral body and enable physicians to reach cranially or caudally migrated sequestrations. Reviews of decompressive lumbar radiculopathy surgery have stated that there is equal efficacy when comparing the transforaminal endoscopic technique to standard microdiscectomy. However, questions have been posed by some authors in the literature regarding the utility of the endoscopic techniques with regard to patients with concomitant lateral recess stenosis and neurologic deficits.

The authors present a case of an endoscopically resected lumbar reherniated extrusion causing lateral recess stenosis and foot drop. The endoscopic approach is performed in an awakened patient with the use of local anesthetic. The optimal technique is described, including the use of the target, or bull’s eye, view fluoroscopically to allow for enhanced accuracy when positioning the endoscopic working channel, as well as to allow for an increase in the intraforaminal space. The bull’s eye approach is a more intuitive technique for placement of the endoscopic working channel for pain physicians as they are accustomed to navigating the foramen in this view. The use of an endoscopic approach with the initial surgery also allowed for the creation of minimal scar tissue, minimizing reoperative complication risks. The author’s technique may offer a significant advantage in overcoming difficulties with lateral recess stenosis described in the literature and allow for more precise placement of the endoscope, particularly for pain physicians.

Key words:  Endoscopic transforaminal discectomy, lateral recess stenosis, reherniation