Translaminar contralateral endoscopic foraminotomy for foraminal stenosis and lumbar disc herniation at L5-S1

Abstract

L5-S1 pathologies including foraminal disc herniation, foraminal stenosis and spondylolisthesis are well-recognized causes of radicular pain, functional limitation, and diminished quality of life, with many patients requiring surgical intervention due to refractory symptoms or progressive neurological compromise [1,2]. Traditionally, surgical decompression at L5-S1 has involved interbody fusion procedures, aimed at restoring foraminal height and stabilizing the segment to relieve nerve root impingement [3]. However, these procedures can result in prolonged recovery times, increased surgical morbidity, and the long-term risk of adjacent segment degeneration [4,5]. In recent years, endoscopic techniques have emerged as minimally invasive, motion-preserving alternatives for patients with radiculopathy due to foraminal compression [5,6]. Among these, the translaminar contralateral endoscopic foraminotomy (TCEF) approach allows for direct visualisation and precise neural decompression of the L5 nerve root without compromising segmental stability, offering faster recovery, less postoperative pain, and significant reduction in hospital stay [[7], [8], [9]].

The authors report a video technical note on a TCEF in a 39-year-old male with four years of worsening L5 radiculopathy and low back pain. MRI demonstrated a bilateral pars defect with low-grade spondylolisthesis, severe foraminal stenosis and annular bulging (Fig. 1). Under general anaesthesia, fluoroscopic guidance confirmed the L5–S1 level and contralateral translaminar entry point, and a 10-mm incision was made just lateral to the midline. A dilator was advanced to the L5 lamina (Fig. 2A), followed by placement of a 10-mm working cannula (Fig. 3A and B) and stenosis scope. A small laminotomy under the L5 spinous process and lamina was performed, creating a wider working corridor within the canal and providing access to the epidural space and contralateral L5-S1 foramen (Fig. 2B, C and 3C). A 30° endoscope provided high-definition magnified visualization, facilitating precise discectomy and decompression of the L5 nerve root using endoscopic graspers, rongeurs, and radiofrequency probes (Fig. 3E–G). The incision was closed with a single subcutaneous suture and the procedure was completed in 53 min with estimated blood loss of <1 cc. Postoperative imaging confirmed adequate decompression and preservation of the facet joint. Early clinical outcomes demonstrated the patient had resolution of radicular symptoms and no neurological complications.

Across three performed cases, the TCEF technique was associated with rapid recovery, less than 24-h length of stay (two of three patients discharged the same day), and preservation of spinal stability. This highlights the advantages of TCEF as a non-fusion alterative for L5–S1 foraminal decompression as it provides enhanced visualization of the foraminal corridor, enables precise discectomy and minimises the risk of iatrogenic instability [7,11,12]. Furthermore, its versatility makes it suitable for a wide range of herniation morphologies at the L5-S1 level [1,9,10].