Transforaminal Full-Endoscopic Ventral Facetectomy for Lumbar Lateral Recess Spinal Stenosis under Local Anesthesia

This article describes a reproducible protocol for performing transforaminal full-endoscopic ventral facetectomy (TF-FEVF) under local anesthesia for lumbar lateral recess stenosis. Lateral recess spinal stenosis (LRSS) in the lumbar spine is generally treated with posterior decompression surgery under general anesthesia. The invasiveness of posterior decompression has decreased with the development of endoscopic techniques such as interlaminar full-endoscopic spine surgery and unilateral biportal endoscopy. However, these techniques still require general anesthesia. With population aging in developed countries, older patients with LRSS are becoming increasingly common. In older patients with severe comorbidities, general anesthesia may pose a substantial risk. LRSS can also be decompressed by transforaminal full-endoscopic spine surgery (TF-FESS), such as discectomy or foraminotomy, and may benefit elderly patients in poor general condition. In 2017, we developed TF-FEVF as a decompression procedure that can be performed under local anesthesia. This article outlines the surgical indications, operative workflow, and key anatomical landmarks of TF-FEVF. It also describes, step by step, the technique used to achieve effective local anesthesia. Under fluoroscopic guidance, 1% lidocaine is infiltrated in the subcutaneous tissue (3 mL), fascia/muscle (7 mL), facet joint (8 mL), and caudal endplate (2 mL) for local anesthesia. The working cannula is inserted and attached to the lateral wall of the superior articular process (SAP). The ventral and cranial portions of the SAP are extensively resected to widen Kambin's triangle while preserving the dorsal facet complex whenever possible. Next, the ventral surface of the inferior articular process is drilled, allowing exposure and elevation of the ligamentum flavum (LF). Resection of the elevated LF enables adequate decompression of the traversing nerve root. Finally, adequate decompression of the traversing nerve root is confirmed endoscopically. At our institution, more than 200 patients have undergone TF-FEVF, including 10 patients older than 90 years without complications.