Objective: Partial resection of the superior articular process (SAP) is commonly performed during transforaminal endoscopic lumbar foraminotomy (TELF) for the treatment of lumbar foraminal stenosis (LFS). The present study evaluated the efficacy and feasibility of total SAP resection using the selective superior articular process resection (SSAPR) technique, in comparison with conventional TELF. Methods: This retrospective cohort study included 79 patients with symptomatic LFS who were treated using TELF (52 segments) or SSAPR (34 segments) between March 2018 and September 2022. Clinical outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and MacNab criteria. Vertebral slippage was measured to assess segmental stability, and postoperative complications were systematically analyzed. Results: The study cohort consisted of 79 patients (39 men and 40 women; mean age, 61.9±14.2 years) who were followed for a mean duration of 14.5±2.2 months. At the final follow-up, no significant differences were identified between the TELF and SSAPR groups in VAS or ODI scores (p=0.603 and p=0.776, respectively). Vertebral slippage increased significantly in the TELF group, from 5.49±3.64 mm to 8.75±6.78 mm (p=0.019), whereas only minimal changes were observed in the SSAPR group, from 3.67±3.57 mm to 3.86±3.17 mm (p=0.858). Grade 2 dysesthesia occurred in 12.8% of TELF cases but was not observed in the SSAPR group (p=0.07). Conclusion The SSAPR technique provides effective foraminal decompression with improved surgical efficiency and a lower risk of postoperative nerve irritation, while maintaining segmental stability. These findings support the clinical utility of total SAP resection as a safe and viable alternative to conventional partial SAP resection for the treatment of LFS.

Endoscopic transforaminal lumbar interbody fusion (TLIF) offers substantial advantages in the management of degenerative spinal diseases, including accelerated postoperative recovery. However, its technical complexity and steep learning curve pose risks for nerve root injury. Optimizing nerve root protection in full-endoscopic facet-sparing TLIF (FE fs-TLIF) and full-endoscopic facet-resecting TLIF (FE fr-TLIF) is essential for enhancing surgical safety. This study aimed to improve the nerve root protection in FE fs-TLIF and FE fr-TLIF by optimizing cage glider selection and insertion techniques based on the specific cage shape—banana-shaped or bullet-shaped. The goal was to ensure safe cage positioning and mitigate nerve root injury during discectomy, endplate preparation, and cage insertion. These strategies were validated through cadaveric simulations and clinical implementation. In FE fr-TLIF utilizing bullet-shaped (straight) cages, one-tip and two-tip cage gliders effectively protected the traversing nerve root by facilitating medial cage entry, thereby minimizing irritation of the exiting nerve root. Conversely, in FE fr-TLIF with banana-shaped cages, the lateral tilt of the cage holder during implantation required the use of a two-tip cage glider to protect the traversing and exiting nerve roots, thereby mitigating the potential risk of nerve irritation. In FE fs-TLIF, a one-tip cage glider is preferred for safeguarding the exiting nerve root, while the traversing root is inherently protected by the medial wall of the facet joint. The use of a two-tip cage glider in FE fs-TLIF can cause injury to the nerve root during glider insertion. In addition to the selection of cage gliders, improper cage insertion steps can also contribute to postoperative neurapraxia. The appropriate selection of cage gliders with corresponding insertion techniques is critical for nerve root protection in endoscopic TLIF. Tailoring these choices to the specific approach (FE fs-TLIF or FE fr-TLIF) and cage type (banana or bullet) enhances surgical safety and clinical outcomes.

Chronic low back pain (CLBP) is a common health problem and a major cause of patient disability worldwide. The number of people with low back pain (LBP) and their years lived with disability are increasing despite technological advances. There remains a definitive gap between the evidence for effective management of CLBP and current practices. Degenerative disc disease is a major contributor to chronic back pain and also leads to activity limitation and work absence. CLBP is a complex, multidimensional condition yet to be fully understood. In many patients with LBP, magnetic resonance imaging scans show no obvious neural compression. Sensitized nociceptors within the posterior annulus have long been identified as a source of discogenic pain. However, the recent literature also supports the nociceptive capacity of the basiverterbal nerve, which carries vertebrogenic pain from the endplates. In degenerative disc disease, there is pathological neurotization of the sinuvertebral and basivertebral nerves due to stimulation of inflammatory pathways resulting from endplate damage. Radiofrequency ablation of the sinuvertebral nerve and basivertebral nerve provides effective and well-sustained pain relief to patients with LBP. The popularity of endoscopic spine surgery is increasing because of its magnified and clear visualization due to constant water irrigation. The objective of this manuscript is to provide a comprehensive review of discogenic pain, vertebrogenic pain, pathoanatomy, pathophysiology, and the pain generation pathways involved in degenerative disc disease and the role of endoscopic radiofrequency ablation in sinuvertebral and basivertebral neuropathy.

Objective: This study aimed to illustrate the techniques of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) using double cages and compare surgical outcomes with those using a single cage. Methods: We retrospectively analyzed 62 patients who underwent single-level UBE-TLIF using 3-dimensional (3D)-printed titanium cages (29 with a single cage and 33 with double cages). Radiological parameters, including Bridwell fusion and subsidence grading, were assessed via x-ray and computed tomography at 6 months and 1 year. Clinical outcomes were measured using the visual analogue scale (VAS) for lower back and leg pain, as well as the Oswestry Disability Index (ODI). Results: At the 6-month follow-up, the overall fusion rate (grades I + II) was significantly higher in the double-cage group (86.2% vs. 100%, p=0.04); however, no significant difference was noted at the 1-year follow-up (89.6% vs. 100%). The double-cage group showed lower cage subsidence rates at both follow-ups (3% vs. 31%, p=0.01; 12.1% vs. 38%, p=0.03). The double-cage group exhibited significantly greater improvements in leg pain (VAS: 7.6 to 1.7 vs. 7.2 to 1.4, p=0.03) and ODI (28.6 to 10.8 vs. 28.3 to 9.4, p=0.01) at 1 year. Conclusion UBE-TLIF with 3D-printed titanium cages achieved a favorable fusion rate at the 1-year follow-up, regardless of whether single or double cages were used. However, double cages accelerated fusion at the 6-month follow-up and significantly reduced cage subsidence at both the 6-month and 1-year follow-ups. These benefits contributed to improved VAS scores for leg pain and ODI at the final follow-up.