Objective: Cervical foraminotomy is a critical surgical intervention for addressing foraminal stenosis. Traditional magnetic resonance imaging may be insufficient for diagnosing transcanal stenosis. This lacuna is efficiently solved by using 2-dimensional sagittal-oblique multiplanar reconstruction computed tomography (CT) scans (2D-SOMPR). Standard medial facetectomy is insufficient if pathology extends to the outer foramen. This study investigates a combined approach, utilizing unilateral biportal endoscopy with CT scan-aided imaging, to achieve decompression in complex foraminal stenosis. Methods: A cohort of 23 patients with severe transcanal foraminal stenosis underwent the combined foraminotomy technique. Thirteen patients received single-level decompression, while 4 underwent multilevel procedures. Three patients with bilateral root involvement underwent hemilaminectomy for cervical myelopathy. Results: All patients reported complete neurological symptom relief at a mean follow-up of 12 months. Visual analogue scale and Neck Disability Index scores showed significant improvements, with 22 patients achieving excellent outcomes. Minor transient irritation of the exiting nerve root was observed in 8 patients, resolving within 8 weeks. One patient with preoperative C5–6–7 root palsy experienced partial recovery. No permanent neurological deficits, infections, or surgical complications were noted. Conclusion The combined standard and inclinatory foraminotomy approach is a safe and effective solution for complex cervical foraminal stenosis. This technique ensures complete neural decompression while preserving facet joint function.

Objective: The management of hidden zone lumbar disc herniation has been considered technically challenging due to its difficult surgical exposure. Paraspinal unilateral biportal endoscopy (UBE) is a minimally invasive surgical procedure that has recently gained popularity and has several advantages. Therefore, the authors describe their novel technique of paraspinal UBE for the treatment of upmigrated lumbar disc herniations in the hidden zone of MacNab and present clinical outcomes. Methods: Twelve patients underwent paraspinal UBE to retrieve the upmigrated disc herniation from under the axilla of the exiting nerve root. The operation duration, blood loss, complications, and recurrences were recorded. Clinical outcomes were assessed using the Oswestry Disability Index (ODI) and visual analogue scale (VAS) scores. Patient satisfaction was evaluated using the modified MacNab criteria. Results: After a mean follow-up period of 12.9 months, all patients experienced complete relief from neurological symptoms. VAS and ODI scores significantly improved at the final follow-up. According to the modified MacNab criteria, 11 patients achieved an excellent outcome, while one patient had a good outcome due to transient exiting nerve root irritation that resolved with medication after 8 weeks. No major complications were noted. Conclusion The paraspinal UBE procedure ensures adequate visualization and removal of the herniated disc with minimal bony resection. In conclusion, paraspinal UBE is a safe and effective surgical procedure for managing disc herniations in the hidden zone of MacNab, particularly at higher lumbar levels.

Objective: Transforaminal percutaneous endoscopic discectomy (TPED) is a minimally invasive surgical procedure used to treat herniated disc fragments in the hidden zone of MacNab. This study aimed to investigate the efficacy, advantages, and safety of TPED for superiorly migrated lumbar disc herniation in the hidden zone of MacNab, focusing on patients with isolated causative factors such as prolapsed discs. Methods: A cohort of patients with clinical conditions involving isolated causative factors of herniated discs in the hidden zone of MacNab were selected for TPED. Patients with conditions contributing to clinical symptoms were excluded. Twelve patients with hidden-zone disc herniations underwent TPED. Under fluoroscopic guidance, precise skin markings were performed, followed by chromodiscography and epidurography. A nonstandard floating approach was utilized for TPED. The assessment of patients included visual analogue scale and Oswestry Disability Index scores. The outcomes were evaluated based on the modified MacNab criteria after 12 months. Results: Successful removal of the herniated fragments was achieved in all 12 cases of hidden-zone disc herniations that underwent TPED. According to the modified MacNab criteria, 11 out of 12 patients achieved excellent outcomes, while one patient attained a good outcome. Conclusions The transforaminal approach in TPED was confirmed to be a highly effective and minimally invasive technique for managing hidden-zone disc herniations. The procedure yielded satisfactory to excellent results, accompanied by a significantly shorter rehabilitation period and minimal blood loss. Importantly, the pars interarticularis and lamina remain fully intact with the transforaminal approach.