title: "Outside-in" technique, clinical results, and indications with transforaminal lumbar endoscopic surgery: a retrospective study on 220 patients on applied radiographic classification of foraminal spinal stenosis.
abstract: OBJECTIVE
  To analyze and describe appropriate surgical indications for endoscopically performed transforaminal decompression with the outside-in technique with foraminoplasty in patients with lateral stenosis with and without herniated disc.
  
  
  BACKGROUND
  Endoscopic microdiscectomy is growing in popularity for the removal of lumbar disc herniations. Recent advances in surgical techniques allow for percutaneous endoscopically assisted bony decompression as well.
  
  
  METHODS
  A retrospective study of 220 consecutive patients undergoing percutaneous endoscopic transforaminal foraminoplasty and microdiscectomy at 228 levels was conducted with intent of identifying appropriate surgical indications in patients with monoradiculopathy. The mean follow up was 46 months ranging from 26 to 54 months. Preoperatively, foraminal and lateral recess stenosis was graded on preoperative MRI and CT scans by dividing the lumbar neuroforamen into three zones: a) entry zone, b) middle zone, and c) exit zone. In addition, the presence of disc herniation causing neural element compression in the lateral recess and neuroforamen was noted. Disc herniations, if present, were recorded as either extruded and contained disc herniations. Surgical outcomes were classified according to the Macnab criteria. In addition, reductions in VAS scores were assessed.
  
  
  RESULTS
  According to the Macnab criteria, excellent and good results were obtained in 85% (186/220) of patients with monoradiculopathy. The mean VAS score decreased from 7.5 ± 1.5 preoperatively to 2.8 ± 1.9 at the final follow-up (P < 0.01). Concomitant extruded disc herniations and contained disc bulges were recorded in 24 and 82 patients, respectively. There were no approach-related complications. Clinical failures occurred in patients with bony stenosis in the lateral recess and entry zone of the neuroforamen. Less favorable outcomes were observed in patients with concomitant contained disc herniations when compared to extruded disc herniations (P < 0.03) as well in patients older than 50 years of age (P < 0.021).
  
  
  CONCLUSIONS
  Percutaneous, endoscopic decompression using outside-in technique works well in patients with monoradiculopathy due to lateral stenosis in the mid and exit zone of the neuroforamen. Decompression in the entry zone maybe inadequate using the transforaminal outside-in approach. Future studies with greater statistical power should determine as to whether pain relief was achieved via microdiscectomy or foraminoplasty.
authors.affiliation: Center for Advanced Spinal Surgery of Southern Arizona, Tucson, AZ.
authors.forename: Kai-Uwe
authors.initials: KU
authors.lastname: Lewandrowski
keywords: Percutaneous endoscopic transforaminal lumbar foraminotomy; Preoperative Classification of Lumbar Foraminal Spinal Stenosis; microdiscectomy; outside-in technique