Name: Endoscopic Approach to Lumbar Foraminal Decompression
Uploaded: 2026-08-28T08:39:00Z
Duration: 15 min 48 s
Channel: Arthrex
Description: Vincent Hagel, MD (Lindau, Germany), demonstrates an endoscopic lumbar foraminal decompression via a modified Wiltse approach.

Spine

<p>Vincent Hagel, MD (Lindau, Germany), demonstrates an endoscopic lumbar foraminal decompression via a modified Wiltse approach.</p>

Not Hidden

English  - en

video

VID1-009595-en-US | A | Endoscopic Approach to Lumbar Foraminal Decompression

Vincent Hagel, MD

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

Operationstechnikvideos

Surgical Technique Videos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

Vídeos de técnicas cirúrgicas

Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

Videos de técnicas quirúrgicas

Endoscopic Approach to Lumbar Foraminal Decompression

Speaker  Hi, I'm Vincent Hagel, a neurosurgeon from Lindau, Germany. Today I'm going to be demonstrating a foraminal decompression via a modified Wilkie approach. So we'll demonstrate the modified Wilkie approach, which is a technique used to decompress foraminal stenosis. First step is approach planning. Therefore, we have to mark midline and usually go about 5 to 7cm off midline parallel to the disc space as our skin entry point. Now we will mark a line through the center of the disc space. Now, from that skin entry point, I'm trying to place that needle on top of the facet joint of that level 4 or 5. Obviously here on the left side. All right. So that's a good position of that needle right here on the posterior surface of the facet joint. So put that guidewire and get the skin incision. Now, over that guide wire, I placed the guiding rod onto the same spot, onto that posterior surface of the facet joint, and then step by step, dilate soft tissue while always keeping these dilators in that position. Posterior surface of the facet joint. After having dilated that soft tissue. Next step is to introduce the working cannula again on the same spot, making sure that we stay on that posterior surface of the facet joint. And once that working cannula is in place, we can remove those dilators. Just double checking with fluoroscopy the final position of that working cannula. That looks good. We do another lateral shot. Speaker  So we're on the lateral ideally posterior surface after facet joint here. So in AP and lateral view we see the final position of that working cannula on the posterior surface of the facet joint. Additionally, on the lateral surface of the facet joint, exactly the spot where we want to dock on in order to then start with the endoscopic view. Now, after introducing the endoscope, we have a small layer of soft tissue on top of that facet joint. So we remove that layer to expose the facet joint itself. And you see bone underneath. It's always good to tap. Make sure that there's facet joint underneath as we originally wanted to find. And also after removing some of that soft tissue, this exposes the facet joint capsule underneath, which is the structure that we want to see to go from there as our main landmark. Now with this radiofrequency, we just shrink more of that soft tissue in our way in order to expose that landmark being the facet joint. And again, just by palpation, I feel bone underneath. So that should be facet joint underneath. Now after having exposed here, the posterior surface of that joint will just slightly go towards lateral until we drop off the lateral edge of that facet joint. And this is our direction to eventually work towards to get down into the foramen. So just removing more of that soft tissue here in order to expose the facet joint. It's just important to make sure to expose the sufficiently that bone to have good orientation before we intentionally start drilling. Speaker  We don't want to accidentally remove too much of that bone, but it seems like we have exposed the facet joint here itself to where we have superior articular process out here, and inferior articular process over here, to where we can now start removing some of that bone over here. So this is superior articular process. That's the hypertrophic part of the bone that compresses the exiting root. So that's the part that we want to take down and benefit of using this endoscopic modified approach is that we're more so undercutting this this structure instead of taking too much down of it as you would with a standard approach. So we'll just carefully work our way towards the foramen here. Now, it's important at this stage to have a good orientation of the anatomy here in order to not accidentally get off too far cranial or caudal, as there is the pedicle of L4 or L5. And we don't want to accidentally take off parts of the pedicle as this would compromise stability of that segment. So if you're not sure at this stage about orientation, then it's always good to bring in fluoroscopy for another shot just to confirm you're in the right position. So for orientation purpose, we took an X-ray, as you see here on the left side, with an instrument placed along our drilling site. Speaker  And you can see the tip of that instrument in the foramen away from the cranial as well as lower pedicle. So we're good with that direction entering into the foramen. So we can continue our bone removal exactly at that site. So as we are on the right track right here, we'll just continue removing more of that superior articular process which will eventually lead us into the foramen. So this hypertrophic bone right here, that's a structure that mainly adds to that foraminal stenosis. So most important of course is to take down sufficiently this this part of the hypertrophic bone. And again drill is the most effective way to use that. Once we get down into the foramen, we'll change the Kerrison punches just to be on the safe side. But main bone work has to be done with the trill as seen here between. We'll just change to the RF probe to shrink that soft tissue out of our way. So here we start to see our entry into the foramen. If I extend that probe, I can get into the foramen and into the canal. So that's good. Good orientation to start more bony decompression with our kerrison punch from there. So again that's another instrument just to palpate to make sure that we are entering into the foramen. And we can again double check with fluoroscopy to see the position of our instrument to go from there. So now we have a good end plate view, which gives us an even better orientation. Speaker  On the image, we see that the tip of this instrument is in the medial aspect of the foramen, which means we have to go as far as the tip of this instrument, but not beyond it. And we are just in craniocaudal direction in the center of the foramen. So we have to go a little bit up and a little bit down to get a full extent of that foraminotomy right here. So first step is just to extend that decompression a little bit downward since the exiting root runs, if so, rather in the upper part of the frame. And so we'll just choose the safer side and go down here into the lower part first. And then we can also extend that decompression a little bit upward to make sure we'll reach the cranial parts of that foramen just as well. Soft tissue out of our way. And we can again nicely see the facet joint itself up here with the Superior articular process here, inferior articular process up here and in between the joint line here, which is good orientation as the tip of this superior articular process here is oftentimes main reason for compression of the nerve root. So we've already taken down some of the tip of that superior articular process here. We'll do a little bit more with the kerosene punch in just a second after having removed that soft tissue. Speaker  To have better orientation here. Over here we start to see the pedicle of L4. So that's pedicle L4 going over into the inferior articular process up here. And then we have superior articular process coming from down here reaching up here. So we'll remove a little bit more of that tip of the superior articular process. And then we should eventually find the nerve root hiding somewhere behind here. Cleaning a little bit more of that soft tissue to expose these essential structures before taking down a little bit more of the bone and eventually trying to find that exiting root somewhere underneath here. So this is the tip of the superior articular process, the structure that usually compresses that exiting root. So this is the most essential part of the procedure to take down that bony part here to sufficiently decompress. That exiting nerve root in this case at the level L4 five. It would be the L4 root that's compressed. And we'll expose that nerve in just a second after having taken down that bone. And again, the benefit of this approach is that we're coming from more lateral as the standard we'll see approach would, which allows us to nicely undercut that superior articular process as seen here. Meaning that we don't really take down that much of the inferior articular process, as in the standard approach, would usually be necessary. Usually, I prefer to leave a small layer of bone down in the depth and take that down with the kerosene as it's a little bit safer and more controlled, in my opinion, compared to using that drill all the way down. Speaker  We just have a few more bits of bone there in our way that we want to take down, and then that should be a sufficient bony decompression before we'll remove some soft tissue to eventually expose that exiting root. With this procedure, a lot of times you have soft tissue getting back into your field of view. So every once in a while we do have to use the RF or other instruments to shrink that tissue out of our way, get a good view back on our essential structures. Now, this should be the last layer of soft tissue just on top of that exiting route. So we have to be careful taking that soft tissue. But once we take that layer down, that should expose the exiting nerve root underneath it. So we have some hypertrophic yellow ligament back here, which is also of course a structure that adds to the compression of that root. We'll take that in just a second. But we've already done a sufficient bony decompression. Again we have the inferior articular process up here. Superior articular process over there. We have taken down enough of that hypertrophic superior articular process to where? From now on, we'll just do some ligament removal, and that should then be a sufficient decompression of that exiting root. Speaker  And we start to see that exiting root appearing down here. The structure here still some fat tissue covering it, which we will remove. And that will expose even more of that exiting root here. We nicely see the pedicle of L4 over here. Up here going over into the inferior articular process. And so beside the pedicle, we can nicely enter now into the foramen here and into the canal. So we're good up here. We're good down here below the exiting root where we have pedicle of L5 down here. There's just a little bit of soft tissue covering that exiting root over here, which we will take down in a second and then should be more or less done. Decompressing that route. So that was just finishing up the bone work with the kerosene here. Take a little bit of that hypertrophic ligament to get far enough medial to make sure that the exiting root is decompressed over the whole distance. So just a few last bytes of that superior articular process, and then a little bit more of soft tissue work. And that should be a sufficient decompression. Then. We have L4 pedicle here going over into the inferior articular process over here. We have the facet joint itself here the joint line. We have superior articular process here. We have the exiting nerve root here. This is pedicle here. We get around the medial wall of the pedicle into the canal. So this is here usually the site of the maximum compression due to a hypertrophic superior articular process here coming from down here. Speaker  So we reduce significantly that hypertrophic superior articular process especially the tip of it which usually compresses the nerve root here. Additionally there is a little bit of hypertrophy yellow ligament seen here which we took down as well to where now this exiting root is completely free from inside the canal all the way out here into the foramen. And over here, that would be the extraforaminal area. So we did sufficient decompression of that exiting root all the way from the canal into the extraforaminal area. All right. This was the procedure of modified approach in order to decompress a foraminal stenosis, especially that foraminal stenosis due to a hypertrophic facet joint, especially hypertrophic superior articular process compressing the exiting nerve root. Where a standard transforaminal approach does not come into terms, since it would be too dangerous to dilate directly into the foramen. In these cases, docking onto the superior articular process, and then just taking down that hypertrophic sap into the foramen is the better and safer alternative. And using the endoscope, it's very sparing on the soft tissue. Additionally, we can come from more lateral in order to do an undercutting of that superior articular process as seen here, to where we only have to take down minimal parts of that inferior articular process, thereby hoping to spare the function of that facet joint. Thank you.