Lumbar foraminal pathology: Biportal endoscopic spine surgical approaches

Spinal endoscopic approaches, full-endoscopic or biportal, allow for access to various lumbar foraminal pathologies while preserving the integrity of back muscles and facet joints. These minimal invasive procedures can eliminate the need for wide decompressions potentially decreasing the need for instrumented fusion. Early symptomatic recurrence most often arises due to inadequate decompression. Understanding the intricacies of foraminal pathology rather than assuming continued post-surgical pain is a result of spinal instability can change the paradigm of endoscopic spine surgery from endoscopic assisted fusion to true minimally invasive surgery. Surgeons should think whether early revision of spinal decompression could arise from insufficient foraminal decompression. This paper aims to elucidate the reader on foraminal pathoanatomy allowing the surgeon to understand when sufficient decompression is achieved and inform the surgeon on the technical aspects of surgery to minimize iatrogenic instability and incidental complications.