Augmenting Endoscopic Transforaminal Spinal Decompression Surgery (Full Endoscopic Spine Surgery) Using Stimulated Electromyography Neuromonitoring Dilators.

Background: Full endoscopic spine surgery via a transforaminal approach (FESS-TFA) offers a minimally invasive approach for spinal decompression. However, it carries a risk of nerve root irritation or injury. Existing intraoperative neuromonitoring primarily provides retrospective warnings of potential nerve disturbance.

Objective: To introduce the use of stimulated electromyography neuromonitoring dilators in FESS-TFA for proactive nerve protection, enhanced localization, and potential reduction in radiation exposure.

Methods: This technical note describes the first use of neuromonitoring dilators in FESS-TFA. A 6-mm dilator tipped with a stimulation electrode is introduced to provide real-time directional feedback regarding nerve proximity, allowing the surgeon to actively avoid accidental injury to the exiting nerve root. With the creation of a safe tract, subsequent introduction of working instruments would theoretically reduce the risk of neural injury.

Results: The technique was successfully applied in a case of T11/T12 severe spinal stenosis, facilitating safe instrument passage and nerve localization. We describe the surgical technique and provide illustrative intraoperative details.

Conclusion: Neuromonitoring dilators represent a promising innovation in FESS-TFA with the potential to enhance patient safety and possibly streamline the procedure. Larger-scale studies are warranted to quantify the true impact of this technique on complication rates, operative time, and radiation exposure.

Clinical relevance: This technique highlights a significant advancement in reducing neural complications during minimally invasive spinal surgeries. By proactively preventing nerve irritation or injury and reducing radiation exposure, it contributes to optimizing surgical workflows and improving patient outcomes.

Level of evidence: 5: