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foramen. This image highlights roof of the foramen over the kambin’s triangle, a ventral perspective. This may affect the cauda or roots by anterior changes in disc, annulus, osteophytes along edges of the vertebrae and posteriorly by facet changes and ligamentum flavum changes. Let us analyze cases here, with severe claudication Image187 200

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3a Image here shows the sap hypertrophied tissue.in section taken in upper foramen. This also matches newer understanding of stenosis seen on cross 16 sections in MRI. We however believe that roof of the upper foramen mainly contributes to the symptomatology. Clinical analysis is based on questionnaire mentioned earlier. This highlight Standing time, walking distance, Walking time in the patient of claudication. 207

3.Illustrative Cases 4a. Same patho anatomical changes are seen in Failed traditional back surgery due to foraminal fibrosis, recurrent herniation, and subarticular lateral recess stenosis LEG A image201 Bimage202 c We can visualize the hidden zone of Macnab and relieve compression in this zone by decompressing the axilla between the traversing and exiting nerve in cases of failed traditional surgery. Imaging studies in this “pain generating” region do not always have clear findings. The application of 208

diagnostic and therapeutic injections may provide a prognosis for this type of decompression. This transforaminal decompression can be done without “burning any bridges for subsequent more traditional decompression and fusion if needed. 4A: 2 . Case: Following patient has residual pain at operated and stabilized site due to non-removal of pain generator, treated by endoscopic removal of trapped fragments and a sub annular access to clean the tear. Image203 Image204 209

Image205 use of hook to mobilize the tethered root is seen. Image206 Image207 Adjacent segment disc lesion 210

Patient has symptoms arising from level above fixation and is treated with confirmed diagnosis by discogram showing an annular tear and leak with persistent trapped fragments. 4b. Mild and soft tissue central spinal stenosis Image below shows use of hook over tip of SAP. The reddish structure below is the exiting nerve root. Use of laser and drill is shown. In left sided foraminal access. Image208 211

209 210 Use of diamond tip drill on facet under surface and hypertrophied tissue. 212

Stenotic complaints can also be discogenic where a hard collagenized posterior annulus and its cephalad edge adds to compression needing excision and ablation. Image211 image212 We land in foramen, medialize the annular window using annular cutter and thin out the central and para central annulus. We thus concentrate more on stenosis plane rather than interlaminar indirect decompression by removal of the only medial portion of the ligamentum flavum. 213

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216 Image from a left sided foraminoplasty. Working on tip of sap and exposing and decompressing DRG is shown. 217 215

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223 Use of curette is shown in following images on the sap and relevant calcified hardened hypertrophied tissue. 224 218

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229 230 Curette on SAP seen under c arm. 221

4c: Foraminal or endplate osteophytosis Image231 image232 Use of side firing HO YAG laser shown on the facet and osteophytes, tip and base of osteophyte seen ablated. 222

Image233 Image234 Image235 Image236 Shows a use of side curette [spoon is on side of the tip and hinge is base] on the tip of sap or hard tissue to be removed. 223

Image237 Image238 Images for osteophyte at upper endplate 23.18 to 23.25 Illustrating use of a burr over bone edge Second set of images added to show same pathology Set 1 : 9 images osteophytes at upper end plate seen and treated Set 2: 19 images similar pathology pushing root towards pedicle. 224

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Above series of 9 images show view from left foramen towards the upper endplate with white top osteophyte being drilled and roots being mobilised. 229

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Adequate decompression of the traversing nerve showing fully decompressed sagging nerve root. 239

4d. Juxta facet and pedunculated cysts We may be able to extend the indications depending on the surgeon’s surgical expertise, available technology and infrastructure. In addition to disc herniations at all levels from D10 to S1 we can tackle facet cysts. A transfacet access is possible. Facet joint normally accommodates 2 mm probes. Using a bone drill on the facet can improve the access. Use of laser with a side fire probe makes working inside the facet easy and effective. sc5 sc4 240

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5a: Mild stable Listhesis with anterior bridging Image261 Anterior bony bridge is seen so a decompression to relieve symptoms is possible by transforaminal endoscopy even in presence of mild listhesis. Image262 242

image263 Image264 Patient with Listhesis but with severe medical co morbidities was treated successfully by endoscopic decompression and root mobilization. The above examples can show the versatility of this approach and capabilities of gore system. Recent literature also supports treatment of Listhesis using transforaminal access and endoscopy as it reduces iatrogenic instability and is more targeted towards symptomatic relief. 243

5B: In case of unstable spine, dynamic cause gives claudication. The solutions are combined foraminal decompression, ablation, irrigation and excision for sciatica, transfacet or transpedicular stabilization to treat instability and facet denervation for facet related pain in case needed. This is labelled as hybrid [combo] surgery. We do a transforaminal fusion under local anesthesia with “new implants” that are used intradiscal. They are generally supplemented by use of posterior stabilization and are not stand- alone implants. There are several unresolved issues in unstable spine. The very concept of instability is still unrefined. Imaging studies may not significantly contribute to decision making and limits of acceptable instability are undecided. The causation of symptoms in unstable spine is unclear. We can isolate the pain generators in and near the foramen and so conceptually separate inflamed part needing ablation, irrigation and decompression and mechanically unstable part of the problem needing stabilization. Surgery is much simplified as it can be done under epidural anesthesia obviating need for neuromonitoring. Recent reports from literature say decompression alone may suffice and have questioned routine use of stabilization in mild forms of spondylolisthesis. Morbid nature of stabilization in patients with likely medical co morbidities is being questioned with special reference to quality of life issues. Hybrid surgery for tackling unstable spine is not the topic of this book so has ONLY been mentioned and not detailed. 244

We use the dilator thru foramen to retract the exiting nerve and protect it during open facet removal that is precursor step in transforaminal lumbar interbody fusion. The pic below shows the dilator on left outside the funnel. Funnel is for putting bone grafts inside the disc space. Image266 Use of dilator to isolate pain generators is seen on left. The dilator guards the exiting nerve during facet removal. Use of irrigation helps in separating surgical planes for mini TLIF. Surgery is done under ropivacaine where motor system is unaffected during anesthesia. Ref for chap 2 and 3 to be added. 245