Staged Full-endoscopic Foraminotomy for Multilevel Lumbar Stenosis with Scoliosis: A Case Report

Abstract

This report discusses the case of a 70-year-old male orthopedic surgeon with multilevel lumbar foraminal stenosis and degenerative scoliosis (Cobb angle 21°) who presented with right leg radiculopathy and foot drop. To accommodate his inability to take extended leave and his desire to avoid fusion, we performed a staged transforaminal full-endoscopic lumbar foraminotomy, consisting of one procedure per level, under local anesthesia. The procedures targeted the L5/S1, L4/5, and L3/4 levels sequentially at 1-month intervals. The patient's foot drop resolved immediately after the first surgery. At the 3-month follow-up after the final procedure, his motor deficits showed marked improvement, and his Oswestry Disability Index score decreased from 12% to 8%. He returned to his clinical duties the day after each discharge and was able to continue managing his private clinic without interruption. He resumed playing golf 2 months after the final surgery. A staged, non-fusion transforaminal full-endoscopic lumbar foraminotomy approach under local anesthesia was a safe and effective strategy for multilevel foraminal stenosis, even in the presence of deformity, providing excellent functional recovery with minimal disruption to the patient's professional life.

Introduction

Lumbar foraminal stenosis (LFS) is a significant clinical challenge, particularly in aging populations, and has an estimated prevalence of 8%-11%.¹⁾ As a degenerative condition, it is one of the most important pathologies in patients presenting with leg and lower back pain.¹⁾ The clinical complexity of LFS is often heightened by the presence of coexisting spinal deformities, such as degenerative scoliosis. The stenosis leads to compression of the exiting nerve root, which manifests as debilitating radicular symptoms, including severe leg and lower back pain, paresthesias, and motor weakness.²⁾ These symptoms can markedly impair a patient's functional capacity and quality of life, as assessed by patient-reported outcome measures such as the Oswestry Disability Index (ODI) and EuroQol 5-Dimension questionnaire.³⁾

Extensive posterior decompression with instrumented fusion has traditionally been considered the standard surgical treatment for multilevel LFS, particularly when accompanied by deformity. However, this approach is associated with significant drawbacks, and its challenges are often magnified in patients with scoliosis. Fusion surgery is more invasive than decompression alone, with greater blood loss and longer hospital stays.^4,5) Furthermore, spinal fusion is recognized as a potential cause of adjacent segment disease, a late complication that can adversely affect long-term outcomes and necessitate additional surgical interventions.⁶⁾ There is also a notable risk of implant-related complications, with a recent multicenter study reporting that 2.6% of patients required reoperation for such issues.⁷⁾ These limitations highlight the need for alternative, less invasive surgical strategies that can effectively decompress the neural elements while minimizing iatrogenic injury and preserving spinal kinematics.

In response to these challenges, full-endoscopic spine surgery has emerged as a compelling, less invasive alternative.⁸⁾ The transforaminal approach is considered the least invasive spinal surgery because it can be performed under local anesthesia with minimal tissue trauma.^9,10) Specifically, transforaminal full-endoscopic lumbar foraminotomy (TF-FELF) allows for direct decompression of the nerve root while preserving the integrity of muscles and facet joints, thereby functioning as a motion-preserving surgery.¹⁰⁾ The ability to perform this procedure under local anesthesia significantly reduces the physiological burden on the patient and facilitates rapid recovery.¹¹⁾ This report describes the successful application of a staged TF-FELF approach in a patient with multilevel foraminal stenosis and significant degenerative scoliosis (Cobb angle 21°) who had high functional and occupational demands that precluded extensive fusion surgery.

Case Report

This report was prepared in accordance with the CARE guidelines, and all procedures complied with the ethical principles of the Declaration of Helsinki.

Patient information and patient's perspective

The patient was a 70-year-old man who presented with a 6-month history of progressive right leg radiculopathy, weakness, and paresthesia. As an orthopedic surgeon running his own private clinic, his professional responsibilities made it impossible for him to take an extended leave of absence for surgery and recovery. He was an avid golfer and expressed a strong desire to avoid spinal fusion to preserve mobility and increase the likelihood of returning to his sport. Therefore, a minimally invasive, staged treatment strategy with a rapid recovery profile was deemed essential.

Preoperative clinical and radiological findings

Clinical outcomes were assessed preoperatively and postoperatively using the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), the ODI, and a 100-mm visual analog scale (VAS) for pain and numbness. The final surgical outcome was evaluated using the Macnab criteria.

On physical examination, the patient was found to have significant atrophy of the right quadriceps muscle. Neurological testing revealed severe motor deficits consistent with L4 and L5 radiculopathy; the patient had foot drop on the right, with manual muscle test (MMT) grades of 4/5 for quadriceps, 2/5 for tibialis anterior, and 2/5 for extensor hallucis longus. Strength was 5/5 in the iliopsoas and 4/5 in the flexor hallucis longus. His preoperative ODI score was 12%, indicating mild functional disability. He rated the severity of his low back pain as 20 mm on a 100-mm VAS, his buttock and leg pain as 20 mm, and his buttock and leg numbness as 52 mm.

Radiographs revealed degenerative lumbar scoliosis with a main curve Cobb angle of 21°, measured between the superior endplate of L1 and the inferior endplate of L5, lumbar lordosis of 51°, and a pelvic incidence of 59° (Figure 1A). Magnetic resonance imaging and computed tomography (CT) confirmed severe bony foraminal stenosis on the right side at the L3/4, L4/5, and L5/S1 levels (Figure 1B-E). Furthermore, a coexisting far-lateral disc herniation was identified at the L5/S1 level, contributing to compression of the exiting L5 nerve root.

Figure 1

Preoperative radiological findings. (A) Anteroposterior radiograph of the lumbar spine showing degenerative scoliosis. (B) Sagittal T2-weighted magnetic resonance scan showing foraminal narrowing at the L3, L4, and L5 levels (arrowheads). (C-E) Axial T2-weighted magnetic resonance scans at the L3/4, L4/5, and L5/S1 levels, respectively, showing severe right-sided foraminal stenosis compressing the nerve roots.

Surgical technique

The procedure was performed with the patient in the prone position under conscious sedation and local anesthesia. The skin entry point was set 5-8 cm lateral to the midline based on preoperative imaging.

After creating a trajectory with local anesthetic, an 8-mm inner diameter working cannula was docked on the superior articular process (SAP). An endoscope was inserted, and under continuous irrigation, a high-speed drill was used to resect the ventral-cranial portion of the SAP. A partial resection of the inferior articular process was then performed to allow full visualization of the ligamentum flavum (LF).

Once exposed, the LF was detached from its remaining bony attachments with the drill. The freed LF and the coexisting disc herniation at L5/S1 were endoscopically removed (Figure 2A-F). After confirming nerve root mobilization and achieving hemostasis, the incision was closed with a single dermal suture. A detailed description of this technique has been published elsewhere.¹²⁾

Figure 2

Postoperative CT scans and intraoperative endoscopic views. Postoperative axial CT scans at L3/4 (A), L4/5 (B), and L5/S1 (C) showing significant enlargement of the right foramen after osseous decompression (arrows). Intraoperative endoscopic views at L3/4 (D), L4/5 (E), and L5/S1 (F) confirm that the corresponding nerve roots (L3, L4, and L5) were fully decompressed and visualized after foraminotomy.

CT: computed tomography; IAP: inferior articular process

Therapeutic intervention and postoperative course

The patient underwent three separate procedures, one level per session, under local anesthesia at 1-month intervals, targeting the L5/S1, L4/5, and L3/4 levels sequentially. The surgical order was prioritized based on the severity of neurological deficits. We first addressed the L5/S1 level, corresponding to the most severe symptom (foot drop, MMT 2/5). The subsequent procedures for L4/5 (quadriceps weakness, MMT 4/5) and L3/4 (sensory disturbance) followed. This 1-month interval allowed for neurological recovery assessment and accommodated the patient's professional schedule. Each procedure was completed within a 3-day (2-night) hospital stay. This staged approach perfectly matched the patient's demanding schedule; he managed his outpatient clinic in the morning, was admitted in the afternoon, underwent surgery the next day, and was discharged the following day to resume his clinic in the afternoon. This minimized clinic closure to only one day per procedure.

Dramatic neurological recovery was observed immediately after the first surgery at the L5/S1 level. The initial L5/S1 surgery resolved the foot drop, improving the MMT grades for tibialis anterior and extensor hallucis longus from 2/5 to 5/5, but the L4-related quadriceps weakness with an MMT of 4/5 and associated difficulty in climbing stairs persisted, justifying the L4/5 procedure. After the second surgery, his strength improved to an MMT of 4+/5. At this point, canceling the final L3/4 procedure would have been an option had his symptoms fully resolved. However, he still reported residual numbness in the anterior thigh, which was consistent with L3 radiculopathy, and this led to the final L3/4 procedure. This confirms that we addressed symptomatic stenosis at each stage rather than prophylactic decompression.

At the 3-month follow-up after the final procedure, the patient's neurological improvements, as detailed in Table 1, were maintained. His quadriceps strength had also recovered to 4+/5. His clinical recovery was accompanied by a marked improvement in functional status, as evidenced by a decrease in his ODI score from 12% to 8%. The clinical outcome was rated as "excellent" according to the Macnab criteria. Postoperative CT scans confirmed adequate decompression of the nerve roots at all three operated levels (Figure 3A and B). Follow-up standing X-rays at 3 months showed no significant progression of the scoliosis, with a postoperative Cobb angle of 18° (Figure 3C and D). The patient resumed playing golf 2 months after the final surgery, and at the 6-month follow-up, he reported a complete and pain-free return to his sport. The key clinical improvements are summarized in Table 1.

Table 1

Summary of Preoperative and 3-Month Postoperative Clinical Outcomes

Parameter	Preoperative	3-month postoperative
JOABPEQ: Japanese Orthopaedic Association Back Pain Evaluation Questionnaire; MMT: manual muscle test; ODI: Oswestry Disability Index; VAS: visual analog scale
JOABPEQ score
Pain-related disorders	42.9	71.4
Lumbar spine dysfunction	66.7	100
Gait dysfunction	92.9	100
Social life dysfunction	78.4	100
Psychological disorders	88.3	97.1
ODI	12%	8%
VAS score (0-100 mm)
Low back pain	20	5
Buttock/leg pain	20	0
Buttock/leg numbness	52	15
MMT grade (0-5), right leg and foot
Iliopsoas	5	5
Quadriceps	4	4+
Tibialis anterior	2	5
Extensor hallucis longus	2	5
Flexor hallucis longus	4	5
Macnab criteria	-	Excellent

Figure 3

Comparison of preoperative and postoperative sagittal CT images. (A) Preoperative sagittal CT image showing severe osseous foraminal stenosis at the L3, L4, and L5 levels (dotted outlines). (B) Postoperative sagittal CT image confirming significant enlargement of the foramina after resection of the superior articular processes (arrowheads), indicating successful decompression. (C) Postoperative 3-month standing anteroposterior X-ray. (D) Postoperative 3-month standing lateral X-ray.

CT: computed tomography

Discussion

This report demonstrates the clinical efficacy of a staged TF-FELF for multilevel foraminal stenosis complicated by scoliosis. The key findings were that this sequential, minimally invasive procedure not only led to dramatic neurological recovery and an excellent functional outcome, as evidenced by an "excellent" rating using the Macnab criteria and marked improvements across all domains of the JOABPEQ, but also caused minimal disruption to the patient's demanding professional schedule. By decompressing the neural elements effectively over three separate sessions under local anesthesia, this approach achieved clinical success comparable with that of more invasive options while avoiding the significant morbidity and extended recovery typically associated with extensive spinal fusion.

Staged strategy for effective decompression

This case demonstrates that staged, minimally invasive decompression can yield outcomes comparable with those of more extensive surgeries for multilevel foraminal stenosis. By separating the procedure into three sessions under local anesthesia, the cumulative surgical stress was minimized, allowing for interval recovery and marked neurological improvement. This successful application of a staged strategy is echoed in the literature, where similar approaches have resulted in good clinical outcomes.¹³⁾ Crucially, our results challenge the assumption that scoliosis necessitates fusion, as evidence suggests that endoscopic decompression is an effective treatment for stenosis even when deformity is present.¹⁴⁾ A recent meta-analysis found no significant difference between endoscopic foraminotomy and fusion surgery for foraminal stenosis in terms of clinical outcomes, but noted that endoscopy had the benefit of a shorter operation time.¹⁵⁾ Our findings reinforce this notion, suggesting that TF-FELF achieves good decompression while avoiding the morbidity associated with fusion.

This approach is not suitable for all cases of degenerative scoliosis. We believe this procedure is indicated for patients with (1) predominant radiculopathy rather than mechanical low back pain, (2) mild to moderate scoliosis (e.g., Cobb angle < 30°), and (3) no significant instability on dynamic radiographs. Conversely, cases with significant instability, progressive deformity, or predominant mechanical pain may be contraindications for decompression-alone surgery. Furthermore, it has been reported that decompression alone in segments with preserved disc height and lateral slip carries a higher risk of postoperative instability.⁵⁾ Our case had collapsed disc spaces, suggesting relative stability, which we considered a favorable factor for this motion-preserving approach. In our institution, TF-FELF under local anesthesia is typically limited to one or, at most, two levels per session to ensure patient comfort, manage total local anesthetic dosage, and maintain a reasonable operative time. For multilevel (three or more) symptomatic stenosis, we consider staged procedures.

Minimizing disruption to professional life

A key advantage of the strategy described here was the negligible impact on the patient's professional responsibilities. The patient's rapid return to work was facilitated by the combination of a minimally invasive endoscopic technique and local anesthesia, which minimizes postoperative pain and systemic stress. Our findings are consistent with previous reports demonstrating that prompt return to work (RTW) is a distinct benefit of this procedure.¹⁶⁾ The patient's recovery timeline outperformed the already impressive mean time until RTW of 5.8 days reported specifically for medical doctors undergoing similar endoscopic surgery.¹⁷⁾ By enabling an orthopedic surgeon to resume clinical practice almost immediately after each procedure, this case exemplifies how a staged, non-fusion approach can effectively eliminate the professional and financial downtime typically required after conventional spinal surgery.

This immediate return to professional duties, facilitated by avoiding the systemic impact of general anesthesia, was the primary advantage and the patient's key requirement.

Implications for patient-centered care

The significance of this case extends beyond its technical success, as it exemplifies the practical application of patient-centered care in complex spine surgery. Rather than defaulting to a standard extensive fusion based on multilevel pathology, our treatment strategy was guided by the patient's specific life circumstances, his professional responsibilities, and personal lifestyle goals. This reflects the core tenets of shared decision-making, which empowers patients to participate in preference-sensitive health decisions.¹⁸⁾ In this case, the strategy was determined using this approach. The patient, himself an orthopedic surgeon, strongly wished to avoid general anesthesia due to concerns about its invasiveness, such as endotracheal intubation. Furthermore, we believe that performing TF-FELF under local anesthesia in an awake and aware condition is inherently safer, as it allows for real-time intraoperative feedback from the patient, thereby minimizing the risk of nerve root injury.^19,20) Although a symptom-based approach was possible, the patient desired a complete resolution of symptoms from all responsible levels (L3, L4, and L5) to return to golf. Thus, a planned staged approach was chosen over a single-stage general anesthesia procedure to align with his medical preferences, safety considerations, and functional goals. This report illustrates how tailoring the surgical plan to the individual's values can lead to an outcome that is not only clinically effective but also preserves the patient's quality of life and socioeconomic functioning.

Limitations and future directions

The findings in this case must be interpreted with caution. We acknowledge that this staged approach was feasible because the patient's primary symptoms were motor deficit and numbness, with relatively mild leg pain (VAS 20 mm). Had the patient presented with intractable pain, a single-stage procedure, such as a multilevel decompression under general or local anesthesia, might have been prioritized. This specific presentation-predominant motor deficit over pain-should be considered a key factor in the successful application of this monthly staged strategy. Additionally, the 3-month radiological follow-up period is a significant limitation. This short duration was unavoidable as the patient resided far from our institution and was unable to make frequent visits due to his own clinic's demanding schedule. Although the long-term durability of this decompression and the risk of scoliosis progression require further observation, we confirmed via telephone interview at 6 months that the patient remains pain-free and has fully returned to his sport.

Conclusions

Staged transforaminal full-endoscopic lumbar foraminotomy under local anesthesia is a safe and highly effective strategy for treating multilevel foraminal stenosis, even when complicated by degenerative scoliosis. This patient-centric, non-fusion approach afforded excellent clinical and neurological recovery while minimizing disruption to a patient's professional and personal life. It therefore represents a compelling alternative to extensive fusion surgery.

Acknowledgments

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of Interest Disclosure

All authors have no conflict of interest.

Informed Consent

Written informed consent was obtained from the patient for the publication of this case report.

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