Endoscopic transfacet Decompression for Severe Lumbar Spinal Stenosis: A Technical Note, Illustrative Clinical Series, and Surgeon Survey Regarding Post-Decompression Instability
Authors: Lewandrowski Kai-Uwe , Dowling Álvaro , Kim Choll , Kwon Brian , Ongulade John , Ito Kenyu , de Carvalho Paulo Sergio Terxeira , Lorio Morgan P. 
Published: January 2025

Background: Lumbar spinal stenosis (LSS) remains a predominant cause of debilitating back and leg pain, affecting many aging populations. Traditional decompression surgeries can be invasive and pose significant risks and recovery time. This study elucidates the techniques and preliminary outcomes of endoscopic transfacet decompression in treating severe LSS. Methods: A retrospective review was performed on 65 patients with severe LSS who underwent endoscopic transfacet decompression. The patient outcomes were analyzed using the VAS for leg pain and the modified Macnab criteria. Pre-operative and post-operative scores were compared, and any complications were analyzed. An online survey was administered to 868 surgeons using Likert-scale ratings to evaluate surgeons’ experience with endoscopic decompression in patients with painful spondylolisthesis. The survey responses were analyzed using descriptive statistics and Polytomous Rasch analysis to evaluate surgeon endorsement. Results: The study included 65 patients, of which 29 (44.6%) were female and 36 (55.4%) were male, with a mean age of 65.79 ranging from 38 to 84 years. The available mean post-operative follow-up period was 31.44 months, ranging from 24 to 39 months. The VAS score for leg pain reduced significantly from pre-operative 7.54 ± 1.67 to 2.20 ± 1.45 by 5.34 ± 2.03 (p < 0.001) with a large effect size (Cohen’s d = 2.626). At the final follow-up, functional Macnab outcomes were reported as excellent by 20 (30.8%), good by 37 (56.9%), fair by 5 (7.7%), and poor by 3 (4.6%) of patients. There were no incidental durotomies, nerve root injuries, wound complications, or instances of post-operative instability. Only five patients (7.7%) developed post-operative dysesthesia. Incomplete decompression led to fair and poor outcomes in 8 (12.3%) patients. No revision surgeries were performed. post-operative instability was not observed. The surgeon survey corroborated these observations, where the polytomous Rasch analysis showed consensus on the effectiveness of the percutaneous endoscopic decompression of low-grade spondylolisthesis. Differential item functioning (DIF) analysis showed no significant bias in item responses between orthopaedic and neurosurgeons. Conclusions: The endoscopic transfacet decompression technique delineated herein showcased excellent Macnab outcomes in managing severe LSS, with a combined success rate of 87.7%. Patients also experienced a statistically significant reduction in leg pain. Dysesthesia rates were lower than with the transforaminal approach, likely because of limited exiting and traversing nerve root manipulation. This technique might represent a viable, less invasive alternative to open microsurgical dissection and decompression for patients with severe LSS, where fusion may be required. This approach was found to be highly accepted among endoscopic spine surgeons.