This case report and video demonstrate the technique of full-endoscopic J-shaped transforaminal L5 exiting nerve decompression in Bertolotti syndrome. Bertolotti syndrome, characterized by a congenital lumbosacral transitional vertebra, often results in mechanical lower back pain and nerve root compression. A 69-year-old male presented with progressive radiating pain in the right leg and tingling in the L5 dermatome. Lumbar spine MRI revealed a right foraminal disc herniation at the L5–S1 level, with calcification and foraminal stenosis. The patient was also diagnosed with Castellvi type I Bertolotti syndrome, featuring a large L5 transverse process and a high iliac crest. These anatomical variations complicated the transforaminal approach, creating a narrow safety zone for conventional methods. The approach began with docking on the L5 transverse process. Endoscopic drilling was performed in a J-shaped configuration to partially resect the transverse process and alar wing, facilitating endoscope insertion into Kambin’s triangle. Foraminal decompression was achieved by removing the tip of the superior articular process (SAP), thereby decompressing the L5 exiting nerve root. Full-endoscopic spine surgery offers a safe and effective alternative to traditional open techniques for L5 nerve decompression in Bertolotti syndrome. This video presentation illustrates the intraoperative endoscopic approach, detailing the decompression techniques and highlighting the minimally invasive advantages of this method.
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Objective To present an innovative, modified endoscopic approach for foraminal/extraforaminal pathologies, to reduce postoperative dysesthesia (POD) following the conventional transforaminal endoscopic approach (the access angle more than 45° from the midline), since POD is one of the major documented disadvantages that may compromise patient satisfaction.
Methods We introduce a modified posterolateral technique, termed the intertransverse approach, utilizing a steeper access angle less than 25° through the intertransversarii muscle and the intertransverse space with expanding Kambin triangle via lateral facetectomy/foraminoplasty, to reduce dorsal root ganglion/exiting nerve root irritation under direct visualization and lower the incidence of POD. Consecutive patients undergoing endoscopic spine surgery via the intertransverse approach for foraminal and/or extraforaminal disc herniations or bony stenosis were retrospectively reviewed. Clinical outcomes were reviewed with the primary outcome being POD.
Results Twenty-two patients were included in the review. Patients showed significantly improved clinical outcomes (visual analogue scale leg and back pain and Oswestry Disability Index) postoperatively. There was a low rate of dorsal root ganglion (DRG)-related POD (9.1%, 2 of 22) that was minimal and resolved soon.
Conclusion The inter-transverse endoscopic approach is feasible for lumbosacral foraminal and extraforaminal decompression with significantly improved clinical outcomes and the added advantage of a low rate of DRG-related POD compared to traditionally reported rates in the literature for the conventional transforaminal approach.
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