A 70-year-old man with severe pulmonary comorbidities was referred to our institution for treatment of a right L5 nerve impingement. He had suffered from spinal canal stenosis and herniated nucleus pulposus (HNP) at the level of L4-L5 for more than a year and had been treated conservatively. However, the pain could not be alleviated, and his primary care physician scheduled posterior decompression surgery. During this procedure, the anesthesiologist refused to induce general anesthesia because of the patient's very poor pulmonary condition. Subsequently, the patient was referred to us. We used a transforaminal approach with percutaneous endoscopic discectomy, with the patient under local anesthesia. First, herniated nucleus pulposus fragments at the disc level were removed. With a trephine drill, the upper part of the L5 pedicle was removed, which allowed for the extraction of dorsally migrated fragments. Following complete removal of the herniated nucleus pulposus fragments, osseous decompression was performed. The osseous endplate of L5 (anterior part of the lateral recess) was removed to enlarge the lateral recess so that decompression of the L5 nerve root was possible. The patient's lower back pain and right leg pain subsided following surgery. Percutaneous endoscopic discectomy is useful for patients with severe comorbidities as it can be done with local anesthesia.

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A 39-year-old man presented with an extremely rare discal cyst at the L3-4 level manifesting as a left L4 radiculopathy. Two months after onset, he suffered right L4 radiculopathy with new lumbar disc protrusion. Five months after medical treatment, the patient's symptoms improved, and the discal cyst showed complete regression on magnetic resonance imaging. Most cases of discal cyst are surgically treated, with only two previous cases of spontaneous regression. The present case suggests clinical and radiological recovery of symptomatic lumbar discal cyst can be obtained by only conservative therapy.

Transforaminal lumbar interbody fusion (TLIF) procedure is widely used, but the surgical indications for TLIF in elderly patients remain controversial because of potential risks such as inferior bone quality and higher rate of postoperative complications. Clinical efficacy and operative risk of TLIF in elderly patients are unclear. This study investigated the clinical effect and safety of TLIF for lumbar degenerative spondylolisthesis with radiculopathy or neurogenic claudication in patients aged 70 years or older. The clinical records were retrospectively reviewed of 35 consecutive patients aged 70-86 years (mean 74.8 years) who underwent one or two-level TLIF. The preoperative diagnosis included degenerative spondylolisthesis with segmental instability. Clinical outcomes were assessed by the Japanese Orthopaedic Association score, visual analogue scale, Oswestry Disability Index. Radiological fusion rate was also investigated. Clinical and radiological results were compared with those of 43 younger patients. Clinical outcome measures were significantly improved after operation in the elderly patients, but improvement rates were significantly lower than those of younger patients. Fusion rate was similar in both groups. Overall postoperative complications were increased in aged patients, although the prevalence of complications directly related to surgical technique was not significantly increased. Postoperative complications not related to the surgical procedure were factors affecting poor results. TLIF is acceptable for achieving clinical recovery and lumbar fusion with high radiographic fusion success even in elderly patients, although clinical benefits were limited compared with those of younger patients. Postoperative morbidity was mainly related to general or non-operative site complications.

Herniated nucleus pulposus (HNP) in the lumbar spine is usually found in the neural canal (in the intracanal space) and occasionally in the extracanal space, where it is known as a lateral HNP. HNP is rarely found simultaneously in both spaces. However, we experienced such a case in a 48-year-old man who presented with right leg pain and lower back pain that had lasted for more than a year. MRI revealed HNP in both the right intracanal and extracanal spaces at L2-L3. A transforaminal approach was used to complete a percutaneous endoscopic discectomy. An 8-mm incision was made with the patient under local anesthesia, and the percutaneous endoscope was inserted at the affected disc space. First, the HNP fragments in the intracanal space were removed, and then the cannula and endoscope were extracted to the extracanal space where the extracanal fragments were removed. Two hours after the surgery, the patient stood and walked. Right leg pain and lower back pain had disappeared. Unlike other techniques such as Love's procedure and the microendoscopic discectomy technique, the use of a transforaminal approach with the percutaneous endoscopic technique enables the HNP fragments in the intracanal and extracanal spaces to be removed at the same time with a single approach.