Background:In spine surgery, biportal endoscopy (BE) is a minimally invasive approach for addressing a range of degenerative lumbar pathologies, including degenerative lumbar spondylolisthesis. The biportal technique benefits from the separation of the endoscopic viewing portal and the working portal for surgical tools, which facilitates an expanded visual field and greater operative flexibility1-3. BE enables both decompression and transforaminal lumbar interbody fusion (TLIF) within a single procedure4. Furthermore, integrating stereotactic navigation with BE enhances the precision of pedicle screw placement, decompression, intervertebral disc removal, end-plate preparation, and navigated cage insertion.5,6Description:After positioning the patient prone on a radiolucent table, the surgical field is prepared and draped in a sterile fashion. A reference pin is inserted into the iliac crest to facilitate stereotactic navigation. With use of this navigation, 2 separate 1.5 to 2-cm stab incisions are made just lateral to the cranial and caudal pedicles. The pedicles are probed and tapped in order to allow later pedicle screw fixation. Two additional skin incisions are made on the contralateral side, and percutaneous pedicle screw fixation is performed. A 30° arthroscope is introduced through the cranial incision, and a working portal is established through the caudal incision with use of a semitubular retractor. Irrigation is performed, typically set at 30 mmHg. Radiofrequency ablation is utilized to create a working space and to detach the paraspinal muscles from the underlying lamina, extending caudally into the interlaminar space and laterally to remove the facet joint capsule. Ipsilateral laminotomy or laminectomy is performed with a standard arthroscopic shaver and burr until the cranial insertion of the ligamentum flavum is visualized. Contralateral decompression is achieved by removing the ventral portion of the lamina above the ligamentum flavum, after which the ligamentum flavum is detached and removed. The ipsilateral facet joint is then removed with use of a burr and Kerrison rongeurs until the exiting nerve root is visualized and protected. An anulotomy is performed to access the disc space. End-plate preparation is conducted with use of stereotactic navigation and direct visualization through the endoscope. After trialing, an expandable cage is placed under direct visualization and navigation guidance. The endoscope is utilized to confirm the proper placement of the cage and to coagulate any epidural bleeding. Ipsilateral pedicle screws are placed with use of navigation, and rods are introduced under the fascia. Set screws are applied, and fluoroscopic images are obtained to verify the correct placement of implants.Alternatives:Surgical alternatives for degenerative lumbar spondylolisthesis include both open and tubular decompression, with or without fusion. Potential fusion techniques comprise open posterolateral fusion, open TLIF, microscopic tubular TLIF, anterior lumbar interbody fusion, and lateral lumbar interbody fusion.Rationale:BE TLIF is a minimally invasive procedure that limits osseous and soft-tissue damage and reduces postoperative pain and length of hospital stay compared with traditional open TLIF7-9. Multiple studies have demonstrated similar fusion rates with improved early visual analogue pain and Short Form-36 scores and decreased estimated blood loss for BE TLIF compared with microscopic tubular TLIF10-12. From a technical perspective, BE allows ultra-high magnification, which can assist with adequately decompressing the neural structures and providing direct visualization of end-plate preparation. BE also provides better ergonomics during surgery, as the surgeon is able to stand in a relaxed posture with the head upright and looking straight forward.Expected Outcomes:Long-term outcomes are similar between BE TLIF and microscopic tubular TLIF. However, Luan et al. reported that BE TLIF for lumbar degenerative diseases had the advantages of less intraoperative blood loss, less early postoperative low-back and leg pain, shorter length of hospital stay, and faster early functional recovery13.Important Tips:Gain experience with >50 biportal endoscopic decompression surgeries.Ensure proficiency in managing potential complications such as dural tears and postoperative epidural hematomas before starting TLIF surgery.Understand the stereotactic navigation systems to recognize and address discrepancies between on-screen guidance and actual cage insertion.Acronyms and Abbreviations:BE-TLIF = biportal endoscopic transforaminal lumbar interbody fusionMT-TLIF = microtubular transforaminal lumbar interbody fusionPSIS = posterior superior iliac spineSAP = superior articular processRFA = radiofrequency ablation

The "sandwich allograft" technique is indicated for correction of long-bone deformity in patients with osteogenesis imperfecta (OI) or another bone dysplasia. The external press-fit created by the large surface area of the allograft provides circumferential stabilization and introduces normal collagen to the long-bone nonunion site. Split allografts sandwich around the bone to promote stability and healing and to correct the deformity. This technique addresses the main issues in treating nonunion sites in patients with OI. First, osteogenesis has plateaued at the nonunion site, and this technique is osteoconductive. Second, traditional fixation techniques are not effective, as plates and screws do not achieve good fixation in brittle bone, and the circumferential fit of the allograft provides a different means of stabilization. Finally, the allograft bone is structurally stronger than the host OI bone. Careful patient selection and preoperative planning are critical to ordering allograft with the correct length and width, as well as the correct type of internal fixation. The nonunion site is exposed circumferentially, and the periosteum is elevated. In instances in which there is previous intramedullary fixation, the implant should be assessed for any migration or breakage, which would warrant removal. New intramedullary fixation is then performed to align the bone ends at the nonunion site. Fresh-frozen allograft was selected in the example case because it is thought to be more osteoinductive. The allograft is then halved longitudinally and its ends are contoured and trimmed. Allograft ends are also contoured to fit the fracture proximally and distally. The native bone is compressed at the nonunion as much as possible. The 2 allograft halves are then sandwiched on opposing sides of the nonunion site, surrounding the nonunion. They are held with use of a Verbrugge clamp and compressed with use of cortical screws. Finally, during closure, the previously elevated muscle envelope apposes the new construct. Nonoperative treatment of OI varies with the severity of the disease and the functional status of the patient1. Age should also be considered, as fractures occur most often in early childhood and fracture rates decline after the child reaches skeletal maturity2. Discontinuing contact sports and performing physical therapy and rehabilitation can help to both avoid and treat fractures. Operative treatment includes the insertion of intramedullary rods for fracture treatment and deformity correction. Rigid plate constructs are typically avoided to prevent osseous resorption from the stress shielding3. However, the use of a unicortical locking plate has been shown to be an effective supplement to intramedullary rod fixation4. Stabilization of fractures in patients with OI is challenging because of poor bone quality, which commonly results in nonunion. The traditional treatment of nonunion, which includes plates and screws, does not achieve good fixation in cases with brittle bone. This makes the allograft sandwich another treatment option with specific advantages for long-bone nonunion. The allograft sandwich procedure can successfully treat nonunion in patients with OI. Puvanesarajah et al. treated 13 nonunions with the allograft sandwich technique, with 12 nonunions healing during the study period2. The only nonunion for which treatment was unsuccessful did eventually show healing after 1 revision procedure. There were no infectious or neurologic complications reported in the cohort. Potential complications include refractures and screw prominence that may cause pain or irritation. The procedure is most applicable to treating nonunion of long-bone fractures in patients with low bone quality related to underlying disorders such as OI.Preoperative radiographs must be thoroughly evaluated for the extent of the nonunion, state of the implant from any previous fracture interventions, and nearby anatomic structures that can make fixation techniques challenging.The allograft sandwich should cradle most of, if not fully encircle, the nonunion site.At least 4 cm of the proximal and distal ends of the nonunion should be covered.Apposition of the fracture site may be challenging if the native bone has a small diameter. BMP = bone morphogenetic proteinIM = intramedullaryOI = osteogenesis imperfectaORIF = open reduction and internal fixation.

Seymour fractures are open, distal phalangeal physeal fractures with an associated nail-bed injury that occur in pediatric patients1. Although first described in the finger, an equivalent injury can occur in the distal phalanx of the great toe, often via a direct axial load at the apex of the toe, resulting in Salter-Harris type-I or II or juxta-epiphyseal fractures with a concomitant nail-bed laceration2-12. Closed reduction and splinting were initially recommended in these fractures1; however, they are now commonly treated with formal irrigation and debridement and the administration of prophylactic antibiotics in the acute setting in order to minimize the risk of complications such as infection10-12. To our knowledge, there are no detailed resources describing this surgical technique. With the patient in the supine position, a nonsterile tourniquet is applied, the operative foot is thoroughly cleansed and prepared in a sterile field, and the operative extremity is exsanguinated. A digital block is then administered. With use of blunt instruments, the nail plate is removed or lifted to allow visualization of the underlying structures. A lacerated nail bed, or germinal matrix, will likely be observed, appearing as a glistening and highly vascularized soft-tissue structure at the proximal end of the nail, responsible for nail growth. Small incisions near the extension creases of the distal interphalangeal joint may be required to retract the eponychial fold and inspect the laceration and fracture site. Next, thorough irrigation and debridement are performed to clean the fracture site and remove any contaminants or nonviable tissues. The fracture is then manually reduced under direct visualization, ensuring proper alignment of bone fragments. Any interposed soft tissue, such as the germinal matrix or periosteum, is extricated from the fracture site with use of fine instruments. If the fracture is deemed unstable, percutaneous pinning with 0.045-in or 0.062-in Kirschner wires is performed to stabilize the fracture. Kirschner wires are inserted through the skin and driven across the fracture site and distal interphalangeal joint. Appropriate placement of pins is confirmed on fluoroscopy, and the nail bed is repaired with use of absorbable sutures. In cases with gross contamination or osteomyelitis, it is prudent to avoid pin fixation. A sterile dressing is applied, and the foot is immobilized in a well-padded short-leg cast or splint to protect the fracture and pin and to maintain alignment. Postoperatively, the patient is given a short course of oral antibiotics (e.g., cephalosporin) to prevent infection. Radiographic images are obtained at the first regular follow-up appointment (within 1 week postoperatively), and the Kirschner wires are removed once sufficient healing has occurred (typically 4 to 6 weeks postoperatively). Alternative treatments include nonoperative treatment with thorough irrigation, antibiotic administration, and closed reduction. This technique provides direct visualization and reduction of the fracture, unlike closed reduction and splinting, which may result in re-displacement, nonunion, and inadequate stabilization. The ability to perform thorough irrigation and debridement reduces the risk of infection, a common complication in Seymour fractures, and enhances overall healing outcomes1. Percutaneous pinning with Kirschner wires provides superior stability compared with splinting or suture fixation alone, particularly in unstable or displaced fractures. Fixation with use of a Kirschner wire ensures that the fracture remains properly aligned throughout the healing process, preventing malunion and deformity. Compared with suture stabilization alone, this method offers better maintenance of reduction, especially in cases with substantial displacement or instability. Given these advantages, pin or Kirschner wire fixation is preferred in most cases, as it provides more reliable stabilization, minimizes the risk of complications, and improves overall healing outcomes. Patients are expected to have a high rate of successful recovery with minimal long-term sequelae, ensuring a return to normal function and cosmesis of the toe. Studies have shown that early and definitive surgical intervention significantly reduces the risk of complications, such as infection, growth arrest, malunion, and nail deformity2-12. In a cohort of patients undergoing this procedure, there were no occurrences of growth arrest or notable nail deformity during follow-up11. Baker et al. demonstrated that patients who underwent treatment within 48 hours had a significantly lower rate of osteomyelitis and other adverse outcomes12. Greater awareness of this fracture pattern can prevent delays in treatment and complications.Consider hyperflexion of the great toe to remove interposed tissue from the fracture site.Kirschner wires with a smaller diameter can be utilized if the phalangeal anatomy is small. K-wire = Kirschner wireI&D = irrigation and debridementDIP = distal interphalangeal jointAP = anteroposteriorMRI = magnetic resonance imaging.

Hip decompression effectively treats early-stage osteonecrosis of the femoral head (ONFH) by slowing disease progression and potentially delaying joint replacement. Biological adjuvants like bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) support bone regeneration and improve outcomes1-7. The present video article demonstrates a simple, coreless hip decompression technique with BMAC and PRP injection for early-stage ONFH. The procedure is performed in the same operating room setting as traditional core decompression, with the patient supine on a radiolucent table for fluoroscopic guidance. One or both legs are draped free for access to the iliac crests. Bone marrow is harvested percutaneously from the anterior superior iliac crest with a trocar needle kit, centrifuged, and prepared for injection. We recommend precoating needles and syringes with 1:1,000 heparin to prevent clotting. The BioCUE System (Zimmer Biomet) is typically utilized for centrifugation. Hip decompression is performed with use of a trocar and cannula (PerFuse System; Zimmer Biomet), with subsequent injection through the cannula into the femoral head. A 0.5-cm skin incision is made. The trocar is placed lateral to the femur and advanced percutaneously through the lateral femoral cortex, with a starting point proximal to the lesser trochanter. The trocar is then advanced along the femoral neck into the necrotic region by performing mallet strikes on the instrument's strike cap. Anteroposterior and frog-leg lateral views assist in positioning the trocar within the necrotic area. Internal leg rotation, which aligns the patella upward, helps position the trocar horizontally parallel to the floor. Positioning is adjusted using repeated imaging as needed. Once the patient is positioned, the trocar is removed, leaving the cannula in place. With the cannula retracted 1 cm, a 30-mL syringe is utilized to inject BMAC and PRP into the necrotic lesion. Because of sclerotic resistance, substantial pressure is needed, but retraction of the cannula helps. Following injection, the cannula is withdrawn another 1 cm, and demineralized bone matrix is injected to prevent escape of the BMAC. Alternative treatments for ONFH include traditional core decompression with a sliding hip screw drill or an X-REAM device (Stryker), both of which carry a higher risk of fracture because of the larger diameter of the tract and require limited weightbearing postoperatively. Bone-cement injection can stabilize the femoral head but lacks regenerative properties. Core decompression with either BMAC or PRP alone, rather than in combination, also serves as an alternative treatment strategy. Open approaches, like osteotomy, are more invasive, have longer recovery times, and may complicate future hip arthroplasty if unsuccessful. This technique enables minimally invasive hip decompression and delivery of adjuvant cell therapy or grafting, typically without the use of power instruments. This approach avoids the risk of injuring the bone due to the heat from power tools, protecting the BMAC injection site. Patients are generally discharged the same day and permitted full weight-bearing immediately, even in bilateral surgeries. Hip decompression for ONFH has shown variable rates of success8,9, but adding BMAC or PRP may improve outcomes1-3. Houdek et al. reported that among 35 hips treated with decompression plus BMAC and PRP for corticosteroid-induced ONFH, 88% avoided THA at 3 years2 and 70%, at 7 years3. Patients with grade-1 or 2 Kerboul angles had a 90% survivorship rate, underscoring the benefits of BMAC and PRP. Insert the trocar into the lateral cortex, positioned distal to the vastus ridge and proximal to the lesser trochanter, to reduce iatrogenic subtrochanteric fracture risk.Avoid advancing closer than 5 mm to the subchondral cortex to prevent joint-surface disruption or collapse, especially with eccentric lesions.If resistance occurs during injection, retract the cannula a few millimeters laterally to increase delivery space and reduce pressure. BMAC = bone marrow aspirate concentrateONFH = osteonecrosis of the femoral headPRP = platelet-rich plasmaAP = anteroposteriorTHA = total hip arthroplastyARCO = Association Research Circulation Osseous classificationMRI = magnetic resonance imaging.

Percutaneous transforaminal endoscopic discectomy (PTED) is a minimally invasive technique for the treatment of symptomatic lumbar disc herniation (LDH) that is growing in popularity. The procedure involves the insertion of a transforaminal spinal endoscope for direct access and removal of intra and extra-foraminal disc fragments1. The patient is preferably placed in a prone position. A spinal needle is advanced under fluoroscopic guidance into the foramen to the medial border of the inferior pedicle. A guidewire is introduced through the needle cannula, and sequential dilators are advanced into the foramen. A partial facetectomy/foraminotomy is performed so that a 10-mm working cannula and spinal endoscope can be introduced. Endoscopic pituitary rongeurs are utilized to remove the extruded disc material. Once the extruded fragments are no longer visualized, a probe is utilized to verify that no remaining disc material is present, and a diagnostic endoscopy is performed. The cannula is removed, and the incision is closed in a standard fashion. Nonoperative alternatives to PTED include activity modification, nonsteroidal anti-inflammatory drugs and/or acetaminophen, physical therapy, and epidural steroid injections2. When surgical intervention is indicated, alternative techniques for decompression include conventional microdiscectomy, tubular microdiscectomy, and unilateral biportal endoscopic discectomy3, as well as lumbar fusion techniques. PTED shares similar indications as open and tubular discectomy, including soft LDH confirmed on imaging, persistent radiculopathy, new sensory/motor neurologic deficits, and failed nonoperative treatment of >6 weeks1. Compared with open and tubular discectomy, PTED offers several advantages, including a smaller skin incision, feasibility under local anesthesia, direct visualization, avoidance of muscle retraction, minimal bone removal and neural manipulation, preservation of spine stability and adjacent anatomy, decreased intraoperative blood loss, and shorter operative times4-11. In patients with a far lateral or foraminal LDH, PTED may avoid the need for fusion12. Considerations for PTED include the narrow working corridor, representing a risk of iatrogenic injury or incomplete decompression, and the associated learning curve13,14. Relative contraindications include recurrent LDH, paracentral LDH, extruded LDH, sequestration of the disc, significant obesity, isthmic spondylolisthesis, and severe canal stenosis11. Additionally, accessing the lower lumbar levels via a transforaminal approach may be difficult in patients with a high iliac crest. PTED is a safe procedure that has been shown to improve patient-reported outcomes and functional status. In a recent meta-analysis, Gadjradj et al. reported a pooled complication rate of 4.6% (range, 0% to 8.6%) for PTED8. Hoogland et al. reported 85% excellent/good satisfaction in patients who underwent PTED, compared with 8% poor satisfaction, as well as improvements in visual analogue scale back and leg pain scores of 6.0 and 5.6, respectively, at 2-year follow-up. Chen et al. found that PTED resulted in similar patient-reported outcomes with similar rates of complications, recurrence, and reoperation and shorter in-bed times and lengths of stay compared with open discectomy5. The exiting nerve root is at risk during the approach. The foramen is entered at the furthest point from the nerve root by targeting the superior-most portion of the inferior pedicle (anteroposterior view) and the posterior-inferior corner of the disc (lateral view).For procedures performed with the patient under awake anesthesia, the patient should be monitored for nerve-root injury by asking them to report pain and move their feet. When a patient is fully anesthetized, neuromonitoring should be utilized. Neuromonitoring is especially important to remove fragments in difficult-to-access locations.Because of the narrow corridor, it may be difficult to confirm full decompression. Thoroughly reviewing the patient imaging to understand the fragment location is necessary. Postoperatively, it is important to evaluate patients to identify cases of incomplete decompression.The dorsal root ganglion is sensitive to irritation. Prior to closure, we irrigate the working cannula with a steroidal solution.The learning curve for PTED has been shown to be 31 cases, which is longer than traditional microdiscectomy techniques14. PTED = percutaneous transforaminal endoscopic discectomyLDH = lumbar disc herniationAP = anteroposteriorPSH = past surgical historyMRI = magnetic resonance imagingOR = operating roomPACU = post-anesthesia care unit.

Endoscopic decompression of lumbar spinal stenosis has been gaining popularity as the least invasive of several minimally invasive surgical treatment options. This procedure offers similar outcomes to those of conventional open procedures; however, endoscopic procedures are technically demanding and involve a substantial learning curve. The typical endoscopic approach is a "uni-portal" approach that utilizes a special spinal endoscope and endoscopic instruments. However, a "bi-portal" approach has been developed more recently, which utilizes a regular arthroscope and the same type of instruments that are utilized in open spine surgery. The patient is placed in a prone position under general anesthesia with electromyographic neuromonitoring. The primary portal is made at the interlaminar space with use of an obturator and a working cannula. The side of the approach is chosen according to the side of symptoms and radiographic compression. A 15°-angle, 10-mm external diameter spinal endoscope is introduced through the cannula, and the interlaminar space is exposed with use of a radiofrequency bipolar probe. Cranial and caudal laminectomies are performed with use of a 5-mm endoscopic high-speed burr or endoscopic osteotomes. A 5- to 7-mm accessory portal can be created 2 to 2.5 cm caudally (for the left side) or cranially (for the right side) on the same line as the primary portal in order to enable use of a short-distance dissector, curets, and/or osteotomes. Decompression is performed at the central and ipsilateral lateral recess with use of an endoscopic drill, various sizes of Kerrison rongeurs, and curets. Finally, the contralateral lateral recess is accessed by tilting the working cannula, and decompression is performed until the contralateral traversing nerve root and medial border of the caudal pedicle are exposed. Alternative surgical treatments include conventional open microscopic laminectomy and decompression and other minimally invasive surgical options involving the use of a tubular retractor or similar minimally invasive retractor systems. The development of endoscopic spine surgery has expanded indications from simple lumbar discectomy to lumbar central, foraminal, and extraforaminal stenosis, as well as revision surgery. However, the endoscopic approach to lumbar spinal stenosis is challenging and has not been widely adopted because of the steep learning curve and technical difficulty. A fully endoscopic, uni-portal approach is the least invasive option for lumbar decompression because all access and decompression procedures are performed within the limited space inside the working cannula. However, this "full-endoscopic" approach may limit the access angle to the surgical field because the working channel is fixed by the trajectory of the endoscope. Also, spinal endoscope-specific, long, small-diameter instruments are needed for use in the long, narrow endoscopic working channel. In contrast, an arthroscopic bi-portal approach enables the use of a regular arthroscope and surgical instruments. This approach offers variable working angles and the versatility of various shorter- and larger-diameter instruments, which can make the procedure more efficient, similar to open surgeries. However, a bi-portal approach requires the creation of a separate working portal because the arthroscopic portal does not have a working channel in it. Also, more soft-tissue dissection is needed to create a submuscular working space. Uni-portal and bi-portal approaches can be combined as needed to take advantage of both options. Compared with open surgery or other minimally invasive surgical approaches to lumbar spinal stenosis, the mid- and long-term clinical outcomes and complication rates are similar or identical. Endoscopic decompression provides superior short-term outcomes in terms of back pain (as measured on a visual analog scale), duration of hospital stay, and return to work. The main disadvantage is the technical difficulty of the approach. For a left-side approach, the main portal is made on the lower border of the cranial lamina on a fluoroscopic anteroposterior view. An accessory portal can be made on the vertical line over the primary portal, approximately 2 to 2.5 cm caudal. For a right-side approach, the main portal is on the upper border of the caudal lamina, and the accessory portal is approximately 1 inch cranial (if the surgeon is right-handed). The accessory portal enables the use of various short, strong instruments and expedites the procedure compared with the fully endoscopic uni-portal approach.Irrigation hydrostatic pressure provides natural dura retraction and some bleeding control in muscles, the bone surface, and the epidural space. In general, the pressure is set to 45 mmHg.Bleeding control is one of the time-limiting factors. Before creating the portal(s), injection of 20 to 30 mL of 0.25% bupivacaine with epinephrine 1:100,000 around the facet joint and cranial and caudal laminae can minimize muscle bleeding. Bone surface bleeding from drilling can be controlled through the use of radiofrequency bipolar cautery, bone wax, and low-speed reverse-direction drilling over the cancellous bleeding foci. BMI = body mass indexCT = computed tomographyEQ5D = EuroQol-5 DimensionMRI = magnetic resonance imagingODI = Oswestry Disability IndexVAS = visual analog scaleOR = operating roomAP = anteroposteriorPO = postoperative.

The present video article describes transforaminal lumbar interbody fusion (TLIF), a common spine procedure, performed with use of a less common technique-utilizing a biportal endoscopic spine surgery (BESS) approach. This procedure is performed for the treatment of degenerative spondylolisthesis. The procedure is performed with the patient in the supine position. An endoscopic portal and a working portal are developed at the level of interest. Fluid is pumped into the working space with use of a standard arthroscopy tower. Using the camera endoscope to visualize; shavers, burrs, and a Kerrison rongeur are passed through the working portal to clear the disc and to create space for insertion of an interbody device. Trial TLIF cages are placed through the disc defect, which can be observed both directly and on radiograph. An appropriate final implant is placed, and percutaneous pedicle screws are typically placed at the instrumented level. Alternatives include nonoperative treatment with physical therapy, weight loss, and/or corticosteroid injection. Surgical options for degenerative spondylolisthesis include lumbar decompression and instrumented fusion. Interbody fusion can provide indirect decompression and increase fusion success rates. This procedure utilizes a minimally invasive endoscopic approach with small incisions, resulting in decreased muscle trauma, which has been shown to reduce postoperative pain and recovery time. Outcomes of the biportal endoscopic technique are similar to those reported for open or conventional TLIF, with the benefit of improved postoperative pain compared with those procedures. Position the patient on a Jackson frame with hip and thigh pads to maintain lordosis for the fusion procedure.Utilize fluoroscopic guidance when determining starting points. The goal is for the portals to be centered over the ipsilateral pedicles of the targeted level.It is best to maintain the camera portal in your non-dominant hand and the working portal in your dominant hand.Stand on the side that the patient reports has worse pain.When dissecting, there is no need to go to the lateral edge of the facet; going further can result in excessive bleeding and decreased visualization. BESS = biportal endoscopic spine surgeryTLIF = transforaminal lumbar interbody fusionMRI = Magnetic Resonance ImagingPEEK = polyetheretherketoneK-wire = Kirschner wireCT = computed tomographyPROM = patient-reported outcome measureVAS = visual analog scaleODI = Oswestry Disability Index.