radicular back pain is an important public health issue that can result in long term disability and poor quality of life .
conservative therapy is the initial treatment of choice , but fails to provide relief in a substantial number of patients .
central and foraminal stenosis with entrapment of descending and/or exiting nerve roots is a common cause of radicular pain , with an estimated incidence of 8 to 11% 1 2 3 .
spinal stenosis of the thoracic vertebrae is less common than that of the cervical and lumbar regions . in our experience ,
patients tend to be older and are more commonly male . due to the close proximity to thoracic and abdominal organs
, open surgical operations can be difficult and carry a greater risk of complications due to the requirement of a transthoracic approach .
the most efficacious intervention for thoracic stenosis refractory to conservative management is uncertain at this time .
here we report on our experience with 12 patients diagnosed with thoracic radiculopathy due to central or foraminal stenosis treated with endoscopic laminoforaminoplasty via a small incision , of less than one inch .
twelve patients were treated with endoscopic laminoforaminoplasty ( elfp ) of the thoracic spine for radicular pain .
all patients were diagnosed with radicular pain involving the lower thoracic levels ( at or below t6 ) .
prior to surgery , all patients were treated with conservative therapy , including physical therapy and epidural steroid injections , which failed to provide adequate relief .
intravenous ( iv ) antibiotics were administered perioperatively ; cefazolin was used unless there was an allergy , in which case ciprofloxacin was substituted .
remifentanil and midazolam were the most commonly used sedating agents . utilizing fluoroscopy , the entry site was then determined and a 3/4-inch incision was made at a 30-degree angle to the vertebrae . through this incision ,
a guide wire was inserted down to the lamina of the stenotic vertebra . over this guide wire
a bullet system was inserted to dilate the tissues to a final diameter of 14.5 mm .
a 5 mm laparoscopy scope , with 3.2x magnification , was used to visualize the procedure .
pituitaries and kerrisons were then used to remove bulk tissues and bone to open up the spinal canal .
a standard burr with a 6 mm bit was used to remove bone and smooth the bony edges of the opening . a holmium
outcome measures were percent change from baseline in oswestry disability index ( oswestry ) and visual analog scale ( vas ) pain scores .
the author acknowledges that there are no conflicts of interest or financial benefits with the results of the study .
all twelve patients ( 10 males , 2 females ) completed the surgery without complication .
average age was 60.2 years ( range : 49 - 73 ) . at baseline ,
most patients reported moderate to disabling pain , with average scores of 6.7 and 24.75 on the vas and oswestry , respectively and the individual patient data is presented in table 1 .
utilizing the student 's t - test , the data was separated into pre and post surgical scores . even though the sample size is small
, the improvement is significant with a p value of 0.005 . with all patients ,
average follow - up scores were 2.9 and 12.08 on the vas and oswestry , respectively .
one patient with moderate symptoms , two with severe symptoms , and two with crippling symptoms did not report significant improvement on vas or oswestry . of the twelve patients , 8 had foraminal stenosis and 4 had central issues per both mri and surgical report .
thoracic radiculopathy is rare , as evidenced by the paucity of literature regarding the appropriate management of these patients . in our experience ,
patients with thoracic central and foraminal stenosis are more likely to be male , and tend to be of older age than patients with cervical or lumbar disease .
also , the stenosis tends to be foraminal and not central since 66% of patients had foraminal stenosis .
the correct surgical management of these patients is based largely on data regarding lumbar and cervical radiculopathy . however , in the thoracic vertebrae proximity to both thoracic and abdominal internal organs as well as prominent vascular and neural structures increases the risk of adverse events with invasive approaches .
open surgical correction is the current standard of care for foraminal stenosis of cervical and lumbar vertebrae .
open surgery requires a longer operative time , hospital stay , and postoperative recovery period and carries significant risks .
the anterior approach requires a transthoracic approach with close proximity to the major abdominal and thoracic organs and neurovasculature 4 , and posterior approaches require subperiosteal of the paraspinal muscles , which can result in increased pain and spasms 5 . as with any deeply invasive procedure , blood loss , infection , prolonged hospital stay , and postoperative pain are potential complications .
in contrast , interventions that are less invasive , such as endoscopic laminoforaminoplasty , should decrease the risk of major adverse events , allow for same day hospital discharge , and decrease the need for postoperative analgesia and immobility 5 6 . in the current study ,
at the same time , reports in the literature suggest similar patient outcomes to conventional open approaches 7 4 8 9 . in this study ,
7 of 12 patients ( 58.3% ) experienced noticeable improvement as evidence by decreased vas and oswestry scores at postoperative follow - up , results consistent with published data .
patients additionally benefit from a decrease risk of complications , short hospital stay , and faster recovery .
this approach should be considered in patients with simple thoracic radiculopathy due to central or foraminal stenosis who fail to benefit from conservative management .
finally , we do recommend that a larger study would be beneficial in confirming our data due to our small study group .
 background : spinal stenosis of the thoracic spine is less common than that of the cervical and lumbar regions . due to the close proximity to thoracic and abdominal organs , surgical operations can be difficult and carry a greater risk of complications . the most efficacious intervention for thoracic stenosis , whether central or foraminal , refractory to conservative management is uncertain . 
 we aimed to evaluate the efficacy of endoscopic laminoforaminoplasty ( elfp ) in the treatment of thoracic radiculopathy.methods : twelve patients with radicular pain involving the lower thoracic levels ( at or below t6 ) were treated with elfp.results : seven of twelve patients showed marked improvement in pain scores . 
 average follow - up scores were 2.9 and 12.08 on the visual analog scale ( vas ) and oswestry disability index , respectively . 
 the significance was 0.005 between the pre and post surgical data . 
 one patient with moderate symptoms , two with severe symptoms , and two with crippling symptoms did not report significant improvement on vas or oswestry . 
 no complications were encountered.conclusions : endoscopic laminoforaminoplasty offers an alternative to fusion or conventional laminotomy with similar success rates . 
 patients additionally benefit from a decrease risk of complications , short hospital stay , and faster recovery . 
Introduction
Materials and Methods
Results
Conclusions