Search Results (140)

Background/Objectives: Adult degenerative scoliosis (ADS) is a spinal disease causing pain and reduced mobility, often occurring with degenerative lumbar spinal stenosis (DLSS). While fusion stabilizes the spine, it has drawbacks like loss of motion and adjacent segment degeneration. Minimally invasive techniques, such as tubular unilateral laminotomy for bilateral decompression (tULBD), provide a less invasive alternative, but their impact on ADS with DLSS is underexplored. This study examines the short-term effects of navigated tULBD on radiological and clinical outcomes in this patient population. Methods: This retrospective single-center study analyzed patients aged ≥18 years with DLSS and ADS (Cobb angle ≥ 10°), with or without grade I spondylolisthesis, who underwent navigated tULBD between June 2019 and October 2022. Radiological parameters were assessed pre- and post-operatively using AI-powered FXA™ Version 1.33, Raylytic Software GmbH, Leipzig, Germany, while clinical outcomes were evaluated using the Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain. Statistical analyses were conducted with R Studio. Results: This study included 20 patients (mean age 74.6 ± 7.6 years, body mass index [BMI] 26.08 ± 3.7 kg/m²), with a median follow-up of 2 months. Most underwent single-level decompression (45%), with a median of 2 surgical levels (IQR: 1–3). Radiological parameters showed no significant changes (p > 0.05). Clinically, the median NRS back improved from 5 (IQR: 3–9) preoperatively to 2 (IQR: 0–2) postoperatively (p = 0.009) and 1 (IQR: 0–4.5) at follow-up (p = 0.004). NRS leg scores dropped from 3.5 (IQR: 0–5) to 0 postoperatively and at follow-up (p = 0.02, p = 0.04). ODI improved from 37.8 (IQR: 29–42.5) preoperatively to 17.5 (IQR: 5–24) at follow-up (p = 0.04). There were no neurological complications. Conclusions: Navigated tULBD is a promising, minimally invasive option for mild ADS and DLSS. It provides significant pain and disability relief without adversely affecting stability and alignment. Long-term studies are needed to confirm durability and efficacy, particularly in severe cases. Full article

Low-back pain (LBP) is a leading cause of disability worldwide. When symptoms persist beyond 4–6 weeks, when red flags are suspected, or when precise patient selection for procedures is needed, imaging—primarily MRI (Magnetic Resonance Imaging)—becomes pivotal. The purpose is to provide a pragmatic, radiology-first roadmap that aligns an imaging phenotype with anatomical targets and appropriate image-guided interventions, integrating MRI-based phenotyping with image-guided interventions for subacute and chronic LBP. In this narrative review, we define operational MRI criteria to distinguish radicular from non-radicular phenotypes and to contextualize endplate/Modic and facet/sacroiliac degenerative changes. We then summarize selection and technique for major procedures: epidural and periradicular injections (including selective nerve root blocks), facet interventions with medial branch radiofrequency ablation (RFA), sacroiliac joint injections and lateral branch RFA, basivertebral nerve ablation (BVNA) for vertebrogenic pain, percutaneous disc decompression, minimally invasive lumbar decompression (MILD), and vertebral augmentation for painful fractures. For each target, we outline preferred and alternative guidance modalities (fluoroscopy, CT, or ultrasound), key safety checks, and realistic effect sizes and durability, emphasizing when to avoid low-value or poorly indicated procedures. This review proposes a phenotype-driven reporting template and a care-pathway table linking MRI patterns to diagnostic blocks and definitive image-guided treatments, with the aim of reducing cascade testing and therapeutic ambiguity. A standardized phenotype → target → tool approach can make MRI reports more actionable and help clinicians choose the right image-guided intervention for the right patient, improving outcomes while prioritizing safety and value. Full article

Background/Objective: Oblique lumbar interbody fusion (OLIF) achieves indirect decompression through restoration of disc height. Because maintenance of the restored disc space is essential for sustained neural decompression, solid fusion without cage subsidence is a key determinant of successful surgical outcomes. This study aimed to evaluate preoperative and intraoperative predictors of cage subsidence and radiographic fusion after OLIF. Methods: Seventy patients (119 levels) who underwent OLIF using a polyether–ether–ketone cage and posterior screw fixation between 2015 and 2023 were retrospectively reviewed. Preoperative bone quality was assessed using the computed tomography-based Hounsfield unit (HU) and magnetic resonance imaging-based vertebral bone quality (VBQ) score on T1-weighted images. Radiographic parameters of anterior and posterior disc height (ADH, PDH), segmental and lumbar lordotic angle (SLA, LLA), foraminal height (FH), and cage position were measured preoperatively at one-year follow-up. Results: Cage subsidence occurred in 21.0% of spinal levels (25/119 levels). Multivariate analysis identified these measures as independent predictors: HU (OR 1.017; p = 0.012), VBQ score (OR 2.716; p = 0.016), and PDH distraction (OR 1.418; p = 0.019). ROC analysis identified cutoff values of HU < 145.86 (AUC = 0.654), VBQ score > 3.30 (AUC = 0.723), and PDH distraction > 4.79 mm (AUC = 0.672). None of the evaluated factors were significantly associated with one-year radiographic fusion. Conclusions: Lower HU, higher VBQ score, and excessive PDH distraction are independent risk factors for cage subsidence after OLIF, although these factors do not appear to affect short-term fusion outcomes. Full article

Background/Objectives: Spinal decompression surgery shows variable outcomes, with reoperation rates up to 37.5%. Surgeons lack objective intraoperative tools to assess decompression adequacy. Mechanomyography (MMG) measures nerve excitability through mechanical muscle responses to electrical stimulation. While compressed nerves require higher stimulation thresholds, optimal quantification approaches remain undefined. We explored associations between intraoperative MMG threshold changes and six-week pain outcomes, comparing metrics anchored to a 2.0 mA reference threshold versus percentage-based measures. Methods: Prospective exploratory pilot study of 42 patients (112 nerves) undergoing lumbar or cervical decompression. MMG thresholds were recorded pre- and post-decompression. Numeric Pain Scale scores were obtained preoperatively and at six weeks. Three metrics were compared: percentage change, Threshold Reduction Ratio (TRR; measuring proportion of threshold elevation above 2.0 mA eliminated by decompression), and Threshold Excess (TE; residual threshold remaining above 2.0 mA), with TRR and TE anchored to 2.0 mA based on published normal ranges. Results: Among 40 patients with baseline pain, threshold-anchored metrics showed substantially stronger correlations with pain improvement than percentage-based measures (TRR: r = 0.656, p < 0.001 vs. percentage: r = 0.397, p = 0.011). Threshold Excess was associated with a linear dose–response: each 1 mA above 2.0 mA corresponded to 6.3% less pain improvement (p = 0.001). Patients achieving ≤2.0 mA had 6.1-fold increased odds of complete pain relief versus those above 2.0 mA (76.5% vs. 34.8%, p = 0.013). Internal leave-one-out cross-validation suggested internal stability (TRR shrinkage ≈ 9.3%; TE’s dose–response slope remained stable). Conclusions: In this exploratory pilot study, threshold-anchored MMG metrics (TRR and TE) showed stronger correlations with early pain outcomes than percentage-based measures. These exploratory findings require external validation in independent cohorts before clinical implementation. If validated prospectively, these metrics could provide objective, real-time feedback for clinical interpretation to inform surgical decision-making during spinal decompression, enabling surgeons to tailor decompression to individual physiology rather than relying on standardized anatomical criteria. Future work should explore patient-specific threshold targets that account for age, chronicity, and comorbidities. Full article

Open posterior lumbar surgery involves detaching paraspinal muscles from the spine to decompress neural tissues and to place instruments. While this operation improves the quality of life, it often has adverse effects on skeletal muscles like inflammation, degeneration, and fibrosis. Corticosteroids are well known for their anti-inflammatory function. In this study, we assessed the protective effects of intramuscular injection of corticosteroid on injured paraspinal muscles following surgery on the spine. C2C12 cells were co-exposed to hypoxia and lipopolysaccharide (LPS) to simulate ischemia and inflammatory response after muscle retraction to assess the effect of steroid. In vivo experiment, animals first underwent paraspinous muscle splitting with retractors to induce muscle injury, and later were assessed for neurobehavior, electrophysiology, and protein level related to inflammatory or regeneration following intramuscular (IM) steroid injection. Steroid rescued reduced cell viability caused by hypoxia + LPS, and attenuated induced protein expression of iNOS, COX2, Bad, and Bax. In neurobehavioral assessments (CatWalk, Ethovision, Von Frey test, and open field locomotor), retraction of paraspinous muscles worsened behaviors that were improved by IM steroid injections. The electrophysiology study showed that IM steroid injection lessened the muscle denervation caused by retraction. Similarly, IM steroid injections also attenuated dorsal root ganglion antigenicity of CGRP, Iba-1, and CD68 induced by muscle retraction. Muscle retraction downregulated AChR, desmin, PSD 95, and GAP 43, whereas IM steroid injection attenuated the adverse effects. The restoration of muscle morphology and decreased fibrosis were also facilitated by IM dexamethasone. IM steroid injection appears to protect against retraction damage in paraspinous muscle following spinal surgery. IM steroid paraspinous muscle injection may provide beneficial effects in spinal operations. Full article

Background/Objectives: Spinal fusion with static fixation—surgically joining two or more vertebrae to eliminate motion—is commonly employed to treat degenerative spinal disease. However, the rigidity imposed by static constructs and the increased load on the adjacent segments frequently result in complications such as disc or facet degeneration, spinal stenosis (SS), and segmental instability. This study investigates the effectiveness of pedicle-based dynamic stabilization using the Dynesys system, particularly in a dynamic-transitional optima (DTO) hybrid configuration, in mitigating adjacent segment disease (ASD) and improving clinical outcomes. In this work, we analyzed the mechanical performance and intermediate-term clinical effects of the DTO hybrid lumbar device, focusing on how the load-sharing properties of the Dynesys cord–spacer stabilizers may contribute to junctional complications in individuals with diverse grades of intervertebral disc degeneration. Study Design/Setting: We designed a combined biomechanical finite element (FE) and experimental analysis to predict the clinical outcomes. Patient Sample: Among 115 patients with lumbar SS enrolled for analysis, 31 patients (mean age: 68.5 ± 7.5 years), with or without grade I spondylolisthesis (18/13), underwent a two-level DTO hybrid procedure—L4–L5 static fixation and L3–L4 dynamic stabilization—with minimal decompression to preserve the posterior tension band. Post-surgical follow-ups were conducted for over 48 months (range: 49–82). Outcome Measures: Radiological assessments were performed by two neurosurgeons, one orthopedic surgeon, and one neuroradiologist. The posterior disc height, listhesis distance, and dynamic angular changes were measured pre- and postoperatively to evaluate ASD progression. Methods: Dynamic instrumentation was assigned to the L3–L4 motion segment with lesser disc deterioration, in contrast to the L4–L5 segment, where static fixation was applied due to its greater degree of degeneration. FE analysis was performed under displacement-controlled conditions. Intersegmental motion analysis was conducted under load-controlled conditions in a synthetic model. Results: The DTO hybrid devices reduced stress and motion at the transition segment. However, compensatory biomechanical effects were more pronounced at the adjacent cephalad than the caudal segments. In the biomechanical trade-off zone—where balance between motion preservation and stabilization is critical—the flexible Dynesys cord significantly mitigated stiffness-related issues during flexion. At the L3–L4 transition level, the cord–spacer configuration enhanced dynamic function, increasing motion by 2.7% (rotation) and 12.7% (flexion), reducing disc stress by 4.1% (flexion) and 12.9% (extension), and decreasing the facet contact forces by 4.9% (rotation) and 15.6% (extension). The optimal cord stiffness (50–200 N/mm) aligned with the demands of mild disc degeneration, whereas stiffer cords were more effective for segments with higher degeneration. The pedicle screw motion in dynamic Dynesys systems—primarily caused by axial translation rather than vertical displacement—contributed to screw–vertebra interface stress, influenced by the underlying disc or bone degeneration. Conclusions: Modulating the cord pretension in DTO instrumentation effectively lessened the interface stress occurring at the screw–vertebra junction and adjacent facet joints, contributing to a reduced incidence of pedicle screw loosening, ASD, and revision rates. The modified DTO system, incorporating minimal decompression and preserving the posterior complex at the dynamic level, may be biomechanically favourable and clinically effective for managing transitional degeneration over the mid-term. Full article

Background: Haemophilus influenzae rarely causes spinal epidural abscess or septic arthritis of the facet joints. We report a case of lumbar spinal epidural abscess and facet joint septic arthritis caused by H. influenzae in an immunocompetent host. Methods: A 53-year-old female patient with lumbar spine disc herniation presented with lower back pain 5 days before admission. Results: The patient was diagnosed with an epidural abscess at the right posterolateral aspect of the lumbar spine at the L4-5 level, as well as facet joint septic arthritis at the right L4-L5 and L5-S1 levels. The patient had no neurological deficit. On the 2nd day of hospitalization, the patient underwent decompressive laminotomy and posterior instrumentation. H. influenzae was identified in the blood cultures. She was prescribed intravenous ceftriaxone for 11 days until discharge and levofloxacin for 76 days after discharge. The patient recovered without neurological sequelae. Conclusions: This case represents the first report of septic arthritis of the facet joint and indicates that H. influenzae is a rare pathogen of spinal infection but can lead to a spinal epidural abscess, irrespective of the host’s immune status. Full article

Introduction: Currently, static interbody cages are the gold standard for achieving solid arthrodesis in the spine, enhancing segmental stability, obtaining neuroforaminal decompression, and improving as well as maintaining segmental lordosis. It is well known that restoring sagittal balance and segmental lordosis is crucial for long-term outcomes in lumbar spine fusion. For some cases, expandable interbody cages are emerging as an alternative to static cages. This study aims to evaluate the radiographic outcomes and complications of standard open transforaminal lumbar interbody fusion (TLIF). Methods: A standard open TLIF procedure using expandable cages was performed at 1 to 3 levels in 71 patients (129 levels in total), with a follow-up of two years. All patients underwent radiological assessments preoperatively, immediately postoperatively, and at one and two years postoperatively. Radiological evaluation was conducted using standing lateral X-rays. Results: Segmental lordosis (SL) increased significantly from the preoperative value (9.0° ± 3.6°) to 24 months postoperatively (15.4° ± 3.0°), with improvements maintained throughout the 24-month follow-up period (p < 0.001). Similarly, anterior disc height (ADH), posterior disc height (PDH), and foraminal height (FH) each increased significantly from preoperative to immediate postoperative measurements, and these gains were maintained over the two-year follow-up (p < 0.001 each). Lumbar lordosis increased significantly from the preoperative value (41.9° ± 10.5°) to the immediate postoperative period (45.7° ± 10.8°); however, this improvement decreased slightly at the one- and two-year follow-ups. No revisions were required for cage-related complications. One patient experienced a surgical site infection, and two patients had mechanical complications (screw loosening and proximal junctional kyphosis). Conclusions: Expandable interbody cages enable excellent restoration and maintenance of disc height and segmental lordosis in a standard open TLIF procedures at two-year. Achieving these outcomes depends on several factors, including proper preparation of the vertebral endplates, accurate cage placement and expansion, posterior facet osteotomy, and the application of posterior compression prior to final fixation. These steps are essential to fully maximize the potential of expandable cage technology. Full article

Objective: Bilateral facetectomy (BF) within minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) remains debated regarding its advantages over unilateral facetectomy (UF) in restoring segmental lordosis, addressing spondylolisthesis and decompressing both neural foramina. The evidence is limited. We sought to determine the benefits of contralateral facetectomy on radiographic and clinical outcomes. Methods: We conducted a single-center retrospective analysis on patients with lumbar degenerative disease who underwent single-level percutaneous instrumentation and MI-TLIF with either UF or BF. Plain radiographs, CT and MRI were utilized for comparative radiographic analysis. Various intraoperative and clinical parameters were evaluated to assess surgical effort and clinical outcomes. Results: We included 81 UF and 23 BF cases; complete radiological data were available for 27 and 13 patients, respectively. Both techniques demonstrated a comparable increase in segmental lordosis (UF 2.1° ± 5.3° vs. BF 4.3° ± 5.4°, p > 0.1), which is below the study’s minimum detectable effect (MDE ≈ 5.1° at 80% power). Spondylolisthesis reduction was similar, with UF achieving a mean of 2.8 ± 2.2 mm and BF 2.4 ± 1.9 mm (p > 0.1). Mean posterior disc height did not differ significantly between groups (p > 0.1). The mean intraoperative blood loss was significantly higher with BF (803 ± 347 mL) compared to UF (437 ± 207 mL, p < 0.001). The mean duration of surgery was significantly longer for BF (240 ± 48 min) compared to UF (197 ± 37 min, p = 0.001). Conclusions: This study found no evidence of a large advantage of BF over UF in restoring segmental lordosis, spondylolisthesis and posterior disc height in monosegmental MI-TLIF surgery. Given the higher blood loss and longer operative time observed with BF, its use should be selective for specific indications. Full article

Background: Lumbar foraminal stenosis (LFS) is a prevalent degenerative condition associated with significant radicular pain and impaired quality of life. Advances in minimally invasive and fusion-based surgical techniques have introduced new strategies for decompressing the neural elements. However, comparative data correlating volumetric foraminal expansion with functional outcomes remain limited. Methods: This retrospective cohort study analyzed 256 patients treated surgically for symptomatic LFS between December 2017 and December 2023. Patients were categorized into four surgical subgroups: endoscopic decompression, anterior lumbar interbody fusion (ALIF), microsurgical decompression, and transforaminal lumbar interbody fusion (TLIF). Preoperative and postoperative assessments included magnetic resonance imaging (MRI) to calculate foraminal volume and standardized clinical scales: the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back and leg pain, and SF-36 health-related quality-of-life scores. Statistical significance was determined using p-values, and inter-observer agreement was evaluated via κ-statistics. Results: Postoperative imaging demonstrated a significant increase in foraminal canal volume across all surgical groups: endoscopy (29.9%), ALIF (71.8%), microsurgery (48.06%), and TLIF (67.0%). ODI scores improved from a preoperative mean of 55.25 to 18.27 at 24 months post-surgery (p < 0.001). VAS scores for back pain decreased from 6.37 to 2.1 (p < 0.001), while leg pain scores declined from 6.85 to 2.05 (p < 0.001). Functional improvement reached or exceeded the minimal clinically important difference (MCID) threshold in over 66% of patients. Conclusions: Modern surgical strategies for LFS, particularly fusion-based techniques, yield significant volumetric decompression and durable clinical improvement. Volumetric gain in the foraminal canal is closely associated with pain reduction and enhanced functional outcomes. These findings support a tailored surgical approach based on anatomical pathology and segmental stability. Full article

Background/Objectives: Unilateral biportal endoscopic spine surgery (UBE) has gained popularity due to its minimal invasiveness, endoscopic magnification, bloodless visual field, and broad application to various spinal disorders. We proposed the “no-punch” technique for UBE spine surgery, emphasizing its capability to prevent neural injury and preserve facet joints. This study aims to examine its efficacy in reducing the risk of incidental durotomy through a comparative study. Methods: A total of 914 consecutive patients with various degenerative spine disorders who underwent UBE surgery between October 2018 and July 2023 by a single surgeon in a single institute were included. The Punch Group consisted of 660 patients (830 segments) who underwent UBE surgeries using Kerrison punches. The No-Punch Group included 254 patients (330 segments) who underwent UBE surgeries without using Kerrison punches. We retrospectively reviewed the medical records and operative videos to identify surgical complications, their management, and final treatment outcomes. Results: Sixty-three surgical complications (58 in the Punch Group), including incidental dural tears, nerve root injuries, incomplete decompression, epidural hematoma, and broken instruments, were identified. The No-Punch Group exhibited a significantly lower overall complication rate (8.8% vs. 2.0%), along with a reduced incidence of dural tears (3.9% vs. 0) and neural injuries (5.3% vs. 0.4%). The improvement was particularly notable in lumbar decompression surgeries (5.0% vs. 0.8%) and revision surgeries (9.9% vs. 0%). Conclusions: The “no-punch” technique enhances the safety of UBE surgery for degenerative spine disorders by understanding the injury mechanisms and modifying the surgical techniques accordingly. Full article

Background/Objectives: We report a prospective series of five patients with symptomatic cervicothoracic spinal cord tethering from prior surgical interventions for acquired and congenital spinal pathologies. Each patient demonstrated incidental radiographic evidence of a low-lying conus or a fatty/thickened filum terminale (FT), suggesting concomitant symptomatic conus tethering as a potential contributor. Therefore, all underwent single-stage “tandem detethering”, consisting of microsurgical release of the cervicothoracic pathology followed by FT resection. Methods: Patients’ charts were reviewed for preoperative presentation, imaging, intraoperative findings, surgical details, FT pathology, and six-month outcomes. Results: Preoperative tethering occurred at sites of prior interventions: (i) thoracic arachnoid cyst decompression after Chiari surgery, (ii) cervical lipomyelomeningocele repair, (iii) thoracic ependymoma resection, (iv) syringosubarachnoid shunt placement, and (v) laminectomies for recurrent syrinx. Lumbar MRI demonstrated a low-lying conus in two patients and a fatty/thickened FT in four patients. Intraoperatively, all patients exhibited an abnormal FT (tight, fat-infiltrated, thickened, or dysplastic). No intraoperative complications or neuromonitoring abnormalities were observed. At six months, all patients demonstrated improvement in motor, sensory, pain, and urinary/bowel symptoms. Complications included two pseudomeningoceles requiring repair and one case of recurrent cauda tethering following FT resection. Conclusions: In patients with symptomatic cervicothoracic tethering, a concomitant low-lying conus or pathological FT may contribute to symptomatology by perpetuating biomechanical stress and, if not surgically addressed, may limit neurological recovery. This concept provides a rationale for considering tandem detethering under such circumstances. Full article

Objectives: Transforaminal endoscopic lumbar foraminotomy (TELF) is an emerging minimally invasive surgical technique for lumbar foraminal stenosis. However, its effectiveness is debated because of concerns regarding adequate decompression and its long-term consistency. This study introduced the extended form of TELF, an advanced technique, to provide more extensive decompression using the same approach. Thus, this study aimed to describe the surgical technique and clinical outcomes of this technique. Methods: This retrospective cohort study included patients who underwent conventional (n = 67) or extended (n = 64) TELF. The surgical procedure involved a transforaminal approach with endoscopic decompression, including the removal of the tip of the superior articular process, foraminal ligament, and ligamentum flavum (conventional group), or additional decompression, involving the isthmus and portions of the superior and inferior pedicle walls (extended group). Clinical outcomes were assessed using the visual analog pain scale, Oswestry disability index, and modified Macnab criteria. Results: Despite the longer surgical duration, the extended TELF group tended to show better outcomes in terms of the VAS and ODI scores at the early and final 2-year follow-ups (p < 0.05). The overall success rates were 92.19% and 85.07% in the extended and conventional groups, respectively. No difference was observed in surgical complications between the two groups. Conclusions: Extended TELF, a refined endoscopic technique, achieves better effects than conventional TELF with a lower risk of nerve root irritation by creating a sufficiently safe resection margin. The results support the use of an extended TELF as an advanced form of endoscopic foraminal decompression. Full article

Background and Clinical Significance: Posteriorly migrated lumbar disc herniation [PMLDH] is a rare entity that may present with atypical clinical and radiological features, often mimicking other spinal pathologies. Migration of sequestered fragments through the interlaminar space is exceptionally uncommon, and diagnostic challenges are further amplified in the presence of spinal instability. While MRI and CT are generally sufficient for diagnosis, undetected lesions on preoperative imaging may complicate clinical management. Case Presentation: A 59-year-old male presented with acute low back pain and left-sided radiculopathy. Examination revealed mild motor weakness in ankle dorsiflexion. MRI showed L4–L5 segmental instability with central canal stenosis but no migrated disc fragment. Owing to neurological deficit, decompressive laminectomy with posterior instrumentation was performed. Intraoperatively, a posteriorly migrated sequestered fragment compressing the thecal sac was excised and confirmed as degenerative disc material. Postoperatively, the patient’s neurological deficit and radicular pain resolved, with no new complaints at 3-month follow-up. Conclusions: This case highlights an unusual presentation of PMLDH in a patient with lumbar stenosis and spinal instability, undetected on preoperative imaging. Recognition of the biomechanical predisposition at the L3–4 and L4–5 levels is important in understanding such rare migrations. Although literature emphasizes early surgical intervention for PMLDH, our patient required urgent surgery due to neurological deficits rather than a definitive preoperative diagnosis. Further studies are warranted to clarify the relationship between instability and posterior migration. Full article

Background/Objectives: Upper lumbar spinal stenosis presents unique challenges because vertically oriented facet joints and narrow laminae increase the risk of iatrogenic instability following decompression. Traditional decompression techniques may damage the facet joints, potentially resulting in further instability and degeneration. This study introduces a novel, facet-preserving bilateral–contralateral decompression strategy using unilateral biportal endoscopy (UBE) for upper lumbar stenosis, aiming to defer unnecessary spinal fusion. Methods: This retrospective series of three cases involved patients with upper lumbar stenosis characterized by vertically oriented facets (>60°) and narrow laminae, including cases of adjacent segment stenosis (ASS) and stenosis with grade 1 spondylolisthesis. Patients were selected using the authors’ facet angle–based criteria (>60°) and laminar morphology to identify anatomically vulnerable segments. All patients exhibited vertical facet orientation and narrow laminae, without significant dynamic instability or severe foraminal compromise. Bilateral–contralateral decompression was performed using biportal endoscopy to preserve facet integrity and defer fusion where feasible. Results: This series demonstrated that bilateral–contralateral decompression provided effective neural decompression and symptom relief while preserving facet structures in the upper lumbar spine characterized by vertical facets and narrow laminae. No progression to instability or requirement for additional fusion was observed during the 6-month follow-up, even among patients with ASS and grade 1 spondylolisthesis. Conclusions: The authors propose that bilateral–contralateral decompression may serve as a facet-preserving and fusion-deferral strategy for upper lumbar stenosis with vertically oriented facets and narrow laminae. This approach is particularly applicable in cases such as ASS and spinal stenosis with grade 1 spondylolisthesis, where preserving structural reserve is critical. These preliminary findings highlight the need for prospective validation through carefully designed observational studies and larger case series. Full article