Rationale: The accurate and smooth establishment of a working cannula guarantees rapid and minimally invasive treatment effects using percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation (LDH). With anatomic variations such as a hyperplastic superior articular process (SAP), the conventional transforaminal approach cannot achieve an ideal result.
Patient concerns: A 48-year-old male patient suffered waist and left lower limb pain, with exacerbation of symptoms after exertion.
Diagnoses: L5-S1 disc herniation, hyperplastic SAP of S1.
Interventions: To demonstrate the segment responsible for compression, a lumbar nerve root block was carried out. This was followed by PELD via a transfacet joint approach at L5-S1.
Outcomes: The patient experienced an improved quality of life postoperatively (i.e., visual analog score for pain = 1 and Oswestry disability index = 88). Lumbar function and stability were preserved as of the 1-month postoperative follow-up.
Lessons: The transfacet joint approach could extend the indications for PELD and present an alternative option in selected cases. A new concept of "subsidence foramen" is raised to characterize this anatomic variation, and it may guide working access establishment of PELD. In addition, reading imaging results carefully and individualizing treatments promote the use of PELD as minimally invasive surgery.