Magnetic Resonance Imaging Predictors of Surgical Difficulty in Transforaminal Endoscopic Lumbar Discectomy for Far-Lateral Disc Herniation Under Local Anesthesia

<b>Background/Objectives</b>: Transforaminal endoscopic lumbar discectomy (TELD) is a minimally invasive spinal surgery known for its effectiveness, lower complication rates, faster recovery, and ability to be performed under local anesthesia. However, foraminal narrowing or access pain during the transforaminal approach can delay or hinder surgery in patients with far-lateral lumbar disc herniation (LDH). The objectives of this study were to identify predictive factors from preoperative magnetic resonance imaging (MRI) findings and demographics and discuss the optimization of surgical strategies. <b>Methods</b>: This retrospective study included 75 patients with far-lateral LDH who underwent TELD. Preoperative demographics and MRI findings were analyzed. Surgical data, including operative time, length of hospital stay, and intraoperative pain, were recorded. Postoperative outcomes, including complications, revision surgeries, and global outcomes based on the modified Macnab criteria, were evaluated. Preoperative clinical and radiological factors affecting the operative data and results were analyzed. <b>Results</b>: A higher foraminal stenosis grade was significantly correlated with prolonged operative time (<i>p</i> < 0.01) and extended hospital stay (<i>p</i> < 0.01). Extraforaminal LDH was associated with more severe access pain (<i>p</i> < 0.01) owing to increased nerve root irritation. Access pain was significantly correlated with operative time (<i>p</i> < 0.01) and hospital stay (<i>p</i> < 0.01). Appropriate surgical techniques and intraoperative pain management can mitigate these challenges. <b>Conclusions</b>: Preoperative MRI findings, particularly the grade of foraminal narrowing and herniation zone, can predict surgical difficulty and outcomes in TELD for far-lateral LDH. These insights can guide tailored strategies to reduce access pain and improve procedural success under local anesthesia.