Procedure-Specific Postoperative Drainage Strategy in Transforaminal Full-Endoscopic Spine Surgery: A Quantitative Evaluation of Drain Output and Endoscopic Bleeding Findings.

Authors

Yuji Nagao, Takayuki Kitahara, Naoto Ono, Takafumi Ohshima, Saori Soeda, Daiki Nakajima, Makoto Takeuchi, Hiroshi Kageyama, Junzo Fujitani, Masatoshi Morimoto, Hiroaki Manabe, Fumitake Tezuka, Koichi Sairyo

Published in

International journal of spine surgery. Sep 03, 2026. Epub Sep 03, 2026.

Abstract

Postoperative drain use after transforaminal full-endoscopic spine surgery (TF-FESS) remains controversial, and procedure-specific criteria are not well defined. This study aimed to determine whether postoperative bleeding risk-quantified by postoperative drain output and intraoperative endoscopic bleeding findings-differs by TF-FESS procedure and whether these metrics can inform a procedure-specific drainage strategy.
We retrospectively reviewed 100 consecutive TF-FESS cases: 65 managed with postoperative drains, and 35 managed without drains after an institutional policy change (limited to full-endoscopic discectomy [FED] and lumbar foraminotomy). Procedures included FED, full-endoscopic lumbar foraminotomy (FELF), full-endoscopic ventral facetectomy (FEVF), transforaminal full-endoscopic lumbar undercutting laminectomy (TELUL), and pars crisscross decompression (pars crisscross). Postoperative drain output was analyzed in the drain group. Intraoperative endoscopic bleeding was assessed at 3 standardized steps: approach/foraminoplasty (step 1), procedure-specific decompression (step 2), and final hemostasis (step 3). Multivariable analysis identified predictors of higher drain output.
Drain output differed significantly among procedures (analysis of variance, P < 0.001). FED and FELF showed low drain output, whereas FEVF, TELUL, and pars crisscross showed higher drain output. Invisible bleeding during step 2 was more frequent in TELUL and pars crisscross. On multivariable analysis, TELUL and FEVF independently predicted higher drain output. In the drain-free subgroup (n = 35; FED/FELF), no patient developed neurological deterioration or symptoms requiring emergent hematoma evacuation.
Bleeding risk in TF-FESS is strongly procedure dependent. Drain-free management was implemented only in a selected low-risk subgroup after a policy change; given the small sample size and the low baseline incidence of symptomatic hematoma, this cohort is not powered to assess safety outcomes, and drain-free observations should be interpreted as descriptive feasibility data. Postoperative drainage should be considered for advanced procedures involving epidural venous plexus manipulation and/or extensive cancellous bone exposure (FEVF/TELUL/pars crisscross). Given the nonrandomized, procedure-dependent drain policy, these findings are hypothesis generating.
A procedure-specific, risk-stratified drainage approach may help optimize postoperative management and patient safety in TF-FESS.

PMID:
42692787
Bibliographic data and abstract were imported from PubMed on 04 Sep 2026.

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