1	Minimally Invasive Endoscopic Spine Surgery (MIESS): A Surgeon’s Perspective and Technology Considerations John C. Chiu, M.D., FRCS (US), D.Sc. Chief, Neurospine Surgery California Spine Institute, USA President, ISMISS/SICOT President AAMISMS
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3	Introduction: The past has prepared our path Back pain - degenerative spine disease and treatment Progress through interdisciplinary and international knowledge and integration Spinal surgery and endoscopic MIESS practice MIS technology Need for OR technology convergence system Redefining spine treatment algorithm R&D of innovative technologies Education and training
4	Introduction: Accumulation of the knowledge of surgical human and spine anatomy since the dawn of civilization Mixter and Barr - 1934 first lumbar discectomy Hijikata – 1975 percutaneous lumbar discectomy Lyman Smith – 1963 chemonucleolysis Onick – 1985 percutaneous automated discectomy Ascher and Choy – 1986 laser percutaneous lumbar discectomy Professors Kambin, Schreiber, Leu in the field of MIESS deserve recognition for their contributions, including the concept of Kambin’s safety triangle Further contributions of many investigators in the field of endoscopic and laser MIESS should also be recognized (Sherk, Yonezawa, Knight, Casper, Chiu, Hellinger, Bini, Menchetti, Yeung, Hoogland, Destandau, et al) Techniques advancing MIESS: Endoscopic MIESS decompression, exploration of epidural space and lateral stenosis besides further expansion of MIESS horizon for decompression of lateral recess stenosis, nucleus replacement, laminotomy, foraminotomy, vertebral augmentation, vertebral column stabilization, etc…
5	Introduction: Despite various degrees of success traditional open spine surgery/fusion has created significant iatrogenic trauma and “failed back syndrome” As a result, the search for MIST and MIESS began
6	Introduction:
7	Introduction:
8	Knowledge Integration Advances MIESS:
9	Material and Methods: 3D Medical/Surgical Digital Planning Laboratory
10	Material and Methods: PACS system creates a seamless connectivity in consultation room and OR for viewing/pre-op planning
11	Seamless Digital Information Network inside and outside CSI
12	Technological Convergence OR Control System OR Surgmatix^®
13	Technological Convergence OR Control System OR Surgmatix^®
14	Technological Convergence OR Control System OR Surgmatix^®
15	Computer Assisted Digital OR Suite for Endoscopic MIESS Advanced digital endosuite OR facilitates MIESS High tech integrated surgical environment Requires technological convergence – control system - OR Surgmatix^® Simplified control of complex systems Instant retrieval of images (PACS) Digital integrated network provides instant display Beyond the PACS Dedicated to out patient MIESS
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17	Technological Convergence Control System OR Surgmatix®
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20	MIESS Surgical Indications:
21	Surgical Instruments and Equipment: Endolumbar decompressive tubular system Foraminoscope Cervical endoscopes and others
22	Surgical Instruments and Equipment:
23	Surgical Instruments and Equipment:
24	Surgical Procedure/Technique:
25	Surgical Instruments and Equipment: Continuous EEG monitoring with the computerized SNAP device (SNAP index or BIS Monitor) optimizes anesthesia and reduces drug requirement Continuous intra-operative EMG monitoring prevents undue trauma to the nerve
26	Surgical Procedure/Technique:
27	Surgical Procedure/Technique:
28	Surgical Procedure/Technique:
29	Disc Annulus Repair
30	Surgical Procedure/Technique: Patient is positioned in lateral decubitus position if unilateral and prone for bilateral approach Dilator and then a duck bill tubular retractor/cannula are passed over the stylette Foraminoplasty and decompressive discectomy performed with trephines, forceps, discectome and Holmium laser
31	Surgical Procedure/Technique: Endoscopic lumbar discectomy with lumbar nerve root in close proximity
32	Surgical Procedure/Technique:
33	Surgical Procedure/Technique:
34	Surgical Procedure/Technique: Surgical technique of LTD, fan sweep maneuver and endoscopic views of disc shrinkage
35	Surgical Procedure/Technique: Digital retraction of trachea/esophagus for needle placement—axial view And carotid artery under the fingers (to maintain systolic arterial pressure, at 130-ephedrine may be used to maintain BP)
36	Surgical Procedure/Technique: Mechanical decompressive cervical discectomy Micro-instrumentations of trephine, forceps, curette, drill, discectome and laser probe under fluoroscopy
37	Surgical Procedure/Technique:
38	Surgical Procedure/Technique:
39	Vertebral Augmentation: Combined with Endoscopic Spinal Discectomy Painful post traumatic L2 VCF Surgically treated with vertebral augmentation of morcelized bone chips Drill initiates cavity creation OptiMesh^® Dacron sac filled with bone graft for biologic vertebral augmentation
40	Surgical Procedure/Technique:
41	Results:
42	Results: (symptomatic improvements)
43	Post Operative Care: Ambulatory within one hour and discharged subsequently May shower the following day May use a cervical collar in a vehicle or on a flight as needed (for cervical discectomy) Ice pack is helpful Mild analgesics and muscle relaxant are required at times Progressive spine exercise second post operative day on Computer assisted spinal exercise (MedEx) Return to work in one to two weeks, provided heavy labor and prolonged sitting are not involved
44	Discussion: Outpatient procedure Less traumatic Small incision Faster Recovery Local or brief general anesthesia Laser (or electro) thermodiskoplasty will likely destroy the pain fibers or sinovertebral nerve fibers at the annulus for relief of pain Our surgical triad approach and critical “fan sweep maneuver” further facilitate the disc decompression and improve the surgical result Multiple level spinal discectomy is possible at one sitting
45	"Quick review of evolution of..." Quick review of evolution of less invasive or MISS (4 generations): 1st generation: Intradiscal procedure (downstairs technique) I.e. chymopapain injection, laser spinal discectomy, APLD, IDET, and other types of tissue modulation (thermodiskoplasty) 2nd generation: in addition to above method, moves upstairs, with extra discal, transforaminal and epidural technique for discectomy (upstairs technique) with micro instrument, laser, radiofrequency and bipolar probe application 3^rd generation: in addition to above methods, involves bone work for decompression of spinal stenosis with rongeur, burr, rasp, curette and laser 4^th generation: in addition above methods, utilizes contemporary biotechnology, biocomputer, image guided surgery, robotic aided instruments, virtual spinal endoscopy, vertebral augmentation, spinal fusion, spinal implants, artificial disc, to further MIESS with better precision and accuracy. Further application of biologic integration. “Less is Better, Less is More”
46	Comment and Discussion:
47	R&D for MIESS
48	Digital Technologies for Endoscopic MIESS
49	Education and Training for MIESS
50	Education and Training for MIESS Thorough knowledge of the surgical anatomy and the surgical procedure Specific endoscopic MIESS training Hands-on experience in a laboratory including cadaveric Meticulous pre-operative surgical planning Working closely with an experienced endoscopic spine surgeon through the steep surgical learning curve Use of digital imaging system PACS, enhanced 3D visualization
51	New innovations are on the horizon:
52	New innovations are on the horizon:
53	Conclusion: MIESS has advanced as a result of interdisciplinary, inter-medical and international exchange of knowledge MIESS is an effective, safe, less traumatic and easier spine surgery for treatment of herniated discs and degenerative spinal disease The convergence and utilization of technology and science will further MIESS MIESS is a smart way to perform spine surgery
54	Thank you for your attention!