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- 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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- 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 MISS practice
- Minimally Invasive Spinal technique (MIST)
- Need for OR technology convergence system
- Redefining spine treatment algorithm
- R&D of innovative technologies
- Education and training
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- 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 MISS 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 MISS should also be recognized (Sherk, Yonezawa, Knight,
Casper, Chiu, Hellinger, Bini, Menchetti, Yeung, Hoogland, Destandau, Maziad, et al)
- Techniques advancing MISS: Endoscopic MISS decompression, exploration
of epidural space and lateral stenosis besides further expansion of
MISS horizon for decompression of lateral recess stenosis, nucleus
replacement, laminotomy, foraminotomy, vertebral augmentation,
vertebral column stabilization,
etc…
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- 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 MISS began
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- This system creates a
seamless connectivity in consultation room and OR for viewing/pre-op
planning and authoring
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- Advanced digital endosuite OR facilitates MISS
- High tech integrated surgical environment
- Requires technological convergence – OR 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 MISS
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- Endolumbar decompressive tubular system
- Foraminoscope
- Cervical endoscopes and others
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- Selective nerve blocks, epidural block and spinal sympathetic nerve
block
- Facet arthralgia (medial branch of posterior primary rami)
- Spinal discogenic pain (related to sino-vertebral nerve)
- Cervicogenic headache
- Facet bursitis injection and decompression
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- 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
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- 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
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- Endoscopic lumbar discectomy with lumbar nerve root in close proximity
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- Surgical technique of LTD,
fan sweep maneuver and endoscopic views of disc shrinkage
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- Carotid artery under the fingers (to maintain systolic arterial
pressure, at 130-ephedrine may be used to maintain BP)
- Digital retraction of trachea/esophagus for needle
placement—axial view
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- Mechanical decompressive
cervical discectomy
- Micro-instrumentations of trephine,
forceps, curette, drill,
discectome and laser probe under fluoroscopy
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- 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
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- 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
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- 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
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- 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
- 3rd generation: in addition to above methods, involves bone
work for decompression of spinal stenosis with rongeur, burr, rasp, curette and laser
- 4th 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 MISS with better precision and
accuracy. Further
application of biologic integration.
- “Less is Better, Less is More”
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- Thorough knowledge of the surgical anatomy and the surgical procedure
- Specific endoscopic MISS 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
- Fluoroscopy as “The 3rd Eye” or “Eye of
Wisdom” for confirmation of location of instruments;
endoscopy alone is not
enough
- Use of digital imaging system PACS, enhanced 3D visualization
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- MISS has advanced as a result of interdisciplinary, inter-medical and
international exchange of knowledge
- MISS is an effective, safe, less traumatic and easier spine surgery for
treatment of herniated discs and degenerative spinal disease
- The convergence, utilization and control of science and technology will
further MIST and MISS
- MISS is a smart way to perform spine surgery
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Notes
