1	Multicenter Study of Endoscopic Cervical, Thoracic and Lumbar Discectomy
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3	Contributing Centers
4	Introduction: Open spinal surgery is associated with significant local morbidity and long-term convalescence, with greater expense Therefore, the search for minimal invasive spine surgery (MISS) of minimally invasive technique (MIST) began Explosive advances in bio technology and innovative surgical advances have propelled the rapid development of modern minimally invasive surgery in all areas Including endoscopic spinal surgery It aims at reducing tissue trauma, preservation of spinal motion, and preventing iatrogenic problems
5	Introduction: The purpose of the present study was to gather a comprehensive series of endoscopic discectomies (lumbar, cervical and thoracic) To accurately assess the overall incidence of complications and morbidity, to determine the rate of re-operation, and to adjudge the current role and efficacy of minimal invasive surgery in the armamentarium of a spinal surgeon Success and satisfaction rates were gathered for analysis
6	History: Multicenter studies on percutaneous discectomy (without endoscope) were first reported in 1990 by Onik and others subsequently on automated percutaneous instrumented lumbar discectomy – with approximately 75% success rate Mayer and Brock, 1993, and Hermantin, 1999, did prospective studies that supported PELD was a satisfactory alternative to open surgery with lower morbidity and faster recovery Chiu et al reported 1999 93.5% success rate (good to excellent) for 1000 cases of endoscopic MISS
7	History: Nevertheless review articles by conventional spine surgeons continue to appear minimizing PELD’s usefulness and dubbing it experimental The present study intends to gather a large accumulated experience to assess the efficacy of this operation
8	Materials and Methods: Forty-one spine surgeons of minimally invasive spinal surgery from 20 centers around the world were contacted, and the statistics for 32,100 operations were gathered and analyzed The type of endoscope varied the anatomical approaches or minimized tissue trauma, and methods of tissue modulation included radiofrequency, laser, and bipolar coagulation
9	Materials and Methods: All patients had signs and symptoms of radiculitis and radiculopathy unrelieved by at least 3 months of conservative treatment Ages ranged from 14 to 87 Males 51%; females 49% Confirmatory CT/ MRI/ EMG/ Discograms were obtained Conservative treatment for at least 12 weeks
10	Procedure/Surgical Technique: Lumbar The most common operative access for lumbar PED was the posterior lateral approach (90%) into a triangular working zone for safe access into the intervertebral disc Paramedian or transpinal approach(9.5%) is for large herniated, extruded or paramedian disc Occasional paraspinal approach (0.5%) is used for decompression of lateral disc/stenosis
11	Procedure/Surgical Technique: Extradural transpinal approach for high pelvic brim and a narrow L5-S1 interspaces In addition, a new endoscopically assisted microdiscectomy system can effectively decompress spinal stenosis with rongeur, laser, rasp, curette and abrader or shaver
12	Procedure/Surgical Technique: Tissue modulation was performed by many contributing centers Using lasers, radiofrequency, and/or bi-polar coagulation with temperature controlled shrinkage of collagen tissue (i.e. thermodiskoplasty or annuloplasty)
13	Procedure/Surgical Technique:
14	Procedure/Surgical Technique: Lumbar intervertebral disc nerve supply Denervation of the Sino vertebral nerves by thermal effect to the nerve by laser, RF and bi-polar coagulation
15	Procedure/Surgical Technique:
16	Results: Most cases were same-day; 10% stayed overnight Various evaluations of response to treatment utilized: Mac Nab, modified Mac Nab criteria, Oswestry disability score/index (ODI), visual analogue pain (VAP) scores, patient satisfaction scoring, and/or patient target achievement score (PTA) for assessment and analysis Patient satisfaction averaged over 90% Only 9 of 57 discitis (0.24% ) cases had abnormal cultures 41 (0.17%) reported csf leaks from 9 surgeons
17	Results: Most common complication was sympathetic mediated pain or dysethesia 131 (0.55%); progression to RSD was rare Nearly all 89 (0.38%) motor and sensory deficits were transient 139 (0.59%) patients required a second surgery Obviously, the overall incidence of surgical complications such as discitis, wound infection, transient cerebral fluid leak, motor or sensory loss, and sympathetic mediated pain and dysethesis, was less than 1% in entire series The rate of recorded re-operation for the entire series was less than 1% The mortality is 0 The patient satisfaction was over 90%.
18	Results:
19	Results:
20	Discussion: Prior percutaneous discectomy procedures including automated nucleotome discectomy, percutaneous laser discectomy without endoscopy, have been reported in literature with a success rate up to 80% Refinement of instrumentation, optics, endoscopes and surgical experience have allowed endoscopic MISS removal of sequestered fragments, foraminotomy, decompression of the lateral recess, and even cervical and thoracic discectomy elevated success rate into the 90%
21	Discussion: Surgical outcomes of 32,100 PED (endoscopic discectomy) are equal to or superior to those of open microdiscectomy with minimal morbidity and zero mortality Patients are increasingly aware of the advantages of MISS and MIST, and find them more acceptable and psychologically less daunting PED has been proven to be an established alternative to conventional open surgery for disc herniations
22	Discussion: The primary advantages of this procedure: 0 morality and minimal morbidity (<1%) Outpatient procedure Less traumatic physically and psychologically Tiny incision Costs 40% less than conventional spinal discectomy Earlier return to work Local or brief general anesthesia Exercise program begins same day as surgery Laser thermodiskoplasty: Holmium laser (at lower non-ablative energy level) for disc shrinkage through tightening effect of collagen/disc tissue Direct visualization and confirmation of discectomy
23	Discussion: Additional advantages: In addition, laser thermodiskoplasty will likely destroy the pain fibers or sinovertebral nerve fibers at the annulus for relief of pain The surgical triad approach and critical “fan sweep maneuver” further facilitate the disc decompression and improve the surgical result Multiple level spinal discectomy secondary to disc herniation is possible at one sitting with minimal or no risk This procedure can be done for high risk anesthesia patients including markedly obese patients, emphysema, and cardiac conditions with local anesthesia at much less risk Continuous intraoperative neurophysiological/ EMG monitoring, and direct endoscopic monitoring will reduce the chance of inadvertent neural injury
24	Conclusion: This multicenter study demonstrates endoscopic MISS spine surgery with 0 mortality and less that 1% morbidity It is an effective, safe, less traumatic, and less costly surgical treatment for herniated intervertebral disks and leads to excellent results and speedier recovery Soon, it will replace and/or modify the majority of conventional spine surgeries It is a smart way to perform spinal surgery
25	Hope you enjoyed this presentation!