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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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- 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) began
- The explosive advances in bio technology and innovative surgical
advances have propelled the rapid development of modern MISS
- These make endoscopic MISS a reality, aiming at reduction of tissue
trauma and prevention of iatrogenic problems
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- Thorough knowledge of the surgical procedure and the surgical anatomy
- Specific endoscopic MISS training
- Hands-on experience in a laboratory
- Meticulous pre-operative surgical planning
- Working closely with an experienced endoscopic spine surgeon through
its steep surgical learning curve
- Use of c-arm fluoroscopy as “The 3rd Eye” or “Eye of Wisdom” for
confirmation of location of instruments; endoscopy alone is not enough
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- Infection:
- Avoided by sterile technique and intraoperative I-V prophylactic
antibiotics
- Aseptic discitis: can be prevented by aiming the laser beam in a
“bowtie” fashion to avoid damaging the endplates
- Hematoma (subcutaneous and deep):
- May occur but is minimized by careful technique
- Not prescribing aspirin or NSAID’s prior to surgery
- Applying digital pressure or an I-V bag over the operative site after
surgery
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- Endoscopic Cervical Spine Surgery:
- Esophageal and tracheal injury avoided by careful surgical technique,
identifying and retracting these structures by careful digital
palpation
- Placing a nasogastric tube into the esophagus aids in identifying and
retracting that structure by palpation
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- Vascular Injury – Thoracic: extremely rare
- The thoracic aorta/segmental branches, the intercostal artery and vein,
the azygos system of veins are at risk
- Strict adherence to technique and knowledge of surgical anatomy
prevents complication
- Working in the “safety zone” of the disc, (with interpedicular line
medially and rib head laterally) at neuro foramen, to prevent it from
penetrating the intercostal nerve and vessels, and the pleura
- All instrumentation stays confined within the disc interspace and
foramen
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- Vascular Injury – Lumbar extremely rare:
- Avoiding aorta, vena cava, femoral arteries and veins by accurate
placement of all instruments
- Strict adherence to technique and the applicable foraminal anatomy, and
the “triangular working zone”
- Instruments to be kept within the disc space, foramen and the epidural
space under direct endoscopic vision
- No vascular injury reported since the early experience with
percutaneous procedures
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- To facilitate endoscopic spine surgery and avoid potential complications
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- Inadequate decompression of disc:
- Minimized with application of multiple modalities
- Proper endoscopic instruments
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- Neural Injury: extremely rare
- No spinal cord injuries reported
- Nerve root and spinal cord injury, though possible, but avoidable
- With neurophysiologic monitoring (EMG/NCV)
- Root injury avoided by introducing instruments in the “safety zone”
- And direct endoscopic visualization
- By frequent use of intra-operative C-arm fluoroscopy
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- Neural injury continued:
- Recurrent laryngeal nerve injury, is extremely rare
- Postoperatively one case of
transient hoarseness (out of 1200 cervical cases)
- One case with transient hiccough
- Sympathetic nerve injury:
- Rare but can occur from injury to cervical sympathetic and Stellate
Ganglions
- One post-operative transient Horner syndrome or oculo sympathetic
dysfunction occurred
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- Dorsal Root Ganglion Injury:
- A common complication for posterior lateral lumbar approach with
dysesthesia (mostly transient, permanent less than 1%)
- Careful endoscopic technique and knowledge of foraminal anatomy
- C-arm fluoroscopic monitoring
- Using cannulae and endoscope that fit the foramen
- Careful using laser in the foraminal area
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- Excessive sedation:
- Continuous conscious EEG monitoring with the new computerized SNAP™ monitoring
(SNAP index) improves anesthesia and reduces drug requirement
- Local anesthesia with conscious sedation provides a responsive patient
to facilitate endoscopic MISS and prevents potential complications
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- Operating wrong level:
- A major complication of all spine surgery
- Avoided by using digital C-arm fluoroscopy for accurate anatomic
localization
- Provocative discogram verifies level
- Dural Tear:
- Gross dural tear very rare
- Dural injury evidenced by spinal headache and presumed csf leak (less
than 1%)
- No surgery required to repair a CSF leak
- Spinal headache responds to epidural blood patch
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- Pneumothorax: potential complication for all approaches to thoracic
discs
- Introduction of the micro instruments through the “safety zone” as
described previously prevents complication
- Chest x-ray is obtained immediately after completing the operation to
rule out pneumothorax
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- Bowel and ureteral injuries: extremely rare
- Ureteral injuries not reported with MISS
- Bowel perforation in the early experience with percutaneous lumbar
discectomy
- None in recent multiple center study of 32,100 cases
- Knowledge of the surgical anatomy avoids potential complications
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- Discitis:
- Prophylactic antibiotics
- Continuous irrigation of the interspace
- Introduction of instruments through a cannula without contact with the
skin
- Aseptic discitis:
- Aim the laser in a “bowtie” fashion to avoid damaging the endplates (at
6 and 12 o’clock)
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- Absorbed by water
- A pear shaped cavitation bubble formed by vaporization of water
molecules, undergoes expansion and collapse - resulting in acoustic and shock wave
emission
- Simultaneously a vapor channel is formed that effectively conducts laser
energy to the target “MOSES EFFECT”
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- Endoscopic assisted decompressive spinal surgery:
- Under direct vision, it facilitates decompression of spinal stenosis
- And avoids potential complication
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- Endoscopy facilitate intra spinal canal lesion removal and avoids
neurovascular complications:
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- All potential complications of open approaches are possible for
endoscopic MISS, but rare or much less frequent
- A thorough knowledge of the procedures and the relevant surgical
anatomy, hands-on training on MISS
- Careful selection of patients, and careful pre-operative imaging surgical planning
- Meticulous operative execution
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- In a recent multi-center (20) study of 32,100 cases involving endoscopic
spinal disc surgeries, demonstrates an overall the success rate of 91%
with a complication rate of less than 1%, zero mortality, patient
satisfaction of well over 90%, and second operation only required in
0.79%
- Endoscopic spine surgery is an effective alternative or replacement for
conventional open spinal surgery for discectomy and decompression of
stenosis in degenerative spine disease
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- It has proven to be safe, less traumatic, easier, and efficacious with
significant economic savings
- Decreased potential intraoperative and postoperative complications in
spinal surgery
- Soon, endoscopic MISS will replace or modify the majority of
conventional spine surgeries
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- In order to perform this surgery and to avoid potential complications, a
spine surgeon must have a thorough knowledge of endoscopic spinal
procedures and the surgical anatomy
- Endoscopic MISS has its unique surgical skill set
- Requiring the surgeon to go through a steep learning curve
- Patients must be carefully selected
- Careful preoperative surgical planning
- These surgical procedures must be meticulously executed
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Notes
