1	Lumbar Transforaminal Endoscopic Microdecompression for Herniated Disc Spinal Stenosis and Motion Preservation John C. Chiu, M.D., FRCS (US), D.Sc. Chief, Neurospine Surgery California Spine Institute Thousand Oaks, California, USA President, ISMISS/SICOT
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3	The Goal of Endoscopic Minimally Invasive Spinal Surgery (MISS) This presentation is to demonstrate effective transforaminal endoscopic decompression for degenerative lumbar disc, spinal stenosis, extruded and recurrent disc, and spondylosis compressing the nerve root with endoscopic and non-fusion technique for spinal motion preservation
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) and minimally invasive surgical technique (MIST) began The 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 and preventing iatrogenic problems
5	Introduction: 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 3^rd Eye” or “Eye of Wisdom” for confirmation of location of instruments; endoscopy alone is not enough
6	Introduction: The new biotechnology innovations rapidly propel us into this exciting decade of Minimal Invasive Spinal care These new technological advances usher us into a newer and higher standard of spinal surgery MISS for spinal motion preservation
7	Material and Method: Indications: Low back with leg pain (radicular pain) associated with paresthesia, sensory loss, muscle weakness and/or decreased reflexes Neurogenic claudication on ambulation No improvement after 12 weeks of conservative therapy MRI or CT scan positive for disc herniation Positive provocative discogram Positive EMG considered helpful Multiple discs can be treated at one sitting Post fusion junctional disc herniation syndrome (JDHS) Positive 3 Legs of bar stool – symptoms, physical findings and testing (e.g. EMG, imaging and provocative discogram)
8	Material and Method: Indications: Lumbar disc herniation of JDHS
9	Material and Method: Since 1995, 6009 herniated lumbar discs in 2858 patients Average age of 44.1 (24 to 92) with symptomatic lumbar single and multiple herniated intervertebral discs Males: 1655 - Females: 1203 Each failed at least 12 weeks of conservative care Post operative follow up 6mos to 72mos (average 42mos)
10	Demographics of Herniated Lumbar Discs (6009 disks)
11	Surgical Instruments and Equipment:
12	Surgical Instruments and Equipment: Holmium YAG laser equipment for Laser Thermodiskoplasty (LTD)
13	Surgical Instruments and Equipment: Familiarity and experience in the use of various endoscopic surgical systems including, Spinoscope, foraminoscope and CMIS transforaminal decompressive tubular system To facilitate endoscopic spine surgery To avoid potential complications
14	Surgical Instruments and Equipment: CMIS tubular retractor system with duck bill retractor, trephine, introducer, ronguers, curettes, depth gauge, rasp, disc grasping forceps, cutting forceps, and dissectors
15	Surgical Instruments and Equipment: The lumbar Spinoscope is supported by an arm attached to the surgical table It is inserted through its operating cannula into lumbar epidural space for microdecompressive discectomy and foraminoplasty
16	Surgical Procedure/Technique: Patient Positioning and localization Patient in prone position Patient in Lateral decubitus position Localization – skin marking and placement of needle (portal)
17	Surgical Technique: On a set of bolsters for lumbar spine surgery Head holder with reflective mirror for visualization of patient’s eyes and nasal/oral area
18	Surgical Instruments and Equipment: Continuous intra-operative EMG monitoring prevents undue trauma to the spinal nerve to be decompressed Continuous conscious EEG monitoring with the newest computerized SNAP device (SNAP index) improves anesthesia and reduces drug requirement
19	Surgical Procedure/Technique: MISS decompression of lumbar spinal disc/stenosis with various approaches With posterolateral (transforaminal) approach for lateral stenosis - PLLD With paramedium approach for lateral and central stenosis – TSLD With paraspinal approach - PSpLD With cross canal decompression - CCDF
20	Surgical Procedure/Technique: The patient is positioned in lateral decubitus position if unilateral and prone for bilateral approach The 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
21	Surgical Procedure/Technique:
22	Surgical Procedure/Technique: Endoscopic lumbar discectomy with lumbar nerve root in close proximity
23	Surgical Procedure/Technique: Discectomy with endoscopic cutter-forceps, curettes, graspers, and discectome in a “critical fan sweep” manner Holmium laser right-angle (side-fire) probe to further decompress and to shrink the herniated disc (LTD)
24	Surgical Procedure/Technique: 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”
25	Surgical Procedure/Technique: The bendable tip in situ
26	Procedure/Surgical Technique:
27	New Innovative MISS Surgical System Posterior laminectomy and discectomy with or without fusion is more traumatic and potentially destabilizing Therefore, the search for minimally invasive spinal surgery (MISS) began New SMART endoscopic lumbar system (Karl Storz Endoskope) is designed to bridge the traditional spine surgery and endoscopic spinal surgery It provides an excellent access for future spinal arthroplasty and new spinal innovations
28	Surgical Technique:
29	Surgical Procedure/Technique:
30	Surgical Technique:
31	Surgical Procedure/Technique:
32	Surgical Technique: Any soft tissue into the operative field may be removed by using a rongeur Through this screw opening, a trocar is inserted in the pre-calculated angle into the side opening of the tubular retractor for visualization prior to insertion of the endoscopic tube The adjustable angle allows angle of 15-30° between the endoscope and the operating channel
33	Surgical Technique:
34	Surgical Technique:
35	Surgical Technique: The tubular retractor allows surgical instruments of suction, forceps, rongeurs, bipolar coagulation and the nerve root retractor Endoscope is inserted into the endoscopic channel for visualization of the operative area The 0° or 30° endoscope may be utilized to achieve a distortion free view of the operating field The working tip of the surgical instruments is always visible which avoids the risk of undue neurologic trauma
36	Surgical Technique:
37	Surgical Technique:
38	Surgical Procedure/Technique:
39	Surgical Procedure/Technique: Caudal lumbar laminotomy, decompressive foraminoplasty and resection of medial aspect of facet joint
40	Surgical Procedure/Technique: Pre op CT and MRI evidence of severe L3-4 spinal stenosis
41	Surgical Procedure/Technique:
42	Post Operative Care: Within one hour ambulatory and discharged subsequently May shower on the first post operative day Ice pack is helpful Mild analgesics and muscle relaxant are required at times Progressive spine exercise second post operative day on Allowed to return to work in one to two weeks, provided heavy labor and prolonged sitting are not involved
43	Post Operative Care: Before and after MISS at CSI A physical medicine and rehabilitation unit with computerized assistance Motorized pool and hydro therapy equipped with video camera for monitoring and assessment
44	Results:
45	Results (symptomatic improvements)
46	MISS for Active Professional
47	MISS for the Young
48	MISS for Octogenarian and Beyond 92 year old lady with progressive herniated lumbar discs and spinal stenosis after successful Microdecompressive endoscopic assisted spinal surgery Patient was turned down for conventional spinal surgery/decompression for spinal stenosis and herniated discs
49	MISS for Young and Active Young motocross professional One week post L4-5 SMART endoscopic lumbar discectomy
50	MISS for Medically Difficult Patients Morbid Obesity Santa Clause from the North Pole 51 year old male, 425lbs patient one hour after his L2, L3, L4 discectomy Patient was turned down for herniated lumbar disc surgery by a spine surgeon due to his morbid obesity
51	MISS for Young and Active One month post endoscopic lumbar discectomy Japanese motocross professional
52	Discussion: Endoscopic lumbar spine surgery: Has proven to preserve spinal segmental motion Provides an excellent access or channel for spinal arthroplasty, genome therapy and disc re-growth technology Offers a platform for non-fusion technology and dynamic stabilization And even inter-body fusion with MISS Soon, MISS endoscopic lumbar spine surgery will replace or modify the majority of conventional spine surgeries
53	Discussion: Endoscopic lumbar spinal surgery for the treatment degenerative spinal disc disease has advantages: 0 morality and minimal morbidity (<1%), with numerous advantages Less traumatic physically and psychologically Tiny incision Outpatient procedure Costs less than conventional spinal discectomy Local or brief general anesthesia Exercise program begins first post op day Earlier return to work
54	Discussion: Additional advantages: 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 Laser 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
55	Discussion: Additional advantages: In addition, 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 with markedly obesity, emphysema, elderly (octogenarian and beyond), 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
56	Discussion: In a recent multi-center (20) study of 32,100 cases including 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
57	Discussion: 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
58	Conclusion: The evolving transforaminal endoscopic microdecompression for lumbar disc and spinal stenosis, has proven to be safe, less traumatic, easier, and efficacious with significant economic savings and preserves segmental spinal motion Sufferers with chronic, severe, intractable spinal pain from herniated lumbar discs and degenerative lumbar spinal disease/spondylosis can be treated successfully, with transforaminal endoscopic laser spinal surgery Endoscopic MISS is a smart way to perform lumbar disc surgery
59	Hope you enjoyed this presentation!