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3	The Goal of This Presentation To discuss anterior endoscopic cervical microdiscectomy (AECM) and lateral foraminal decompression, of minimally invasive spinal technique (MIST) Related non-fusion technique to preserve spinal motion preservation Introduction of a triad in surgical approach and denervation of sinu-vertebral nerve to further improve minimally invasive spinal surgery (MISS) Treatment for cervico-discogenic headache
4	Endoscopic Microdecompressive Cervical Discectomy and Foraminal Decompression Neck with arm pain (radicular pain) associated with paresthesia, sensory loss, muscle weakness and/or decreased reflexes Intractable cervicogenic headache Discogenic pain 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 Positive 3 legs of bar stool – symptoms, physical findings, EMG, imaging and provocative discogram
5	Surgical Indications: Post ACF fusion C4 – C6 JDHS MRI showing junctional discs at C3-4 and C7-T1 Anterior endoscopic cervical microdiscectomy (AECD) provides relief
6	Material and Method: Since 1995, 2016 patients with 3655 herniated cervical discs Average age of 43.2 (21 to 80) with symptomatic cervical, single and multiple herniated intervertebral discs Males: 1029 - Females: 987 Each failed at least 12 weeks of conservative care Post operative follow up: 7 to 75 mos. (average 46 months)
7	Demographics of Herniated Cervical Discs (3655)
8	Surgical Instruments and Equipment: CMIS –Cervical operating endoscope with micro forceps in the working channel and digital camera attached
9	Surgical Instruments and Equipment:
10	Surgical Instruments and Equipment: Anterior cervical endoscopic instruments
11	Surgical Procedure/Technique:
12	Surgical Procedure/Technique: Selective nerve blocks, epidural block and cervical sympathetic nerve block Facet arthralgia (medial branch of posterior primary rami) Spinal discogenic pain (related to sinu-vertebral nerve) Cervicogenic headache
13	Surgical Instruments and Equipment: Continuous conscious EEG monitoring with the newest computerized SNAP device (SNAP index or BIS Monitor) improves anesthesia and reduces drug requirement Continuous intra-operative EMG monitoring prevents undue trauma to the spinal nerve to be decompressed
14	Surgical Procedure/Technique: Patients are positioned in an operating room under local anesthesia and conscious sedation
15	Surgical Procedure/Technique: Patients are positioned in an operating room under local anesthesia and conscious sedation
16	Surgical Procedure/Technique: Retraction of trachea/esophagus for needle placement—frontal view
17	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)
18	Surgical Procedure/Technique: Surgical technique for anterior medial approach for spinal needle and stylette placement
19	Surgical Procedure/Technique: Provocative discogram is often done first A N/G tube is placed in the esophagus 3mm skin incision is made The stylette of the spinal needle is replaced with a 12 inch thin stylette which is introduced into the center of the disk The discectomy cannula/dilator is passed over the stylette A larger stylette is placed into the disc Position is checked by fluoroscopy Mechanical discectomy to follow Completed with laser thermodiskoplasty to shrink and to tighten the disc besides sinu-vertebral denervation
20	Surgical Procedure/Technique:
21	Surgical Procedure/Technique: Mechanical decompressive microdiscectomy Micro-instruments of trephine, forceps, discectome in use Corresponding fluoroscopic photos demonstrate AECM Fluoroscopy as “The 3rd Eye” or “Eye of Wisdom” for confirmation of location of instruments; endoscopy alone is not enough
22	Surgical Procedure/Technique: Mechanical decompressive microdiscectomy Micro-instrumentations of curette, cutting forceps and side-fire laser probe Corresponding fluoroscopic photos demonstrate AECM
23	Surgical Procedure/Technique: Mechanical microdiscectomy decompression Herniated disc fragment removal
24	Surgical Procedure/Technique:
25	Surgical Procedure/Technique: Mechanical micro decompressive cervical discectomy Laser thermodiskoplasty for disc shrinkage and tightening
26	Surgical Procedure/Technique: Mechanical decompressive Foraminoplasty for osteophytes/stenosis
27	Surgical Procedure/Technique: Mechanical decompressive Foraminoplasty for osteophytes/stenosis
28	Surgical Procedure/Technique: Mechanical decompressive discectomy Foraminoplasty for osteophytes/stenosis
29	Surgical Procedure/Technique:
30	Surgical Procedure/Technique:
31	Surgical Procedure/Technique: Mechanical decompressive discectomy Foraminoplasty for osteophytes/stenosis
32	Surgical Procedure/Technique: Endoscopic views of uncinate joint and nerve root after disc decompression, and fissure in cervical disc
33	Surgical Procedure/Technique:
34	Surgical Procedure/Technique:
35	Post Operative Care: Ambulatory usually in about one hour and discharged subsequently May shower the following day May use a cervical collar in a vehicle or on a flight as needed 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, providing heavy labor and prolonged sitting are not required
36	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
37	Surgical Outcome:
38	Surgical Outcome: (symptomatic improvements)
39	Case Illustrations: Case I
40	Case II Large 8mm herniated C6-7 disc compressing spinal cord - pre and post operative MRI scans
41	Case III
42	Discussion: Endoscopic MISS (of MIST) is an effective alternative or replacement for open spinal surgery for discectomy, foraminoplasty and decompression of stenosis in degenerative spine disease New biotechnology, instrument advances and accumulation of endoscopic spinal surgical experience, make the procedure of cervical foraminal discectomy and decompression (foraminoplasty) possible Open cervical spinal surgery/fusion results in higher complication and morbidity besides longer convalescence Post cervical spinal fusion patients, as high as 25 – 52% of them developed Junctional Disc Herniation Syndrome (JDHS) or Adjacent Segmental Disease (ASD) within 3-4 years
43	Discussion: As demonstrated in the recent multi-center (20) study of 32,100 cases including endoscopic cervical spinal disc surgeries with an overall success rate of 91% (single level) With a complication rate of less than 1%, zero mortality, patient satisfaction of over 90% (for single and multi-levels) Second operation only required in 0.79% Resuming usual activity in a few days and full active lives in 2-6 weeks These procedures can be extremely gratifying for patients and surgeon Soon spinal arthroplasty, spinal motion preservation and dynamic stabilization will become an integral part of all cervical spinal surgery
44	Discussion: In order to perform AECM and to avoid potential complications, one must have a thorough knowledge of endoscopic cervical spinal procedures and the surgical anatomy Endoscopic cervical 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 Fluoroscopy as “The 3^rd Eye” or “Eye of Wisdom” for confirmation of location of instruments; endoscopy alone is not enough These surgical procedures must be meticulously executed
45	Discussion: Potential Complications and their Avoidance 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 C-arm fluoroscopy Recurrent laryngeal nerve injury, is extremely rare Postoperatively one case of transient hoarseness One case with transient hiccough
46	Discussion: Potential Complications and their Avoidance 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 Esophageal and trachea injury due to trauma or perforation can occur: But are avoided by careful surgical technique and by identifying and retracting these structures By careful digital palpation and retraction at the site of needle insertion By placing a nasogastric tube into the esophagus aids in identifying and retracting that structure by palpation.
47	Discussion: Potential Complications and their Avoidance Spontaneous Cervical Fusion: secondary to using larger working channel, trephine (5mm or more) and trauma to the endplate causes spontaneous fusion at C6-C7
48	Discussion: Potential Complications and their Avoidance 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
49	Discussion: Potential Complications and their Avoidance 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)
50	Discussion: What are the new advances on the Horizon?
51	Conclusion: The anterior endoscopic cervical microdiscectomy (AECM) has proven to be safe, less traumatic, easier, and efficacious To treat chronic, severe, intractable spinal pain from herniated cervical discs, and degenerative cervical spinal disease/foraminal stenosis AECM preserves spinal segmental motion, avoids JDHS, and provides an excellent access for spinal arthroplasty Spine surgeons are eagerly embracing the minimally invasive spinal technique (MIST) With proper experience, it is a smart way to perform cervical spinal surgery
52	Hope you enjoyed this presentation!