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Category: Book Chapters

Selective Endoscopic Discectomy™ : Twelve Years Experience

More than Twelve years have passed (1991) since I learned and adopted Arthroscopic Microdiscectomy from pioneer endoscopic spine surgeon Parviz Kambin, who, along with Sadahisa Hijikata, first established the technique for percutaneous nucleotomy in the early 1970’s. A cadaver dissection of the traditional posterior anatomy of the lumbar spine compared with the foraminal anatomy clearly illustrates the feasibility and advantages of the foraminal approach to the lumbar disc.

Endoscopic Discectomy and Foraminal Decompression In Interventional Spine: An Algorithmic Approach

Endoscopic disc surgery is evolving rapidly because of improvements in surgical technique, endoscope design, adjunctive surgical tools, and instrumentation. New endoscopes and complementary surgical devices enhances the endoscopic spine surgeon’s ability to also probe spinal anatomy in a conscious patient. The surgeon can then evolve his diagnostic and surgical skills with this newly found ability to evaluate pathologic, anatomic, and physiologic processes causing the patient’s pain.

Now that diagnostic spinal endoscopy can be performed, conditions previously not even considered for surgery may be probed, evaluated and surgically treated with greater accuracy. Our understanding of discogenic back pain is enhanced, as endoscopic visualization of pathologic lesions not previously seen, intradiscally and in the “hidden” extra-foraminal zone is increasing our understanding of the pain generators in the lumbar spine.

Microtherapy in Low Back Pain

Experimental in vivo stimulation of the annulus fibrosus of an intervertebral disc produced back pain, and the term “discogenic pain” was coined to establish the association between annulus stimulation and the subjective pain perception. Histologically the end organ neural sensors are located in the outer layers of the annulus, epiannular surface, and the juxta endplate region. Nucleus pulposus and its metabolic byproducts are known contact irritants to the nerve tissues and are known to reduce their membrane excitation threshold. There is no direct contact between the neural end sensors and the intradiscal irritants in an intact disc.

In-Vivo Endoscopic Visualization of Patho-Anatomy in Painful Degenerative Conditions of the Lumbar Spine

The degenerative processes in an aging spine have been defined traditionally only by our knowledge of the biology of disc and facet degeneration, as well as interpretation of post-mortem cryosections by forensic anatomist Wolfgang Rauschning, M.D. In this chapter, visualization of in-vivo patho-anatomy in a degenerating disc and spinal segment is demonstrated at surgery using the Yeung Endoscopic Spine System™ (Y.E.S.S.™), (Richard Wolf Surgical Instrument Company, Vernon Hills, IL, USA). An Institutional Review Board (IRB)-approved study of endoscopic treatment for degenerative conditions of the lumbar spine incorporated intraoperative probing under local anesthesia and endoscopic treatment of the visualized patho-anatomy.

An intraoperative evocative chromo-discogram, using indigocarmine, was used to elicit discogenic pain and label the fissured and degenerative nucleus pulposus for surgical removal and thermal modulation. Painful patho-anatomy was probed in a conscious patient. The most common endoscopic finding was Inflammatory tissue in the disc and annulus. Inflammation was correlated with the presence of annular tears. Patho-physiologic changes that affect the exiting nerve, which contains the Dorsal Root Ganglion (DRG), was associated with stenotic and chemical irritation.

Unavoidable postoperative dysesthesia was associated with the presence of an inflammatory membrane, and removal or thermal coagulation of “anomalous” furcal nerves in the foramen that branched off of the exiting spinal nerve. Neo-angiogenesis and neurogenesis in the inflammatory membrane present in the foraminal triangle was a new finding not reported in traditional clinical studies. Visualization and treatment of pathologic findings inside (annular tears) and outside the disc in Herniated Nucleus Pulposus (HNP), synovial cysts, foraminal stenosis, central stenosis, spondylolisthesis, is demonstrated.

The endoscopic foraminal approach to the spine and disc is a technique that provides access to patho-anatomy in the lumbar spine not usually feasible with traditional surgical methods. Favorable surgical results allow for continued evolution of the endoscopic method, concomitant with the continued evolution of endoscopic spinal surgery.

Endoscopic Surgery and Minimally Invasive Technique

Spinal endoscopy is poised to parallel the development and evolution of knee, shoulder, and ankle arthroscopy. Without endoscopy, spine surgeons must depend heavily on imaging systems that while extremely sensitive in identifying pathologic conditions, do not always correlate that condition with the patient’s pain. Endoscopic disc surgery is evolving rapidly due to the introduction of improvements in endoscope design and instrumentation.

The introduction of various cannula configurations combined with excellent optics gives the endoscopic spine surgeon the ability to probe spinal anatomy in a conscious patient while protecting sensitive spinal nerves, allowing the surgeon to evaluate the pathologic process causing the patient’s pain. When spinal endoscopy can be performed, conditions previously not even considered for surgery may be evaluated and managed.

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