Minimally invasive techniques in spine surgery have progressed rapidly, giving the surgeon endoscopic tools that improve his ability to diagnose and treat discogenic pain. This paper reviews the author’s experience with endoscopic spine surgery for disc herniations and for conditions previously addressed only with more invasive methods or conditions that give the patient no other surgical alternatives.
Endoscopic spine surgery is evolving rapidly due to improvements in surgical technique, endoscope design, and instrumentation. In an experienced surgeon’s hands, the endoscopic foraminal approach can be utilized for most lumbar disc herniations and for the diagnosis and treatment of degenerative conditions of the lumbar spine. The advantage of the foraminal endoscopic technique is the ability to reach, visualize, and treat intradiscal and foraminal pathologic lesions without destabilizing the posterior muscle column and facets. The learning curve is steep, but once mastered, the surgeon is able to reach any pathologic lesion in the foramen, including noncontained disc herniations, foraminal stenosis, foraminal osteophytosis, facet cysts, and annular tears.
Clinical results of posterolateral endoscopic debridement and irrigation followed by percutaneous drainage for pyogenic spondylodiscitis were analyzed.
To report clinical results of transforaminal endoscopic surgery for pyogenic spondylodiscitis and to evaluate the effectiveness of this procedure in treatment of pyogenic spinal infections.
Summary of Background Data
Pyogenic spinal infections have been increasing due to the development of medical treatment for patients with comorbid medical problems. Common treatments for spinal infections are administration of antibiotics or surgical debridement with bone grafts. There have been no reports, however, regarding the clinical outcome of posterolateral endoscopic treatment for pyogenic spinal infections
- Chronic back pain afflicts hundreds of millions of people worldwide
- the most common early cause is deterioration of the intervertebral disc from trauma or aging
- Current therapies to treat back pain from nonsurgical techniques: ie. Physical medicine + pain management, and oral analgesics, are followed by various techniques of MIS and traditional disc surgery, but PREMATURELY ending in fusion.
There are viable minimally invasive technologies and minimally invasive surgical procedures that make it feasible to move away from fusion as an early surgical option for treating chronic low back pain if non-surgical methods fail. Surgeons who are familiar with and who have training in endoscopic spine surgery are able to utilize the transforaminal endoscopic approach to the lumbar spine and use these endoscopic techniques to identify and treat the pain generators with the least invasive, most effective methods available.
Anthony T. Yeung M.D., has reported his 5-10-year results in a preliminary review of endoscopic transforaminal of isthmic and degenerative spondylolisthesis decompression causing sciatica and back pain at international spine meetings. Fifty-five patients from January 2002-December 2012 served as the database for the clinical presentation in patients who specifically chose to stage Yeung’s endoscopic transforaminal decompressive procedure over fusion. The patients were specifically evaluated for endoscopic spine surgery in a shared clinical decision.
This more focused article is subdivided with stratified indications to degenerative spondylolisthesis only, omitting isthmic spondylolisthesis since isthmic spondylolisthesis is traditionally the surgical option of choice for patients who elected to undergo surgical intervention as the standard surgical option versus continuing with non-surgical care. Disc protrusions associated with degenerative spondylolisthesis, disc herniation, patients with concomitant stenosis, who did well with the first study on both degenerative and isthmic spondylolisthesis were analyzed from the first database and stratified for degenerative spondylolisthesis. The patients of the original 10-year follow-up study were 100% satisfied with their decision to try the endoscopic surgery first, even when they subsequently opted for fusion since it would not interfere with a fusion as a secondary staged procedure. There was no attempt to stratify the first patient group who wanted to stage their surgical options, even if fusion became necessary for their pain and activity requirements.
In this 10-year study 33% eventually opted to undergo fusion in order to get more symptom relief. Transforaminal foraminoplasty also provided some unanticipated back pain relief as well. When dorsal endoscopic ablation of the medial branch of the dorsal ramus was later added to the endoscopic procedure to address axial back pain, even better clinical outcomes were obtained by this focused study on degenerative spondylolisthesis, with or without disc protrusion and stenosis.
Lindblom ﬁrst described discography as a useful tool to identify intervertebral disc ruptures in 1948. The management of chronic low back pain presents a challenge to the spine specialist. With improved understanding of it’s pathophysiology, a discogenic etiology is widely accepted and exists in a considerable number of patients with chronic back disorders. The disc has nociceptive innervation capable of pain generation.
An annular tear is the most common cause of chronic low back pain and it may be that annular injuries that do not adequately heal, evolve into painful degenerated discs. Surely chronic discogenic pain results from mechanical stimulation of annular ﬁssures and chemical irritation (neuropathic pain) from inﬂammagenic disc break-down substances.
The intervertebral disc, an important supporting structure of the spinal column, is implicated as a major source of low back pain and sciatica.(Ref 1,2) The pathogenesis of disc degeneration and herniation is complex and multifactorial, but clearly outlined and documented by Wolfgang Rauschning’s work illustrating the patho-anatomy of degenerative disc disease and degenerative conditions of the lumbar spine.(Ref 3) Most disc herniations are not the result of an acute event, but an accumulation of several insults to the spine that lead to degeneration, annular tears, and eventual disc herniation.(Ref 4) There are several theories of disc degeneration including mechanical, chemical, agerelated, autoimmune and genetic. Within the mechanical theory, the following types of abnormal loads have been proven experimentally to cause disc injury: torsion (Ref 5), compression (Ref 5,6), repetitive compressive loading in flexion (Ref 7), hyper flexion (Ref 8), and vibration. (Ref 9)
A retrospective analysis of 41 patients operated for excision of soft lumbar extraforaminal disc herniation (EFDH) by percutaneous endoscopic extraforaminal approach under local anesthesia by a new technique.
To describe a new and safer percutaneous endoscopic technique for the removal of soft EFDH and report the results on the basis of a new objective criterion modified from Oswestry Disability Index (ODI).
Summary of Background Data
EFDHs usually occur in older patients and present with atypical symptoms. Their diagnosis and treatment are still controversial, with various authors describing open midline or paraspinal approaches using the microscope with varying amounts of success. Percutaneous endoscopic techniques have traditionally been considered unsuitable for these herniations.
The patho-genesis of common persistent and chronic low back pain is a difficult condition to treat, because its pathogenesis is multifactorial and may be only partially understood. Non-operative therapeutic methods are the first treatment of choice, with multiple stakeholders offering a myriad of non-surgical treatment options. It includes the use of prescription and nonprescription pain medication, physical therapy, pain management, or multiple nonsurgical methods to treat pain, such as acupuncture or natural pathic methods.
These options provided by non-surgeons usually offer only temporary benefits. For the patients who benefit, and continue to utilize these treatments regularly, they also adopt better life styles, such as weight loss, healthier eating and exercise, which help, but many continue to seek additional treatment options after a reasonable period when symptoms persist or their activities of daily living becomes significantly restricted. Most appropriately reserve surgical options as the last option. A novel minimally invasive surgical option is considered here.
Endoscopic spine surgery is receiving intense interest as minimally invasive techniques, robotics and biologics are the latest focus in spine care that is embraced by a myriad of providers, all touting their area of expertise as the answer to treating painful conditions of the spine. All stakeholders agree that if non-surgical methods of treatment are effective, the natural adaptation of painful degenerative conditions will eventually be mitigated or resolved with some modification of work or activities of daily living that avoids aggravating the clinical condition or delays a rapid advancement to a painful condition.
Each stakeholder in the treatment spectrum is touting, and marketing their areas of expertise, but few stakeholders work together in a truly multidisciplinary and cooperative agenda. Procedural or surgical interventions are easiest to market and to measure its efficacy and cost effectiveness. The cumulative cost of spinal care is, however, becoming less affordable as spinal care does not follow the economics of a free market since increased consumption and availability does not result in decreased cost as an economic model.
There is a need for cooperation and a focus on the diagnosis and treatment of common painful conditions of an aging spine, starting with common back pain that affects tens of millions of patients. Back pain is one of the most costly and debilitating conditions universally affecting work productivity.
In the United States and in industrialized countries, new procedures for back pain tend to “follow the money” aided by industry. In Asian and OUS countries, there is more acceptance of traditional non-surgical treatment from thousands of years of medical treatment history. New and non-traditional treatments based on evolving science, are being made readily available in the information highway by Open Access Journals where researchers can publish their Level V evidence-based concepts for interested parties and other scientists.Anthony T. Yeung’s work focuses on the surgical treatment of the pain generator in the lumbar spine. Patient selection is aided by using diagnostic and therapeutic injections, to identify the likelihood of surgical success when the pain source is targeted. This article focuses on the details of Yeung’s 27 years’ experience on identifying and treating the pain generators in the lumbar spine by an endoscope and combined with an endoscopic system that he has trademarked the Yeung Endoscopic Spine System (YESS™).