The production of chymopapain and its availability in the United States and Europe has been discontinued by its manufacturer. This creates an untenable and unacceptable situation. Our patients are without chemonucleolysis (CNL), a proven treatment for disc related nerve root pain. FDA confirmed that Chymodiactin®, which is injected during the CNL procedure, was not discontinued for reasons of safety or effectiveness
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.
The patho-anatomy in an aging spine is partly defined by Rauschning’s anatomic cryosections. Theories of pain generation and principles of minimally invasive spine surgery are suggested by close examination of these specimens. If the visualized patho-anatomy can be studied in vivo in a partially sedated patient by spinal probing, spinal pain can be better understood, and rational endoscopic treatment options may then evolve.1 A 1997 IRB-approved study provided evidence that endoscopic transforaminal surgery was feasible for the treatment of a wide spectrum of degenerative conditions in the lumbar spine. The technique incorporated evocative chromo-discography to correlate reproduction of pain with in-vivo probing of patho-anatomy. Laser and radiofrequency ablation augmented mechanical decompression to obtain pain relief.1-3 Endoscopic visualization of patho-anatomy ranging from annular tears to spondylolisthesis and stenosis provided clinical evidence that foraminal decompression, ablation, and irrigation could effectively treat these visualized painful conditions with minimal morbidity. This resulted in a better understanding of the pain generators in the lumbar spine, opening up options for surgical pain management.1-5 The procedure does not burn any bridges for more traditional surgical techniques. The learning curve may be steep for some and long for others, but results are very good, concomitant with each individual surgeon overcoming his personal learning curve.
Introduction: Endoscopic spine surgery has attracted both surgeons and nonsurgeons in increasing numbers as endoscopic spine systems, a variety of spine endoscopes, and new and evolving surgical instrumentation are developed. The procedure, using fluoroscopically guided percutaneous techniques, are getting more standard, easier, safer, readily reproducible, and more cost effective. It has also been an avenue for surgeons and a few appropriately trained and certified non-surgeons to participate in a minimally invasive, procedure oriented health care delivery platform that provides cost effective results after failure of nonsurgical methods. Such a multidisciplinary team has been established at the University of New Mexico through a donation to the University by the first author.
Discussion: Asia, especially China and Korea, has seen adoption of endoscopic spine surgery grow exponentially in the past few years, recognizing that endoscopic spine surgery may be the answer to delivering cost effective spine care to their working and aging population. Two basic methods are the mainstay of current endoscopic techniques. The least invasive techniques in the lumbar spine are transforaminal, but translaminar endoscopic approaches are better accepted and easier for endoscopic surgeons to grasp.
Conclusion: Endoscopic spine surgery has great promise in countries with looking for cost effective delivery of health care to its population. Endoscopic surgery is the least minimally invasive surgical platform that will facilitate a move away from fusion as a first line of surgical treatment, delaying or eliminating fusion for patients who may have indications for decompression and fusion, but do well with an earlier and staged procedure that will mitigate the need for open decompression and fusion by 75%, derived by large individual and group databases known to this author.
A retrospective review involving 307 consecutive cases of lumbar disc herniation managed by posterolateral endoscopic discectomy was conducted.
To describe a contemporary posterolateral endoscopic decompression technique for radiculopathy secondary to lumbar disc herniation; to evaluate the efﬁ- cacy of the technique as it is applied to lumbar disc herniation including primary herniation, reherniation, intracanal herniation, and extracanal herniation; and to report outcome and complications.
The standard technique for arthroscopic microdiscectomy (AMD) began as a nucleotomy procedure that resulted in random and variable amounts of disc fragments removed from the central and posterior central part of the nucleus pulposus. This process, as initially described by Kambin, is now enhanced by new endoscope designs and more exacting techniques to target herniated and degenerated disc tissue, whether contained, extruded, or migrated. The previous indications limiting this procedure to contained herniations no longer holds, as improved visualization makes it possible to remove extruded and migrated fragments.
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)
Surgical management of back and leg pain is evolving and changing due to a better understanding of the patho-anatomy well correlated with its pathophysiology. Pain is better understood with in vivo visualization and probing of the pain generators using an endoscopic access rather than just relying on symptoms diagram and image correlation. This has resulted in a shared decision making involving patient and surgeon, focused on a broader spectrum of surgical as well as non-surgical treatments, and not just masking the pain generator. It has moved away from decisions based on diagnostic images alone, that, while noting the image alterations, cannot explain the pain experienced by each individual as images do not always show variations in nerve supply and patho-anatomy.
The ability to isolate and visualize “pain” generators in the foramen and treating persistent pain by visualizing inflammation and compression of nerves, serves as the basis for transforaminal endoscopic (TFE) surgery. This has also resulted in better pre surgical planning with more specific and defined goals in mind. The “Inside out” philosophy of TFE surgery is safe and precise. It provides basic access to the disc and foramen to cover a large spectrum of painful pathologies.
Current surgical philosophy by traditionally trained spinal surgeons focuses on decompression with or without fusion as the “ultimate cure” for a painful spinal segment. Endoscopic surgery-the least invasive of current minimally invasive surgical options—focuses on treating the patho-anatomy of the pain generator. Spondylolisthesis is traditionally represented as a “gold standard” for fusion, but with minimally invasive techniques evolving, there is a new path between traditional open decompression and fusion that offers an alternative. A review of a database of patients who refused fusion, but opting to an endoscopic decompression with sciatica, even in the face of back pain determined that transforaminal decompression for a disc herniation or foraminal stenosis is effective in some patients and result in a decrease in the need for fusion.
The endoscopic transforaminal decompression technique is discussed as a stand-alone or staged procedure that may reduce the number of surgical fusions in the face of degenerative and isthmic spondylolisthesis. When combined with surgical rhizotomy for low back pain, this hybrid procedure includes rhizolysis for posterior column back pain, may offer a cost-effective method for treating common debilitating chronic low back pain.