Endoscopic Spinal Surgery for Herniated Lumbar Discs

Transforaminal Endoscopic Decompression in the Setting of Lateral Lumbar Spondylolisthesis

What's New in Spine Surgery.

History of endoscopic spine surgery: where did it all begin? Development of indications and techniques.

Bleeding is a commonly encountered problem in spine surgery. The increasing popularity of endoscopic spine surgery poses new challenges to spine surgeons, especially those who are embarking on the learning curve. Hemostasis in endoscopic spine surgery can be difficult due to the narrow working channel and bleeding obscuring the endoscopic view, which hinders hemostasis and effective continuation of the operation. To minimize the risk of bleeding and improve hemostasis, a multimodal approach should be employed, including appropriate strategies for perioperative prevention, intraoperative surgical techniques, and postoperative correction/care. In this technical review article, we discuss several hemostatic techniques that are commonly used in endoscopic spine surgery. We also describe a new bone wax application technique in endoscopic spine surgery—called the “bone wax on pattie” technique—to avoid bone wax sticking onto the working channel/endoscope lens, while enabling easier application of bone wax onto the bleeding bone surface. We share some of our experiences with hemostasis in endoscopic spine surgery, and we hope to gather feedback from fellow spine surgeons around the world, so that we can contribute to further developments in the field together.

The incidence of adjacent segment disease (ASD) after lumbar spine surgery is a condition that has become increasingly common as the rate of lumbar spine surgery continues to rise. Minimally invasive techniques continue to be refined and offer an opportunity to treat ASD with minimal tissue disruption, lower blood loss, a shorter hospital stay, and decreased morbidity. The aim of this report is to describe the various minimally invasive options for ASD with a comprehensive review of the existing literature. A retrospective chart review of patients undergoing minimally invasive spine surgery (MIS) for ASD of the lumbar spine was conducted. Four basic techniques and their modifications were identified to address ASD. Illustrative cases, surgical techniques, and post-surgical outcomes are described. Four MIS techniques were identified as common surgical methods to correct ASD. (1) Non-instrumented discectomy, foraminotomy, or decompression, (2) anterior lumbar interbody fusion (ALIF), (3) transforaminal lumbar interbody fusion (TLIF), and (4) lateral lumbar interbody fusion (LLIF) were found to be MIS techniques that address ASD. ALIF and LLIF provide indirect decompression of the neural foramina, while TLIF provides direct decompression. The addition and removal of screws and rods can be combined with any of these techniques. MIS techniques provide decompression of the neural elements, stabilization, and, potentially, fusion for patients with ASD. These illustrated cases and the review of MIS surgical techniques can provide a comprehensive framework for addressing ASD.

Introduction: The history and development of endoscopic spine surgery (PELD) in China is reviewed. Its significance and effect is predicted to have great implications for advancing spine care in China’s working and aging population. Percutaneous spine technology was introduced simultaneously from Japan and the United states by Hijikata and Kambin in the early 1980s. It was called Arthroscopic Microdiscectomy (AMD). The access portal was called “Kambin’s Triangle, with the discectomy technique through a “safe” puncture portal through an anatomical triangular zone in the foramen bordered by the facet and foraminal ligament dorsally, the exiting nerve ventrally, and the endplate of the caudal margin of the triangle. Method: An expanded indication for the transforaminal Kambin technique was introduced to China by Anthony Yeung in 1998, and its evolution and contribution to modern minimally invasive spine care, called the Yeung Endoscopic Spine System (YESSTM) technique, is reviewed. The percutaneous technique has been adopted by surgeons as well as non-surgeons who also undergo surgical training in their rehabilitation programs who integrate the technique through their various affiliations in China for painful degenerative conditions of the spine. Results: The efficacy of the endoscopic technique has evolved significantly since Kambin, with additional contributions by Chinese surgeons and key opinion leaders of surgical and non-surgical Chinese associations that have co-existed, but are focused on providing treatment options for the Chinese population for centuries. Western Medicine has provided great influence on Chinese medicine, but a significant percentage of the Chinese population still cling to traditional treatment, embracing both Old and New methods. With respect to modern surgical techniques, surgeons and no surgeons are cooperative, and focus on results while working together. They recognize that with endoscopic spine surgery, it is important to maintain a success rate comparable to traditional western open surgery with less surgical morbidity utilizing the endoscope. Peer reviewed papers are emerging from China, using the EBM guidelines of Western Journals. Conclusion: A rapidly increasing number of surgeries along with improving results will continue to drive this minimally invasive surgical method to China that bridges the gap between non-surgical pain management, physical medicine, and surgical intervention that focuses on the patho-anatomy and patho-physiology of spinal conditions of pain. This will be known as “surgical pain management, a term coined by Dr Anthony Yeung. Future developments will continue to drive the adoption of endoscopic surgery as a significant advancement for Chinese medicine and surgery.

Due to its ultraminimally invasive nature, endoscopic spinal surgery is an attractive tool in spinal oncologic care. To date, there has been no comprehensive review of this topic. The authors therefore present a thorough search of the medical literature on endoscopic techniques for spinal oncology. A systematic review using PubMed was conducted using the following keywords: endoscopic spine surgery, spinal oncology, and spinal tumors. Collectively, 19 cases described endoscopic spine surgery for spinal oncologic care. Endoscopic spine surgery has been employed for the care of patients with spinal tumors under the following 4 circumstances: (1) to obtain a reliable tissue diagnosis; (2) to serve as an adjunct during traditional open surgery; (3) to achieve targeted debulking; or (4) to perform definitive resection. These cases employing endoscopic techniques highlight the versatility of this approach and its utility when applied to the right patient and with an experienced surgeon. Our systematic review suggests that, given the right patient and an experienced surgeon, endoscopic spine surgery should be considered in the armamentarium for spinal oncologic care for both staging and definitive resection. This systematic literature review showed that endoscopic techniques have been successfully applied across the spectrum of care in spinal oncology, from diagnosis to definitive treatment.

Lumbar disc herniation (LDH) comprises one of the most common causes of low back pain. 35%–72% of LDH is associated with disc fragment migration. The migration of the disc fragments can be high-grade up, low-grade up, high-grade down, and low-grade down. Spine surgeons deal with unique challenges during surgical management of migrated discs. Operational challenges with open surgery include extensive lamina excision, pars excision, and potential for iatrogenic instability without fixation. In contrast, rigid instruments and poor visualization are the challenges with transforaminal endoscopic spine surgery (ESS). Hence interlaminar approach with ESS is an excellent choice with these migrated LDH. The creation of a translaminar crater in the cranial lamina without dealing with the interlaminar window or ligamentum flavum could be an excellent option to deal with these herniations face front. The lamina is the only anatomical barrier between the endoscope and the migrated disc fragment. Hence with a translaminar approach, unnecessary flavectomy can be avoided. In this technical report and video, we demonstrate the surgical technique of performing the translaminar ESS for highly upmigrated LDH with the preservation of optimal natural anatomy.

Transforaminal endoscopic spinal surgery: The future ‘gold standard’ for discectomy? – A review

A paucity of literature on the effect of spinal endoscopic surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients. Evaluation of the effect of endoscopic practice expansion in degenerative spinal conditions and disc herniations on patients' outcome as we shifted from first-generation endoscopic discectomy to second-generation decompression and finally third generation of endoscopic spinal fusion practice. Retrospective cohort study on surgical treatment of degenerative spinal conditions for 616 spinal cases. Basic demographics, preoperative, postoperative 1 week, 6 months, and final follow-up of patients' clinical outcomes in terms of pain score, Oswestry disability index, and MacNab's criteria for pain score were evaluated. 75%, 91%, and 97% of the surgeries with complications rate of 8.2%, 9%, and 3.4% were found in Generation 1, 2, and 3 of endoscopic surgery, respectively. Compared to preoperative scores, each generation VAS and ODI scores all statistically significantly improved. In the final follow-up, compared to preoperative state, the mean VAS improvement was 4.75 ± 1.7, 5.49 ± 1.66, and 5.37 ± 1.70, mean ODI improvement was 45.99 ± 11.8, 48.93 ± 11.2, and 48.43 ± 11.41, and MacNab's criteria showed a trend of upward improvement of 87.3%, 96.0%, and 98.7% cases, which showed good-to-excellent outcome, in Generation 1, 2, and 3, respectively. Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing a good clinical outcome.

Minimally invasive spine surgery (MISS) has transformed spinal surgery by minimizing tissue disruption, reducing recovery times, and lowering complication rates compared with traditional open procedures. MISS uses smaller incisions, specialized tools, and advanced imaging to treat conditions such as degenerative disk disease, trauma, and tumors. Techniques such as endoscopic spine surgery and tubular retractors have expanded its applications, enabling effective treatment with less postoperative pain and faster mobilization. Patient selection is crucial to the success of MISS, requiring detailed imaging analysis and consideration of overall health and pathology. Although MISS provides significant benefits, it is less effective for complex spinal deformities that require extensive sagittal or coronal corrections. Technological advancements, including robotic assistance and augmented reality, are enhancing surgical precision and expanding the scope of MISS. Enhanced recovery after surgery protocols, when combined with MISS, improve outcomes by reducing hospital stays and postoperative pain. Complications such as dural tears and hardware misplacement, although less common than in open surgery, require careful management, with techniques such as intraoperative imaging and robotic navigation aiding in complication prevention. Continued innovation in MISS will broaden its application and improve safety and patient outcomes across various spinal pathologies.

This is a retrospective analysis of a prospectively maintained surgical registry. To characterize postoperative narcotic consumption in patients undergoing either an anterior lumbar interbody fusion (ALIF) or a lateral lumbar interbody fusion (LLIF). There is substantial interest in evaluating the safety, efficacy, and outcomes following minimally invasive techniques for lumbar fusion procedures. However, few studies have characterized postoperative narcotic consumption in patients undergoing ALIF or LLIF procedures. Consecutive patients who underwent either an ALIF or LLIF during 2007-2014 were identified. Inpatient narcotic consumption was recorded in oral morphine equivalents and dichotomized as greater or less than the 75th percentile total consumption (elevated or normal inpatient consumption). Demographic, comorbidity, and perioperative characteristics were tested for independent association with inpatient narcotic consumption and with continued narcotic usage during the months following surgery. A total of 169 patients met inclusion criteria. Of these, 118 (69.8%) underwent ALIF and 51 (30.2%) underwent LLIF procedures. The risk for elevated inpatient narcotic consumption was greater in patients whose body mass index was≥30 kg/m [relative risk (RR), 2.8; 95% confidence interval (CI), 1.6-4.8; P<0.001). The risk for continued narcotic usage at the first postoperative visit was elevated in patients with worker's compensation payment status (RR, 2.0; 95% CI, 1.5-2.7; P<0.001). The risk for continued narcotic usage at the second postoperative visit was elevated in patients with worker's compensation payment status (RR, 2.6; 95% CI, 1.7-4.1; P<0.001) and in patients with preoperative narcotic utilization (RR, 2.2; 95% CI, 1.4-3.5; P<0.001). The present study suggests that while patients with greater body mass index have increased narcotic consumption as inpatients, preoperative narcotic consumption and worker's compensation payment status are the best predictors of continued narcotics usage during the months following surgery. Worker's compensation patients and patients who utilize narcotics preoperatively should be the targets of efforts to reduce continued postoperative narcotic usage.

Advancement in medical treatment leads to increase life expectancy and population ageing.The corresponding increase in the incidence of degenerative spinal conditions are top 10 causes of disabilities worldwide. 1As science advances with new procedures, there is a demand for more advanced technology and surgical techniques in spinal surgery to minimise collateral soft tissue damages to provide improved clinical outcomes with less perioperative morbidities for our patients.This demand gives rise to the evolution of endoscopic spine surgery. 2 Despite the many benefits of spinal endoscopy, there is a steep learning curve in spinal endoscopy. 3Surgeons who are practicising the art of spinal endoscopy should be familiar with open surgical techniques and spinal anatomy.As endoscopic spine surgery is a fast evolving field, it is important for practicing endosocpic surgeon to keep current with the latest literature and updates.Since the previous special edition of Endoscopic Spine Surgery in Neurospine in 2020, there is continual development of technology in spinal endoscope in terms of lens clarity, variety of angulation, light transmission, radiofrequency energy systems, spinal endoscopic instruments, and further refinement of surgical techniques by worldwide endoscopic surgeons.This leads to an expansion of clinical indications for endoscopic spine surgery. [4][5]5][6][7][8] In this special edition, we have articles from uniportal full endoscopic and unilateral biportal endoscopy addressing various conditions in spine with advanced endoscopic techniques involving cervical and thoracic decompression as well as endoscopic spinal fusion techniques.We are confident this current special issue of Endoscopic Spine Surgery in Neurospine will become a core forum for spine scholars who are interested in endoscopic spine surgery.We wish you success in your academic, clinical and endoscopic spine surgical career.

Retrospective case series. To characterize the clinical utility of imaging in the recovery room after lumbar fusion procedures. Two sets of images are commonly obtained at the end of lumbar fusion procedures: intraoperative fluoroscopic images near the time of wound closure and plain film images after the procedure in the recovery room. The latter may have low clinical utility. We identified a consecutive series of lumbar fusion procedures. A panel of 3 reviewers assessed intraoperative and recovery room series both for radiographical adequacy and for issues with the surgical construct. One hundred ninety cases were reviewed, of which 92 were posterolateral lumbar fusions, 42 were anterior lumbar interbody fusions, 24 were transforaminal lumbar interbody fusions, and 32 were anterior-posterior fusions. All intraoperative series were adequate, whereas only 90% of recovery room series were adequate. Recovery room series had visible issues with construct placement in 4 cases. In each of these cases, however, the issue was also clearly visible on the intraoperative series, was found to be acceptable clinically, and did not alter management in any way. This study demonstrates that recovery room images are inferior to intraoperative images and offer little or no incremental clinical utility for detecting issues with surgical constructs after lumbar fusion procedures. In settings where it is still performed, recovery room imaging might be discontinued to realize savings in cost, radiation exposure, and time. 4.

A case report. Presentation of transpedicular approach for endoscopic spine surgery (ESS) in a patient with thoracic spine metastases from lung cancer with incomplete paralysis. The spine is the most colonized site for tumor bone metastases, and approximately 5-10% of patients develop symptoms of nerve and spinal cord compression. Traditional open surgery is the best management strategy to address patients' neurological symptoms, but its demanding physical status and low clinical benefit in end-stage patients limit its application in spinal metastases. With the accumulation of experience and technological breakthroughs in ESS, this technology has become an ideal choice for palliative treatment of patients with end-stage spinal metastases. A patient with thoracic spine metastasis from lung cancer with incomplete paralysis was treated with ESS using a transpedicular approach. A patient with lung cancer thoracic spine metastasis with incomplete paralysis was unable to tolerate traditional open surgery due to her physical condition, so our team used the strategy of spinal endoscopic decompression with tumor resection via transpedicular approach to treat him. After the operation, the patient's pain and neurological symptoms were significantly relieved, and he regained the ability to walk on himself within two months. Moreover, the technique prolonged his survival while safeguarding his quality of life. ESS is ideal for patients with end-stage spinal metastases.