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Endoscopic Lumbar DissectomyChanging Trends

Salman Sharif , J OeretelLiaquat National Hospital & Medical College

Karachi Pakistan

Department of Neurosurgery, Saarland University Medical Center, Homburg/Saar, Germany

Introduction

GOLD standard surgical treatment of lumbar disc herniation has been open microdiscectomy.

A minimally invasive endoscopic discectomy involves dilating the paraspinous muscles and using tubular retractors  and using a 

endoscope.

It is thought that dilating the muscles rather than stripping the muscles decreases surgical morbidity. 

Why Minimally Invasive Spine Surgery?

A basic tenet of surgery is to effectively treat 

pathology with minimal disturbance of normal 

anatomy: leaving “the smallest footprint.”

Back Ground

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HISTORY

• In 1934, Mixter and Barr first explained the traumatic or degenerative origin of disc herniation and its association with lumbago or sciatica

• Forst and Hausmann first insertion of modified arthroscope into the intervertebral disc space for direct visualization of the disc space in 1983

• Kambin and other authors reported about 87% successful outcome rate with arthroscopic microdiscectomy

• 1997, Smith and Foley introduced the MED system,

• 1998,Smith and Foley presented results for their first 100 patients.

• 1999, METRx tubular dilator system with endoscope 

MISS‐Advantages

• Reduced post‐operative pain

• Tiny scars

• Shorter recovery time

• Shorter hospital stay

ENDOSCOPIC TECHNIQUE

• Improved illumination

• Better focus „on spot“

• Superior circumferential view byapplication of angled optics

• Less invasive – smaller less traumaticapproach

Impact of Muscle Retraction

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Impact of Muscle Retraction

Taylor H et al(Spine;2002): Impact of self retaining retractors on paraspinal muscles

Twenty patients; Intramuscular pressure measurement 5, 30, 60 min into the surgery 

Muscle biopsies before and after retraction studied using ATP birefringence.

Significant increase in IMP during retraction Reduced function following retraction(decreased ATP)

THEORITICAL ADVANTAGE

• Minimal muscular trauma

• May be decreased scarring at the durabecause of    

• „mini‐opening“ and higher magnification

• Significant patient demand

• Superior aesthetic result

• Less postoperative pain

MICROENDOSCOPIC DISCECTOMY

• Microendoscopic discectomy (MED) is emerging as a minimally invasive alternative to conventional microsurgical discectomy (MSD). 

• Intralaminar endoscopic spinal endoscopy claims smooth transition from MSD to MED, with a reduced learning curve period

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Journal of Neurosurgery: SpineAkihito Minamide, 2013 / Vol. 19 / No. 6 / Pages 664-671

Endoscope-assisted spinal decompression surgery for lumbar spinal stenosis Technical note

• 366 patients • Microendoscopy provided wide visualization through oblique lenses and allowed

bilateral decompression via a unilateral approach, through partial resection of the base of the spinous process, thereby preserving the supraspinous and interspinous ligaments and contralateral musculature

• 2-year follow-up for 310 patients• The overall results were excellent in 34.9% of the patients, good in 34.9%, fair in

21.7%, and poor in 8.5%.

• Twelve surgery-related complications were identified: dural tear (6 cases [1.9%]), wrong-level operation (1 [0.3%]), transient neuralgia (4 [1.3%]), and infection (1 [0.3%]). All patients recovered, and there were no serious postoperative complications.

Microendoscopic laminotomy is a safe and very effective minimally invasive surgical technique for the treatment of degenerative LSS.

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Lateral recess stenosis interlaminar endoccopic vs. microscopic

Ruetten et al. J Neurosurg Spine 10:000–000, 2009

• 161 patients with FE or microsurgical decompression• Visual analog scale, North American Spine Society 

instrument, and the Oswestry low‐back pain disability questionnaire.

• 74.5% of patients reported no longer having leg pain, and 20.5% had only occasional pain

• The clinical results were the same in both groups at 2 years• Complications and revisions was significantly reduced in the 

FE group..• The clinical results of the FE interlaminar technique are 

equal to those of the microsurgical technique.• At the same time, there are advantages in the operation 

technique, such as reduced traumatization. 

Full‐Endoscopic Interlaminar and Transforaminal Lumbar Discectomy Versus ConventionalMicrosurgical Technique

A Prospective, Randomized, Controlled StudySebastian Ruetten, MD, PhD

• One hundred seventy‐eight patients with endoscopic or microsurgical

• After surgery 82% of the patients no longer had leg pain, and 14% had occasional pain.

• The clinical results were the same in both groups. 

• The recurrence rate was 6.2% with no difference between the groups.

• The endoscopic techniques brought significant advantages In back pain, rehabilitation, complications, and traumatization.

• The clinical results of the full‐endoscopic technique are equal to those of the microsurgical technique.

• Advantages in the operation technique and reduced traumatization. With the surgical devices and the possibility of selecting an interlaminar or posterolateral to lateral transforaminal procedure, lumbar disc herniations outside and inside the spinal canal can be sufficiently removed using the endoscopic technique

Technique for lumbar dissectomy

Minimally invasive compared to open microdiscectomy for lumbar disc herniationDarryl Lau, Seunggu J. Han, Jasmine G. Lee, Daniel C. Lu, Dean Chou⇑

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The final tubular retractor placement

The final tubular retractor is placed.

Intra operative fluoroscopic image

Intraoperative fluoroscopic image showing tubular retractor docked on inferior edge of lamina.

Incision of the muscle facia

Without sufficient incision of the facia:

Compression of the paravertebral muscles at the tip of the work sheath 

In this case the procedure has to be aborted and the work sheath newly inserted 

3. Positioning an trajectory of the trocar

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3. Positioning an trajectory of the trocar

Lamina

Trajectory towards the disc

3. Positioning an trajectory of the trocar

Idealy positioning perpendicular to the lamina

Positioning an trajectory of thetrocar

Pitfalls:

Perforation:

• Lamina

• Interlaminar window

• Dura sack

Tip of the trocar not close enough to the lamina

View after the ipsilateral laminotomy

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Martín‐Láez R, et al

. Complications of endoscopic microdiscectomy using the EASYGO! system: is there any difference with conventional discectomy during the

learning‐curve period?Acta Neurochir (Wien). 2012 Jun;154(6):1023‐32. doi: 10.1007/s00701‐012‐1321‐5. Epub 2012 Mar 24.

• 138 patients • 37 using an MED approach and 101 by a conventional MSD. • Complications 9.8 % MSD group and 8.1 % of the MED group (P = 0.49). • Relieved symptoms 68.63 % MSD and 89.92 % of the MED• No revision surgery was required in the MED group, but it was 

necessary in ten patients of the MSD group.• Between 25 and 30 cases are needed to reach the learning curve's • Even during this initial learning period MED is a safe procedure, with 

comparable results to those obtained with conventional MSD and with a similar complication rate

• Adequate expertise in MSD, a precise selection of initial cases, a proper surgical planning and a careful technique, which are mandatory to avoid unnecessary neurological injury in an otherwise secure surgical approach.

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RECURRENCE

ENDOSCOPIC SPINE SURGERY

• Application possible in a wide range of indication in degenerative spine disease!

• Mainly lumbar!

• Very good results in cervical applications reported!

• Evidence that complication rate no longer higher than with microsurgery!

ENDOSCOPIC SPINE SURGERY

• Reduced muscular trauma by use of sheath system

• The smaller the work sheath, the smaller the muscular and soft tissue damage! 

• The higher the necessity of application of an endoscope!

• Superior aesthetic results

• Evidence!

CONCLUSIONS

Same outcome with less muscular damage and superior cosmetic results

Endoscopy will be play a significant role in thetreatment of degenerative 

spine disease in the future.

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WELCOME TO PAKISTAN