XXVII JORNADA NACIONAL DE ORTOPEDIA Y … CERVICAL WITH IOM.pdfTRAUMATOLOGIA Acapulco, Mexico May...

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Anterior Endoscopic Cervical Discectomy/Foraminoplasty

Surgical Technique with Case Illustration

John C Chiu, MD, FRCS (US), DSc Chief, Neurospine Surgery California Spine Institute

Thousand Oaks, California, USA President AAMISMS

XXVII JORNADA NACIONAL DE ORTOPEDIA Y TRAUMATOLOGIA Acapulco, Mexico

May 1-5, 2013

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California Spine Institute Medical Center, Inc

Calif. Center for Minimally Invasive Spine Surgery

“Guten Tag!”

“Bonjour”

“Buenos Dias”

“Ciao”

“Konnichi wa”

Kinh Môi

“Bienvenida del CSI”

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Overview

1. MISS being disruptive technology with

dilatation technology instead of cutting

technology

2. To discuss endoscopic cervical decompressive

discectomy and foraminoplasty

3. Related non-fusion technique and dilatation

technology for preservation of spinal motion

4. MISS with limited visualization needs precise

MISS approach

5. The importance having MISS technology,

education and training needed for meticulous

MISS

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44

1%

318

8%

890

23%

1576

40%

1039

27%

50

1% C2

C3

C4

C5

C6

C7-T1

Endoscopic Anterior Cervical Discectomy (AECD)

• Since 1995, 2169 patients

with 3917 herniated cervical

discs

• Average age of 43.4 (21 to 82)

with symptomatic cervical,

single and multiple herniated

intervertebral discs

• Males: 1109- Females: 1054

• Each failed at least 12 weeks

of conservative care

• Post operative follow up: 6 to

75 mos. (average 46.4

months)

Demographics of Herniated Cervical Discs (3917)

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Surgical Indications:

• Neck with arm pain (radicular pain) associated with paresthesia, sensory loss, muscle weakness and/or decreased reflexes

• Intractable cervicogenic headache

• Discogenic pain

• At least 12 weeks of failed

conservative therapy

• MRI or CT scan positive for disc herniation

• Positive EMG considered helpful

• Positive provocative discogram

• Multiple discs can be treated at one sitting

• Post fusion junctional disc herniation syndrome

• Positive 3 legs of bar stool – symptoms, physical findings, EMG, imaging and provocative discogram


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• Two post ACF fusion C4-C6 & C5-

C6 JDHS cases

• MRI showing junctional discs

• Anterior endoscopic cervical microdiscectomy (AECD) and foraminoplasty provides relief

In addition, Post Spinal Fusion -

Junctional Disc Herniation Syndrome

(JDHS), Adjacent Segment Disease (ASD)

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AECD Surgical Instruments and Equipment:

• Endoscopic surgical instruments for AECD

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• Advanced endoscopic micro flexible forceps, bone

ronguer and navigable dissecting probe

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• For bony decompression: – Round ball tip drill

– Sharp drill and trephine

• Advanced anterior cervical endoscopic instruments

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• Anterior cervical endoscopic instruments

Discectomes, working channel

sets Tri-chip digital camera with cervical

6°endoscope and forceps

• Holmium YAG laser equipment

• Laser Thermodiskoplasty (LTD)

Endoscopic laser fibers and

Instruments

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Surgical Procedure/Technique:

• Instruments for tissue

modulation

• Percutaneous MIST

interventional procedures:

– Injectional, non ablative and

ablative tissue modulation

technology, laser, RF

(radiofrequency), ultrasound,

cryogenic and others

– MISS surgeons should be

familiar with injectional and RF

facet denervation procedures

and others

– MISS surgeons are uniquely

suited to perform these for the

care of the spinal pain

http://www.dirostech.com/productright.php?a=4

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Surgical Procedure/Technique:

– Selective nerve

blocks, epidural

block and cervical

sympathetic nerve

block

– Facet arthralgia

(medial branch of

posterior primary

rami)

– Spinal discogenic

pain (related to sinu-

vertebral nerve)

– Cervicogenic

headache

Injectional and tissue modulation technology, RF treatment for:

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ANESTHESIA – AECD Surgical Technique:

• Local anesthesia combined with

IV conscious sedation with

surface EEG monitoring optimize

anesthesia and reduce drug

requirement

• The obvious challenge of MISS is

limited visualization and

exposure of the relevant anatomy

and direct visualization of the nerve

• Continuous intra-operative

EMG/neurophysiological

monitoring in a digital operating

room (DOR) prevents undue neural

trauma

• IOM of neural structure, direct

visualization with fluoroscopy and

endoscopy creates safer

endoscopic MISS procedures

ANESTHESIA and Intra-operative neurophysiological monitoring (IOM)

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Intraoperative Neurophysiological Monitoring - IOM

• Trend of spinal surgery is toward less or

minimally invasive spine surgery (MISS)

• MISS aims at being less traumatic, with less

morbidity and improved surgical outcome

• The obvious challenge of MISS is limited

visualization and exposure of the relevant

anatomy in spite of fluoroscopy and endoscopy to

work with, and potentially placing the relevant

neural structures at increased risk of trauma

• INTRAOPERATIVE NEUROPHYSIOLOGICAL

MONITORING (IOM) of neural structure, direct

visualization with fluoroscopy and endoscopy

creates safer endoscopic MISS procedures

• Spontaneous EMG monitoring, at times SSEP

and MEP can provide the surgeon with useful

feedback to avoid neural trauma during MISS

• Intra-operative surface EEG/neurophysiological

monitoring optimizes the anesthesia for MISS

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Surgical Technique - Step by Step with Case Illustration

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Case Illustration I – Large extruded C6-7 disc:

34 year old accountant suffering from intractable increasing neck and left arm pain and weakness. MRI scan showed

large C6-7 extruded disc/osteophyte which was relieved by endoscopic cervical discectomy and foraminoplasty.

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Endoscopic Anterior Cervical Discectomy (AECD) Surgical Technique:

• Supine position with

hyperextension of neck

• Digital retraction of

trachea/esophagus, and the

carotid artery under the first

two fingers

• Systolic arterial pressure

maintained at 130+ ephedrine

may be used to maintain BP

• Needle and stylette inserted

into the disc aided by GPS,

under fluoroscopy and EMG

• N/G tube is placed in the

esophagus to avoid injury

• Patient Positioning and surgical portal of entry

• Needle and stylette placement into the disc under Grid Position

System (GPS)

45°

20°

GPS

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AECD Surgical Technique:

• Small 3mm skin incision

• The spinal needle with a thin stylette is introduced into the center of the disk

• Under fluoroscopy

• Provocative discogram is often done first

• The working cannula/dilator are passed over the stylette gently (dilatation technology)

• Mechanical microdecompressive discectomy to follow

• Completed with laser thermodiskoplasty (LTD) to shrink and to tighten the disc besides sinu-vertebral denervation

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Endoscopic/fluoroscopic/imaging monitoring to provide safe and precise application of aggressive micro grasper forceps, drill, curette, discectome,

and bony ronguer for microdecompression

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Endoscopic Cervical Microdiscectomy and Foraminoplasty Procedure – Step by Step - A

Discogram demonstrated double shadow of large extruded disc/osteophytes

Micro-drill and forceps for microdecompression of disc/osteophyte

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Endoscopic Cervical Microdiscectomy and Foraminoplasty Procedure – Step by Step - B

Microdecompression along posterior spinal canal with safety ronguer, drill and forceps

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Endoscopic Cervical Microdiscectomy and Foraminoplasty Procedure – Step by Step - C

Final removal of disc fragments/debris with ronguer, forceps, laser thermodiskoplasty, irrigation and cleaning with a discectome

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“Fan Sweep Maneuver”

• For maneuvering instrument to precisely increase the area

for microdecompressive discectomy

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• Mechanical microdecompressive discectomy

• Herniated disc fragment removal

• Laser Thermodiskoplasty – disc shrinkage and tightening

Endoscopic Microdiscectomy – Laser Thermodiskoplasty (LTD)

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• Mechanical decompressive discectomy foraminoplasty for

osteophytes/stenosis under fluoroscopy, endoscopy and IOM

Cervical Foraminoplasty Cervical Foraminal Decompression for Foraminal Disc and Stenosis

Microdiscectomy forceps Micro curette

Trephine for osteophytectomy Burr for osteophyte

decompression

Micro cutting forceps

Discectome

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• Endoscopic views of uncinate joint and nerve root

after disc decompression, and fissure in cervical

disc

Uncinate joint and nerve root after

endoscopic microdecompressi

on

Intra operative endoscopic view

of fissure in cervical disc

Nerve root

Uncinate joint

Disc

Disc

Fissure

LTD defect

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Level Stage Watts Joules

Cervical First Stage 8 300

Cervical Second Stage 5 200

• Absorbed by water

• A pear shaped cavitation bubble formed by

vaporization of water molecules, undergoes

expansion and collapse - resulting in acoustic

and shock wave emission

• Simultaneously a vapor channel is formed that

effectively conducts laser energy to the target

with a pressure effect

• Continuous cold saline irrigation is necessary

Holmium YAG laser with photo thermal effect and mechanism:

Protocols for laser thermodiskoplasty (LTD)

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Laser used to shrink and

tighten the disc besides

“purse string” of the disc

defect

“Fan sweep maneuver” of

instrument increased disc

removal and shrinkage

Side fire laser probe

in action

Surgical technique of LTD, fan sweep maneuver and

endoscopic views of disc shrinkage

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AECD Post Operative Care:

• Ambulatory usually in about one hour

and discharged subsequently

• May shower the following day

• May use a cervical collar in a vehicle or

on a flight as needed

• Ice pack is helpful

• Mild analgesics and muscle relaxant are

required at times

• Progressive spine exercise second

post operative day on

• Rehabilitation compliments MISS and

motion preservation

• Allowed to return to work in one to two

weeks (not for heavy work)

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AECD Surgical Outcome:

• For 2169 patients, average follow-up 46 months (6-75 months)

• Overall result: 1952(90%) patients with good to excellent results, fair results 130(6%) patients (single level)

• Various evaluations/tests of response to

treatment: modified Mac Nab criteria, Oswestry

disability score/index (ODI), visual analogue

pain scale (VAS), patient satisfaction scoring,

pain diagram and/or patient target achievement

score (PTA) for assessment were utilized

• Average satisfaction score – 2309 (94% )

patients

• 98 (4.5%) patients had mild residual pain and

parasthesia, although overall their pain

lessened

• Complication rate: less than 1%

• Average return to work: ten days

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Case Illustration I – Octogenarian w/herniated C5-6 disc/osteophyte:

81 yo NS Professor underwent successful laser endoscopic cervical discectomy in spite of transient extreme bradycardia (30), detected, monitored and corrected with atropine in the DOR. Discharged on hour later

Intra operative monitor shows severe dropping of heart rate

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Case Illustration II – JDHS C3, C4 & C6

• 54 year old female suffering post

fusion junctional disc herniation

syndrome (JDHS) (after C5 & C6

corpectomy, discectomy and bone

graft of C5-C6) at C3, C4 & C6

levels with severe radiculopathy

• Complete relief of spinal

symptoms after AECD and

foraminoplasty at C3, C4 & C6

level

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Case Illustration III - Herniated C5-6 disc:

50 yo female under went successful endoscopic microdecompressive cervical discectomy for a large herniated C5-6 disc

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Case Illustration IV- Large herniated C3-4 disc:

English rock star had successful endoscopic cervical discectomy C3-4 with hypoplastic odontoid process

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Case Illustrations V - Large herniated C5-6 disc:

• 44 year old female with increasing intraticable neck and

upper extremity pain and numbness of fingers, mild

spastic gait and weakness of hand grip, mild hyper

reflexia, and hypoesthesia

• AECM - post operatively rapid improvement and

disappearance of all symptoms

Pre operative MRI scan - Large 5 mm herniated C5-6

disc compressing spinal cord with myelopathic

changes of the spinal cord

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Case Illustration VI - Large herniated C5-6 disc:

• 35 year old male rock star with increasing intraticable neck and

upper extremity pain and numbness of fingers, unable to perform

• AECM and left C5-6 foraminal decompressive discectomy

and foraminoplasty gave immediate relief of all symptoms

Pre operative MRI scans - Large foraminal herniated C5-6 disc

compressing C6 nerve root

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Discussion:

• New biotechnology, instrument advances and

accumulation of endoscopic spinal surgical

experience, make the procedure of AECD and

foraminal decompression (foraminoplasty)

possible

• Open cervical spinal surgery/fusion results in

higher complication and morbidity besides longer

convalescence

• Post cervical spinal fusion patient, has high as 25 –

52% of them developed Junctional Disc Herniation

Syndrome (JDHS) or Adjacent Segmental Disease

(ASD) within 3-4 years

• AECD MISS is an effective alternative or

replacement for open spinal surgery for discectomy

and decompression of stenosis in degenerative spine

disease

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Discussion:

• As demonstrated in a multi-center endoscopic cervical

spinal disc surgeries had an overall success rate of

91% (single level)

• With a complication rate of less than 1%, zero

mortality, satisfaction score, over 90% (for single and

multi-levels)

• Second operation required only in 0.79%

• Resuming usual activity in a few days and full active

lives in 2-6 weeks

• These procedures can be extremely gratifying for

patients and surgeon

• Soon spinal arthroplasty, spinal motion preservation

and dynamic stabilization can become an integral part

of all cervical spinal surgery

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AECD Discussion:

• In order to perform AECD and to avoid potential complications, one must have a thorough knowledge of laser endoscopic cervical spinal procedures and the surgical anatomy

• Endoscopic cervical MISS has its unique surgical skill set

• Requiring the surgeon to go through a steep learning curve

• Careful patient selection

• Careful preoperative surgical planning

• Fluoroscopy as “The 3rd Eye” or “Eye of Wisdom” for confirmation of location of instruments; endoscopy alone is not enough

• These surgical procedures must be meticulously executed

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POTENTIAL COMPLICATIONS AND THEIR AVOIDANCE

• Excessive sedation:

– Continuous conscious EEG monitoring with the new

computerized SNAP™ monitoring (SNAP index) improves

anesthesia and reduces drug requirement

– Local anesthesia with conscious sedation provides a

responsive patient to facilitate endoscopic MISS and

prevents potential complications

Surface EEG monitoring (SNAP™)

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• Discitis:

– Prophylactic antibiotics

– Continuous irrigation of the

interspace

– Introduction of instruments

through a cannula without

contact with the skin

• Aseptic discitis:

– Aim the laser in a “bowtie”

fashion to avoid damaging the

endplates (at 6 and 12 o’clock)

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• Spontaneous

Cervical Fusion:

secondary to

using larger

working channel,

trephine (5mm or

more) and

trauma to the

endplate causes

spontaneous

fusion at C6-C7

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• Neural Injury: extremely rare

– No spinal cord injuries reported

– Nerve root and spinal cord injury,

though possible, but avoidable

– With neurophysiologic monitoring

(EMG/NCV)

– Root injury avoided by introducing

instruments in the “safety zone”

– And direct endoscopic visualization

– By frequent use C-arm fluoroscopy

– Recurrent laryngeal nerve injury, is

extremely rare

– Postoperatively one case of transient

hoarseness

– One case with transient hiccough

Continuous

intraoperative

neurophysiologic

monitoring (EMG/NCV)

Intra operative endoscopic view of

fissure in cervical disc

Uncinate joint and nerve root after endoscopic

microdecompression

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• Sympathetic nerve injury:

– Rare but can occur from injury to cervical sympathetic and Stellate

Ganglions

– One post-operative transient Horner syndrome or oculo sympathetic

dysfunction occurred

• Esophageal and trachea injury due to trauma or perforation

can occur:

– But are avoided by careful surgical technique and by identifying and retracting these

structures

– By careful digital palpation and retraction at the site of needle insertion

– By placing a nasogastric tube into the esophagus aids in identifying and retracting

that structure by palpation.

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Conclusion:

• AECD has proven to be safe, less traumatic, easier, and efficacious

• For treatment of intractable spinal pain secondary to herniated cervical discs, and degenerative cervical spinal disease/foraminal stenosis

• It preserves spinal segmental motion, avoids JDHS, and provides an excellent access for spinal arthroplasty

• Utilization of intraoperative neurophysiological monitoring, IOM in a DOR prevents neurological injury and provides a safer MISS

• With proper surgical training and experience, it is a smart way to perform cervical spinal surgery

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Hope you enjoyed this presentation!

“Danke schön”

“Merci” “Gracias”

“Cám ón”

“Arigato”

“Thank you”

John C. Chiu, M.D., FRSC (US), D.Sc.

California Spine Institute

“Gracias por su amable atención”

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spinecenter.com

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XXVII JORNADA NACIONAL DE ORTOPEDIA Y … CERVICAL WITH IOM.pdfTRAUMATOLOGIA Acapulco, Mexico May...

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