• Endoscopic lumbar discectomy with lumbar nerve root in close proximity

Endoscopic Views in Lumbar Microdiscectomy

Introduction: To demonstrate effective transforaminal endoscopic microdecompression for herniated lumbar discs, junctional disc herniations,

spinal spondylosis and spinal stenosis. This is to be accomplished with endoscopic micro spinal instruments, laser application, and newly developed endoscopic decompression instruments (including SMART endoscopic lumbar spinal tubular

retractors, large cannulae, more aggressive trephines, curettes, rasps, and ronguers), in addition to laser application.

2% 3%10%

48%

37%

L-1L-2L-3L-4L-5

Demographics of Disks (3421)

Lumbar

Material and Methods: 3421 herniated lumbar discs in 2000 patients. Average age of 44.2 (24 to 92) with symptomatic lumbar single and multiple

herniated intervertebral discs. Each failed at least

12 weeks of conservative care. Post operative follow up 6mos to 72mos (average 42mos). 2 types of endoscopic systems are used: 1)For posterior paramedium endoscopic assisted

microdecompression of herniated lumbar discs and spinal stenosis, the SMART™ Endoscopic Lumbar Spine System, a progressive gradual serial of endoscopic assisted tubular retractors with appropriate sized dilators and more aggressive

saw-toothed trephines, and laser are utilized for laser thermodiskoplasty (LTD) for reshaping and tightening disc tissue further; 2) For posteriorlateral transforaminal approach, the foraminoscopes are utilized. Again laser application

is also included for LTD.

Results: There was no postoperative mortality,

and had morbidity of less than 1%, in 2000 patients. For single level, 94% of patients had

good or excellent results, 6% had some residual symptoms though improved overall, and 3% of patients did not improve significantly. A newly devised larger and more aggressive endoscopic assisted tubular microdecompressive discectomy

instrument set (SMART lumbar system), safely and

efficaciously allows wider and more complete removal of large or recurrent disc protrusions, scar tissue, bony spurs, and spinal stenosis that cause nerve root compression, while protecting the

adjacent nerve root.

Conclusion: Transforaminal endoscopic laser microdecompression can effectively decompress

herniated lumbar discs and spinal stenosis, and

perform foraminoplasty for lateral and central spinal stenosis. This minimally invasive endoscopic technique aided by new instruments and laser application (LTD), provides a safe and effective modality to achieve results in effective

decompression of lumbar discs and spinal stenosis, preserves spinal motion and provides a channel for spinal arthroplasty.

Transforaminal Endoscopic Microdecompression for Herniated Lumbar Discs and Spinal Stenosis

John C. Chiu, MD, FRCS, DSc

California Spine Institute—Thousand Oaks, CA 91320, USA—www.spinecenter.com

Learning Objective: The presentation provides the information for participants familiar with Transforaminal Endoscopic Microdecompression for

Lumbar Disc and Stenosis and Their Avoidance: 1. Recognize the surgical indications. 2. The surgical technique. 3. Potential complications and

avoidance

References: 1. Atlas SJ, Keller RB, Robson D, et al.: Surgical and non-surgical management of lumbar stenosis: four-year outcomes from the Maine study group. Spine 25:556-

562, 2000 2. Chiu, J., Savitz, MH. Use of Laser in Minimally Invasive Spinal Surgery and Pain Management. In: Kambin P, ed. Arthroscopic and Endoscopic Spinal Surgery – Text

and Atlas. Second Edition. New Jersey: Humana Press; 2005: Chapter 13, pp 259-269.

3. Chiu J, Clifford T, Princenthal R, Junctional Disc Herniation in Post Spinal Fusion Treated with Endoscopic Spine Surgery: In, Szabo Z, Coburg AJ, Savalgi R, Reich H, Yamamotto M, eds. Surgical Technology International XIV, UMP, San Francisco, CA 2005: p.305-315

4. Chiu, J., Endoscopic Lumbar Foraminoplasty In Kim D, Fessler R, Regan J, eds. Endoscopic Spine Surgery and Instrumentation. New York: Thieme Medical Publish-er; December 2004: Chapter 19, pp 212-229.

5. Chiu J, Clifford T. Transforaminal Endoscopic Decompression: In: Savitz M, Chiu J, Rauschning W, Yeung A, eds. The Practice of Minimally Invasive Spinal Tech-nique: 2005 Edition, AAMISS Press, New City, New York, 2005: 60:p 435-441

6. Chiu J, Transforaminal Endoscopic Laser Microdecompression for Herniated Lumbar Discs and Spinal Stenosis: In; Khamlichi A, eds. Reprinted from 13th World Con-

gress of Neurological Surgery, Marrakesh, 6/19-24/2005, International Proceedings, Medimond, Bologna, Italy, pp. 77-82 7. Chiu JC, Clifford T: Microdecompressive percutaneous discectomy: Spinal discectomy with new laser thermodiskoplasty for non-extruded herniated nucleus pulposus.

Surg Technol Int VIII:343-351, 1999

8. Chiu J, Evolving Transforaminal Endoscopic Microdecompression for Herniated Lumbar Discs and Spinal Stenosis. Surg Technol Int 12/2004; XIII: pp 276-286 9. Chiu, JC, Transforaminal Endoscopic Decompression: Technical note. J Minim Invasive Spinal Tech 4:1, pp 24-26, 2004 10. Chiu J, Digital Technology Assisted Minimally Invasive Spinal Surgery (MISS) for Spinal Motion Preservation. In: Lemke H.U, Vannier MN, Invamura RD, eds. Com-

puter Assisted Radiology and Surgery. Amsterdam, San Diego, Oxford, London; Elsevier Medical Publisher; 2004, pp 461-466.

11. Chiu J, Transforaminal Endoscopic Laser Microdecompression for Herniated Lumbar Discs and Spinal Stenosis, World Spine III: The Third Interdisciplinary Congress on Spine Care, Rio de Janeiro, Brazil, 7/31-8/3/2005, Proceedings: pp. 1

12. Clifford T, Chiu JC, Rogers G: Neurophysiological monitoring of peripheral nerve function during endoscopic laser discectomy. J Minim Invasive Spinal Tech 1:54-57,

2001 13. Destandau J: Endoscopically assisted microdiscectomy, In: The Practice of Minimlly Invasive Spinal Technique (Savitz MH, Chiu JC, Yeung AT, eds), AAMISMS EDU-

CATION, Richmond, VA, 2000, pp 187-192

14. Haag M: Transforaminal endoscopic microdiscectomy. Indications and short-term to intermediate-term results. Orthopade 7:615-621, 1999 15. Kambin P, Casey K, O’Brien E, Zhou I. Transforaminal arthroscopic decompression oflateral recess stenosis, J Neurosurg 84:462-467, 1996 16. Katz JN, Stucki G, Lipson SJ, et al.: Predictors of surgical outcome in degenerative lumbar spinal stenosis. Spine 24:2229-2223, 1999 17. Knight M, Goswami A Patko J, et al.: Endoscopic foraminoplasty: An independent prospective evaluation, In: Laser in the Musculoskeletal System (Gerber BE, Knight

M, Seibert WE, eds), Springer-Verlag, Berlin, Germany, 2001, pp 320-329 18. Khoo L, Fessler R. Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis. Neurosurgery 51 (Suppl 2):146-154, 2002 19. Lin PM: Internal decompression for multiple levels of lumbar spinal stenosis: a technical note. Neurosurgery 11:546-549, 1982

20. Malis LI. Instrumentation and techniques in microsurgery. Clin Neurosurg 26:626- 636, 1979 21. Yeung AT, Tsou PM: Posterior lateral endoscopic excision for lumbar disc herniation. Spine 27:722-731, 2002

OR Setup:

Endoscopic OR suite for MISS

MD’s

Staff

RN, Tech

EMG Monitoring

C-Arm Fluoroscopy

MRI Image - PACS

C-Arm ImagesImage Manager - Report

Video Endoscopy Monitor

EEG Monitoring

Left side of OR

Image view boxes

Teleconferencing -telesurgery

Laser generator

• Familiarity and experience in the use of various endoscopic surgical systems

– To facilitate endoscopic spine surgery

– To avoid potential complications

Surgical Instruments and Equipment:

Surgical Procedure:

• Patient Positioning and localization

– Patient in prone position

– Patient in Lateral decubitus position

– Localization – skin marking and placement of needle (portal)

Surgical Technique:

Transforaminal Endoscopic Lumbar Spine surgery

Various endoscopic approaches

• Surgical approaches:Posterior paramedium transforaminal approach

Posteriorlateral transforaminal approach

The posteriorlateral transforaminal approach with a foraminoscope system allows a minimal approach to the foramen and lumbar discs for spinal stenosis

decompression and microdiscectomy. Laser thermodiskoplasty reshapes and tightened disc tissue further for decompression. Duck bill tubular

retractor to protect nerve root

Laser Thermodiskoplasty to shrink and to tighten

the disk

Posteriorlateral transforaminal lumbar Discectomy

Posterior paramedium transforaminal approach

SMART Endoscopic lumbar spine surgery

Bone resection of lumbar lamina

Axial ViewLateral View

Posterior View