Endoscopic Spine Surgery in Singapore

The endoscope used in endoscopic spine surgery is 8-10mm in diameter and serves 4 functions:

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1) Irrigation &#; saline from the inflow port of the endoscope washes out tissue and blood clots that need to be removed.

2) Magnification by lens&#; the camera on the endoscope helps doctors visualise nervous tissue, improving safety and outcome of surgery.

3) Light source &#; the endoscope lights up the surgical area for treatment by doctors. 

4) Working channel &#; delicate endoscopic instruments can be passed through a small working channel in the endoscope to treat the target disc, bone or nerve region. 

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0 ) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Surgical treatment of the degenerative disc disease has evolved from traditional open spine surgery to minimally invasive spine surgery including endoscopic spine surgery. Constant improvement in the imaging modality especially with introduction of the magnetic resonance imaging, it is possible to identify culprit degenerated disc segment and again with the discography it is possible to diagnose the pain generator and pathological degenerated disc very precisely and its treatment with minimally invasive approach. With improvements in the optics, high resolution camera, light source, high speed burr, irrigation pump etc, minimally invasive spine surgeries can be performed with various endoscopic techniques for lumbar, cervical and thoracic regions. Advantages of endoscopic spine surgeries are less tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent epidural fibrosis and scarring, reduced hospital stay, early functional recovery and improvement in the quality of life & better cosmesis. With precise indication, proper diagnosis and good training, the endoscopic spine surgery can give equally good result as open spine surgery. Initially, endoscopic technique was restricted to the lumbar region but now it also can be used for cervical and thoracic disc herniations. Previously endoscopy was used for disc herniations which were contained without migration but now days it is used for highly up and down migrated disc herniations as well. Use of endoscopic technique in lumbar region was restricted to disc herniations but gradually it is also used for spinal canal stenosis and endoscopic assisted fusion surgeries. Endoscopic spine surgery can play important role in the treatment of adolescent disc herniations especially for the persons who engage in the competitive sports and the athletes where less tissue trauma, cosmesis and early functional recovery is desirable. From simple chemonucleolysis to current day endoscopic procedures the history of minimally invasive spine surgery is interesting. Appropriate indications, clear imaging prior to surgery and preplanning are keys to successful outcome. In this article basic procedures of percutaneous endoscopic lumbar discectomy through transforaminal and interlaminar routes, percutaneous endoscopic cervical discectomy, percutaneous endoscopic posterior cervical foraminotomy and percutaneous endoscopic thoracic discectomy are discussed.

Endoscopic spine surgery can play important role in the treatment of adolescent disc herniations especially for the persons who engage in the competitive sports and the athletes where less tissue trauma, cosmesis and early functional recovery is desirable.

Initially, endoscopic technique was restricted to the lumbar, cervical and thoracic disc herniations but gradually it can also be used for spinal canal stenosis and endoscopic assisted fusion surgeries.

Surgical treatment of the degenerative disc disease has evolved from traditional open spine surgery to minimally invasive spine surgery including endoscopic spine surgery. Constant improvement in the imaging modality especially with introduction of the magnetic resonance imaging (MRI), it is possible to identify culprit degenerated disc segment and again with the discography it is possible to diagnose the pain generator and pathological degenerated disc very precisely and its treatment with minimally invasive approach. With improvements in the optics, high resolution camera, light source, high speed burr, irrigation pump etc, minimally invasive spine surgeries can be performed with various endoscopic techniques for lumbar, cervical and thoracic regions. Advantages of endoscopic spine surgeries are less tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent epidural fibrosis and scarring, reduced hospital stay, early functional recovery and improvement in the quality of life & better cosmesis. With precise indication, proper diagnosis and good training, the endoscopic spine surgery can give equally good result as open spine surgery.

HISTORY OF ENDOSCOPIC SPINE SURGERY

Minimally invasive spine surgery treatment started in true sense by Lymen Smith in by injecting chymopapain intradiscally called chemonucleolysis7).

Encouraged by results of chemonucleolysis, Kambin in initiated a feasibility study of mechanical nuclear debulking by inserting Craig cannula via posterolateral approach.

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In Hijikata et al.6) from Japan independently performed mechanical nucleotomy via posterolateral access to the centre of the disc and reported 64% success rate. Following Hijikata&#;s experience Schreiber and Suezawa developed a series of cannulas that were telescoped one over the other and placed in the centre of the intervertebral disc via a posterolateral access. The larger cannulas with a 7 to 8-mm internal diameter (ID) permitted the insertion of larger forceps and more rapid evacuation of nuclear tissue.

Friedman and Jacobson had started using far lateral approach for lumbar disc herniation by using 40 no. French chest tube through incision over iliac crest passed towards intervertebral disc after manual nucleotomy disc fragments was removed with forceps4). This approach was further propagated by Ruetten et al.19).

In , Onik et al.18) promoted the concept of central nucleotomy via a mechanical tool called a nucleotome. The small calibre of the instruments and the simplicity of the procedure contributed to the popularity of the operative technique in the following years.

Introduction of Laser opened new frontier in the minimally invasive spine surgery. In Kambin11) started using laser to vaporise disc fragment but its wide arc of deflection and injury to neural structure restricted an adequate decompression.

Posterolateral access was initially used for vertebral biopsy, chemonucleolysis, and discography and automated nucleotomy but the dimensions of safe zone and landing of instruments were not clearly defined. It was Kambin who had studied extensively on cadaver and described the boundaries of safe working zone for posterolateral approach between exiting and traversing nerve roots. Kambin also illustrated radiographic positioning of needle in anteroposterior and lateral views. He defined Kambin&#;s triangle, base formed by superior endplate of lower lumbar vertebra, roof formed by traversing root and thecal sac curtailed by facet joint and anterior border formed by exiting root. Triangle is loosely covered by adipose tissue and small superficial vein9,10,13).

Merkovic and his resident Schwartz independently measured dimensions of working zone and safe point for needle insertion in anteropoaterior and lateral radiographic views in 12 cadavers for endoscopic spine surgery. It was stipulated that medial one third or mid pedicular positioning should be utilise for subligamentous or intracanalicular(foraminal) disc herniation17).

All previous minimally invasive access studies to the disc were blind. It was Kambin and Sampson who described purely endoscopic visualisation technique for non sequestrated disc herniation as extraforaminal approach, but this technique gradually evolved into translaminar access for discectomy14). In Mathews who was developing fibre optic endoscope for Sofamor Danek started using transforaminal endoscopic discectomy through foramen16).

During many spine surgeons started doing minimally invasive spine surgery by magnification loupe or under microscope. Destandau and Kevin Foley independently developed tubular retractor system and endoscopy aided spine surgery through interlaminar approach although Kevin Foley published first but it was Destandau who developed first and started using his system3,20). In Kambin and Sampson14) developed cannula (10&#;23 mm ID) for interlaminar and transforaminal endoscopy.

In , Anthony Yeung had designed YESS endoscope; manufactured by Richard Wolf Surgical Instrument Company and 510k FDA approved multi-channel fluid integrated working channel rigid endoscope after which the modern era of endoscopic disc surgery was introduced. Yeung&#;s technique of &#; inside out&#; was based on principle of identification and treatment of pain generators into the foramen and the disc, by freeing exiting and traversing roots, by fragmentectomy, visualisation and clearance of annular tear by ablation and irrigation. Further expansion of technique to address decompression of the lateral canal and the hidden zone of Mcnab by cutting the tip of Superior articular process by various cutting and articulated instrument was developed by Gore and Yeung5,21,22).

Hoogland described &#;Outside in&#; approach for transforaminal endoscopic technique by cutting the facet and direct landing into the epidural space but this technique is blind, requires foraminoplasty to access fragment, which can cause bleeding and poor visualisation7).

Choi et al. contributed to the modification of endoscopic technique by access to the far lateral disc herniation, transiliac and interlaminar approach for difficult L5&#;S1 level disc herniations, approach for up migrated and down migrated disc herniations, transpedicular approach for high grade down migrated disc herniation and endoscopic treatment for lumbar spinal canal stenosis1,15).

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