Endoscopic Spine surgery is a minimally invasive spine surgery technique that utilizes an Integrated working channel endoscope to treat various problems in the spine - Disc herniation (Slip Disc), Spinal Stenosis & other degenerative conditions of the spine that are contributing to Back Pain & Leg Pain. The Endoscope allows to visualize & operate on the spine using a keyhole incision (Less than 8 mm).
Endoscopic Spine Surgeries are of two types - Transforaminal & Interlaminar
Transforaminal Endoscopic Spine surgery can treat the majority of conditions in the Lumbar spine whereas Interlaminar surgery is reserved for more serious & complicated conditions.
This Surgery is performed with a patient awake and aware in an operating room set up as a day care / overnight procedure. Surgery time is approximately 30-45 minutes per disc. A small 1/4 inch incision is made on the back to the side of the spine. The entry point is precisely calculated by fluoroscopic intraoperative measurements. Sedation and local anesthesia are provided. The aesthetic will allow the patient to be comfortable during the procedure but will leave enough feeling in the nerves so the patient can actually tell when the nerve is being stimulated or when pressure is taken away from the nerve.
The instrument placement is performed under fluoroscopic or x-ray guidance. A conical probe (obturator) with a side hole for palpating structures and for anesthetizing painful structures is used to dilate a path to the disc. After determining that the probe is in the safe triangular zone between the traversing and exiting spinal nerves, the disc is entered by bluntly fenestrating the annular fibers with the probe in case of Intradiscal pathologies. In case of extruded herniations, a targeted epidural approach is preferred using Hand drills & reamers enlarging the foramen and directly accessing the herniation.
If there is an unusual amount of pain with the docking of the blunt probe on the annulus, the surgeon can opt to visualize the outer aspect of the disc before entering the disc. Anomalous nerves and branches of spinal and autonomic nerves have been visualized and documented as contributing causes of back and leg pain that are currently not recognized by traditional surgeons. This area in the foraminal and extra-foraminal zone has been termed the hidden zone by surgeons Ian MacNab and John McCullouch.
The presence of these anomalous nerves and the ingrowth of nerves from an inflammatory membrane that forms over the sensitive disc annulus is responsible for the pain that is out of proportion to what the MRI shows. This phenomenon is not yet completely understood, but good results have been obtained by identification and ablation of these nerves, and by elimination of the condition causing the inflammation.
The procedure proceeds by a cannula being passed over the blunt obturator followed by insertion of the endoscope and operating instruments. The two spinal nerves are protected by the cannula and only the part of the disc needing surgery will be exposed to the operating instruments. The endoscope is inserted into the cannula and degenerated nucleus pulposus is visualized and selectively removed from the herniation site in the posterior portion of the disc. When treating annular tears a small amount of nuclear tissue is removed from underneath the tear. Often, some of this nuclear tissue is seen interposed within the tear preventing it from healing.
The advanced endoscope has integrated multichannel irrigation channels allowing for continuous cool saline irrigation similar to knee arthroscopy. A radio frequency electrode is used to help control bleeding, shrink the disc tissue or shrink the annulus, and ablate ingrown inflammatory/granulation tissue. Heat from the radio frequency probe may also help depopulate and ablate the pain fibers in the annulus.
Advanced endoscopic techniques will also allow the experienced endoscopic spine surgeon the ability to routinely visualize the exiting nerve root, a nerve that is rarely visualized by traditional spine surgeons when they remove herniated discs. Lateral or foraminal stenosis contributing to back pain& Leg pain can also be treated with this procedure. Overgrown bone and soft tissue compressing the Nerve in the spinal canal & Foramen can be incrementally removed using advanced tools like Motorised Burr, Radiofrequency, Motorised shavers & Holmium YAG Laser.Decompression of the nerves can be confirmed & documented during the procedure. The procedure is performed in a setting where a single day hospitalization is needed.
Some cases dictate access through the posterior or Interlaminar approach. Full Endoscopic Interlaminar surgery is performed similar to the Full Endoscopic Transforaminal approach, the only difference being that, Interlaminar Full Endoscopy has to be performed under regional / General anaesthesia and the anatomy differs as compared to Transforaminal approach. This technique can be used for Discectomy & Multi / Uni Level stenosis of the Lumbar Spine.