chiu cervical

8/7/2019 Chiu Cervical

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None of the Traditional Spinal SurgeryAnterior Endoscopic Cervical Discectomy and Foraminal

Decompression

Chief, Neurospine Surgery, California Spine Institute Founding Chairman President, the American Academy of Minimally

Invasive Spinal Surgery (AAMISMS). Immediate past President of the International Society for Minimally

Intervention in Spine Surgery (ISMISS) Internationally recognized pioneer and leader in minimally invasive spinal

surgery (MISS).

Interests: Promoting interdisciplinary, inter-specialty and international education

Research and Development in MIST

Contribution in surgical informatics development of a digital technological

convergence and control system for DOR (digital OR)

Authored and co-authored numerous peer reviewed articles, chapters andtextbooks, and appointed to editorial boards and an Editor-in-Chief formedical, surgical, and research journals.

Enjoys the practice of martial arts (Grand Master, Martial Arts Hall ofFame and Martial Arts Legend Award)and its philosophy, playing Chineseclassical musical instruments, collecting Asian Art, tennis, skiing, travelingand social networking.

Contact Information: www.spinecenter.com

John C Chiu, MD, DSc, FRCS (US)
http://www.spinecenter.com/http://www.spinecenter.com/


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None of the Above:

Here is How I Do It!

Society for Progress and Innovationsfor the Near EastBeirut, Lebanon

June 23 26, 2010


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Anterior Endoscopic CervicalDiscectomy (AECD) and Foraminal

Decompression

John C Chiu , MD, FRCS (US), DScChief, Neurospine SurgeryCalifornia Spine Institute

Thousand Oaks, California, USAPresident AAMISMS

Society for Progress and Innovationsfor the Near EastBeirut, Lebanon

June 23 26, 2010


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What is Minimally Invasive Spine Surgery (MISS)?

Surgery is trending toward minimallyinvasive surgery worldwide includingAECD cervical spine surgery

Advancements in instrumentation,fiber optics, laser technology,fluoroscopic imaging, high resolutionvideo imaging endoscopy, along with

the accumulated experience inendoscopic laser spine surgery madeMISS possible

Minimally Invasive Spine Surgery (MISS)requires more precise, delicate andeffective method for spinaldecompression

MISS does not de-stabilize thevertebral segments

Can safely treat multiple levelsymptomatic spinal discs, spinal stenosisand high risk spinal patients


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AECD Surgical Indications:

Neck with arm pain(radicular pain) associatedwith paresthesia, sensoryloss, muscle weakness and/ordecreased reflexes

Intractable cervicogenicheadache

Discogenic pain

At least 12 weeks ofconservative therapy

MRI or CT scan positive fordisc herniation

Positive provocativediscogram

Positive EMG

Multiple discs can be treatedat one sitting

Post fusion junctional discherniation syndrome

Positive 3 legs of bar stoolsymptoms, physical findings,EMG, imaging andprovocative discogram


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42

1%

1502

40%

847

23%

303

8%

46

1%

990

27%

C2

C3

C4

C5

C6

C7-T1

AECD Demographics of HerniatedCervical Discs (3730)

Since 1995, 2066patients with 3730herniated cervical discs

Average age of 43.3 (21 to80) with symptomatic

cervical, single andmultiple herniatedintervertebral discs

Males: 1059 - Females:1007

Each failed at least 12

weeks of conservativecare

Post operative follow up:7 to 75 mos. (average 46months)


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AECD Surgical Instruments and Equipment:

Endoscopic surgical instruments for anterior endoscopic

cervical discectomy (AECD)


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Surgical Instruments and Equipment:

Advanced endoscopic micro flexible forceps, bone ronguerand navigable dissecting probe


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AECD Surgical Procedure/Technique:

Local anesthesia combinedwith IV conscious sedation withsurface EEG monitoringoptimize anesthesia and reducedrug requirement

The obvious challenge of MISSis limited visualization andexposure of the relevantanatomy and direct visualizationof the nerve

Continuous intra-operativeEMG/neurophysiologicalmonitoring in a digital operating

room (DOR) prevents undueneural trauma

IOM of neural structure, directvisualization with fluoroscopy andendoscopy creates saferendoscopic MISS procedures

Anesthesia and Intra-operative neurophysiological monitoring (IOM)


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Positioned in the supineposition with mild

hyperextension of neck Digital retraction of

trachea/esophagus, and thecarotid artery under the firsttwo fingers (systolic arterialpressure maintained at 130+ephedrine may be used tomaintain BP)

Needle and stylette insertedinto the disc aided by GPSSystem , fluoroscopy and EMG

N/G tube is placed in theesophagus to avoid injury

Patient Positioning and surgical portal of entry for AECD

Surgical Technique for needle and stylette placement into the discwith GPS

45

20

GPS


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Small 3mm skin incision

The spinal needle with a thinstylette is introduced into thecenter of the disk

Under fluoroscopy

Provocative discogram is

often done first The working cannula/dilator

are passed over the stylettegently (dilatationtechnology)

Mechanicalmicrodecompressivediscectomy to follow

Completed with laserthermodiskoplasty (LTD) toshrink and to tighten the discbesides sinu-vertebraldenervation


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Cervical Endoscopic AECD Technique:

Endoscopic/ fluoroscopic/ imaging monitoring to provide safe and precise

application ofaggressive micro grasper forceps, drill, curette, discectome,and bony ronguer for microdecompression


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Mechanical microdiscectomy decompression Herniated disc fragment removal

Endoscopic Microdiscectomy


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Mechanical decompressive with GPS guidance forforaminoplasty for osteophytes/stenosis

Cervical Decompression Foraminoplastyfor Foraminal Disc and Stenosis can be safely performed

20-35

20-35


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Mechanical decompressive discectomy foraminoplasty forosteophytes/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 osteophytedecompression

Micro cutting forceps

Discectome


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AECD Surgical Procedure/Technique:Fan Sweep Maneuver

For maneuvering instrument to precisely increase the area formicrodecompressive discectomy


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Level Stage Watts JoulesCervical First Stage 8 300

Cervical Second Stage 5 200

Holmium YAG laser - photo thermal effect on the disc shrinking and tightening

Protocols for laser thermodiskoplasty (LTD)

LTD

Fan sweep

maneuver


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AECD Post Operative Care:

Ambulatory usually in about one hourand 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 arerequired at times

Progressive spine exercise second postoperative day on

Rehabilitation compliments MISS andmotion preservation

Allowed to return to work in one to twoweeks (not for heavy work)


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AECD Surgical Outcome:

For 2066 patients, average follow-up 46months (7-75 months)

Overall result: 1859 (90% ) patients withgood to excellent results, fair results124 (6% ) patients (single level)

Various evaluations of response to treatment:

modified Mac Nab criteria, Oswestry disabilityscore/index (ODI), visual analogue pain scale(VAS), patient satisfaction scoring, pain diagramand/or patient target achievement score (PTA) forassessment were utilized

Average satisfaction score 1942 (94% )patients

93 (4.5%) patients had mild residual pain andparasthesia, although overall their pain lessened

Complication rate: less than 1%

Average return to work: ten days


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AECD Surgical Outcome: (symptomaticimprovements)

206683

124033

68065

206681

590

89

14760

0 500 1000 1500 2000 2500

Persistent Numbness

Muscle Spasm

Muscle Weakness

Required Analgesics

Mild Neck Pain

Severe Neck Pain

Pre-Op Post-Op

AECD Cervical disc patients(2066)


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AECD Case Illustration I:

English rock star had successful endoscopic cervical dis cectomy C3-4, one hour post surgery


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AECD MISS Case Illustration II:

81 yo NS Professorunderwent successfulendoscopic cervicaldiscectomy in spite oftransient extremebradycardia (30),detected, monitored andcorrected with atropine

in the DOR. Dischargedon hour later

Intra operative monitor shows severe dropping of heart rate


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AECD Discussion:

As demonstrated in the recent multi-center(20) study of 32,100 cases includtng AECDspinal disc surgeries with an overall successrate 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 only required in 0.79%

Resuming usual activity in a few days and fullactive lives in 2-6 weeks

These procedures can be extremelygratifying for patients and surgeon

Soon spinal arthroplasty, spinal motionpreservation and dynamic stabilization willbecome an integral part of all cervical spinalsurgery


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AECD Discussion:

In order to perform AECD and toavoid potential complications, onemust have a thorough knowledgeof endoscopic cervical spinalprocedures and the surgicalanatomy

Endoscopic cervical MISS has itsunique surgical skill set

Requiring the surgeon to gothrough a steep learning curve

Patients must be carefully selected

Careful preoperative surgicalplanning

Fluoroscopy as The 3rd

Eye orEye of Wisdom forconfirmation of location of

instruments; endoscopy alone isnot enough

These surgical procedures mustbe meticulously executed


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AECD Discussion:Potential Complications and their Avoidance

Esophageal and tracheainjury due to trauma orperforation 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 theesophagus aids in identifying and

retracting that structure by palpation.

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

Spontaneous Cervical Fusion: secondary to using larger workingchannel, trephine (5mm or more) and

trauma to the endplate causes

spontaneous fusion at C6-C7


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Conclusion:

AECD has proven to be safe, lesstraumatic, easier, and efficacious

For treatment of intractable spinal painsecondary to herniated cervical discs,and degenerative cervical spinal

disease/ foraminal stenosis It preserves spinal segmental motion,

avoids JDHS, and provides an excellentaccess for spinal arthroplasty

Utilization of intraoperative neurophysiologicalmonitoring, IOM in a DOR preventsneurological injury and provides a safer MISS

With proper surgical training andexperience, it is a smart way to performcervical spinal surgery


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Hope you enjoyed this presentation!

Danke schn

Merci Gracias

Cm n

Arigato

Thank you

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

California Spine Institute

chiu cervical

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