Endoscopic Spinal SurgeryEndoscopic Spinal Surgery

Aprajay GolashAprajay GolashConsultant NeurosurgeonConsultant Neurosurgeon

Royal Preston Hospital, UKRoyal Preston Hospital, UK

In this presentation I am trying to give a In this presentation I am trying to give a flavour of current spinal endoscopic flavour of current spinal endoscopic surgery and hopefully raise some interest surgery and hopefully raise some interest in this evolving field.in this evolving field.

I am making no attempt to give details of I am making no attempt to give details of any techinques but would be very happy to any techinques but would be very happy to be contacted on be contacted on aprajay.golash@lthtr.nhs.ukaprajay.golash@lthtr.nhs.uk for details. for details.

Let’s see a case!Let’s see a case!

55yr, Female55yr, Female

Spastic paraparesis for 6 months, getting Spastic paraparesis for 6 months, getting worseworse

Options for accessOptions for access

ThoracotomyThoracotomy

Thoracoscopic (Video assisted)Thoracoscopic (Video assisted)

Mini- thoracotomyMini- thoracotomy

Posterior approachesPosterior approaches

Approach I choseApproach I chose

Thoracoscopic Discectomy- because it Thoracoscopic Discectomy- because it retains the advantages of thoracotomy for retains the advantages of thoracotomy for exposure but avoids high morbidityexposure but avoids high morbidity

Clinical outcomeClinical outcome

Good neurological recoveryGood neurological recovery

Less post operative painLess post operative pain

Early mobilisationEarly mobilisation

Intra operative CSF leakIntra operative CSF leak

Post Operative scansPost Operative scans

Endoscopic Spinal SurgeryEndoscopic Spinal Surgery

This is a developing and sometimes This is a developing and sometimes controversial field.controversial field.

While developing, patient safety must be While developing, patient safety must be maintained.maintained.

Outcome compared with “Gold standard” Outcome compared with “Gold standard” (there are no agreed gold standards for (there are no agreed gold standards for many conditions!)many conditions!)

Why endoscopic surgery?Why endoscopic surgery?

Less damage to normal structureLess damage to normal structure

Less blood lossLess blood loss

Quick recoveryQuick recovery

Less post operative painLess post operative pain

Easier approach in Obese patients!Easier approach in Obese patients!

May be done under local anaesthetic & May be done under local anaesthetic & sedation.sedation.

Cervical Endoscopic foraminotomyCervical Endoscopic foraminotomy

Percuteneous access with serial Percuteneous access with serial dialatationdialatation

Endoscopic magnified (but 2-D !) Endoscopic magnified (but 2-D !) visualisation.visualisation.

Minimal injury to musclesMinimal injury to muscles

Same results as open foraminotomy.Same results as open foraminotomy.

Cervical Endoscopic foraminotomyCervical Endoscopic foraminotomy

Indications- Indications- – Ideally for soft disc herniation but can be used Ideally for soft disc herniation but can be used

for “hard” disc.for “hard” disc.– Lateral recess or foraminal stenosisLateral recess or foraminal stenosis

Contra indications-Contra indications-– Large central disc or stenosisLarge central disc or stenosis– Instability or severe kyphosisInstability or severe kyphosis

Cervical Endoscopic foraminotomyCervical Endoscopic foraminotomy

Benefits- (over open procedure)Benefits- (over open procedure)– Minimal muscle traumaMinimal muscle trauma– Decreased hospital stayDecreased hospital stay

Disadvantages-Disadvantages-– Steep learning curveSteep learning curve– Separate approach required for bilateral Separate approach required for bilateral

procedureprocedure

Cervical Endoscopic discectomyCervical Endoscopic discectomy

Anterior percuteneous approach under x-Anterior percuteneous approach under x-ray controlray control

Mainly for soft discMainly for soft disc

C3-C7C3-C7

Better approached from contralaterl sideBetter approached from contralaterl side

May be done as day caseMay be done as day case

Avoids fusionAvoids fusion

Thoracoscopic spinal surgeryThoracoscopic spinal surgery

Herniated disc (even large calcified!)Herniated disc (even large calcified!)

Spinal fracturesSpinal fractures

Anterior release for scoliosisAnterior release for scoliosis

Biopsy for tumour or infectionBiopsy for tumour or infection

Endoscopic Lumbar surgeryEndoscopic Lumbar surgery

Approaches-Approaches-– Interlaminar Interlaminar – Posterolateral Posterolateral – Far lateral or extreme Far lateral or extreme – Anterior retroperitoneal Anterior retroperitoneal – Anterior trans peritoneal Anterior trans peritoneal

Endoscopic Lumbar surgeryEndoscopic Lumbar surgery

Indications-Indications-– Disc herniationDisc herniation– Degenerative disc diseaseDegenerative disc disease– Spinal stenosisSpinal stenosis– InfectionInfection– TumourTumour

Endoscopic Lumbar surgeryEndoscopic Lumbar surgery

Disadvantages-Disadvantages-– Difficult for migrated discDifficult for migrated disc– Long learning curveLong learning curve– Access to L5/S1 may be difficultAccess to L5/S1 may be difficult– Difficult with previous spinal surgeryDifficult with previous spinal surgery

Further DevelopmentsFurther Developments

Images Guided endoscopic spinal surgeryImages Guided endoscopic spinal surgery

3-D endoscopes3-D endoscopes

Intra dural endoscopic proceduresIntra dural endoscopic procedures

I was planning to put some video clips in this presentation but I found many good ones in You tube! Though this is not an alternative to visit some experienced surgeons but is good enough to get a flavour.

Caution!Caution!

Patient safety must be maintained while Patient safety must be maintained while learning curve is achieved.learning curve is achieved.

Patient selection is critical.Patient selection is critical.

No harm in using traditional approach if in No harm in using traditional approach if in any difficulty.any difficulty.