Anterior Endoscopic Cervical Discectomy

XXVII JORNADA NACIONAL DE ORTOPEDIA Y
TRAUMATOLOGIA
Acapulco, Mexico
May 1-5, 2013
Anterior Endoscopic Cervical
Discectomy/Foraminoplasty
Surgical Technique with Case Illustration
John C Chiu, MD, FRCS (US), DSc
Chief, Neurospine Surgery
California Spine Institute
Thousand Oaks, California, USA
President AAMISMS
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California Spine Institute
Medical Center, Inc
“Bienvenida del CSI”
Kinh Môi
“Ciao”
“Bonjour”
“Buenos Dias”
“Guten Tag!”
“Konnichi wa”
Calif. Center for Minimally Invasive Spine Surgery
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Overview
1. MISS being disruptive technology with
dilatation technology instead of cutting
technology
2. To discuss endoscopic cervical decompressive
discectomy and foraminoplasty
3. Related non-fusion technique and dilatation
technology for preservation of spinal motion
4. MISS with limited visualization needs precise
MISS approach
5. The importance having MISS technology,
education and training needed for meticulous
MISS
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Endoscopic Anterior Cervical Discectomy
(AECD)
Demographics of Herniated Cervical Discs (3917)
•
•
Since 1995, 2169 patients
with 3917 herniated cervical
discs
Average age of 43.4 (21 to 82)
with symptomatic cervical,
single and multiple herniated
intervertebral discs
•
Males: 1109- Females: 1054
•
Each failed at least 12 weeks
of conservative care
•
Post operative follow up: 6 to
75 mos. (average 46.4
months)
50
1%
318
8%
44
1%
1039
27%
C2
C3
890
23%
C4
C5
C6
C7-T1
1576
40%
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Surgical Indications:
Surgical Indications:
•
•
•
•
•
•
•
•
•
•
Neck with arm pain (radicular
pain) associated with paresthesia,
sensory loss, muscle weakness
and/or decreased reflexes
Intractable cervicogenic
headache
Discogenic pain
At least 12 weeks of failed
conservative therapy
MRI or CT scan positive for disc
herniation
Positive EMG considered helpful
Positive provocative discogram
Multiple discs can be treated at
one sitting
Post fusion junctional disc
herniation syndrome
Positive 3 legs of bar stool –
symptoms, physical findings, EMG,
imaging and provocative discogram
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Surgical Indications:
In addition, Post Spinal Fusion Junctional Disc Herniation Syndrome
(JDHS), Adjacent Segment Disease (ASD)
•
Two post ACF
fusion C4-C6 & C5C6 JDHS cases
•
MRI showing
junctional discs
•
Anterior endoscopic
cervical
microdiscectomy
(AECD) and
foraminoplasty
provides relief
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AECD Surgical Instruments and Equipment:
• Endoscopic surgical instruments for AECD
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AECD Surgical Instruments and Equipment:
• Advanced endoscopic micro flexible forceps, bone
ronguer and navigable dissecting probe
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AECD Surgical Instruments and Equipment:
• Advanced anterior cervical endoscopic instruments
• For bony decompression:
– Round ball tip drill
– Sharp drill and trephine
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AECD Surgical Instruments and Equipment:
• Anterior cervical endoscopic instruments
Discectomes, working channel
sets
•
•
Tri-chip digital camera with cervical
6°endoscope and forceps
Holmium YAG laser equipment
Laser Thermodiskoplasty (LTD)
Endoscopic laser fibers and
Instruments
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Surgical Procedure/Technique:
•
Instruments for tissue
modulation
•
Percutaneous MIST
interventional procedures:
–
Injectional, non ablative and
ablative tissue modulation
technology, laser, RF
(radiofrequency), ultrasound,
cryogenic and others
–
MISS surgeons should be
familiar with injectional and RF
facet denervation procedures
and others
–
MISS surgeons are uniquely
suited to perform these for the
care of the spinal pain
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Surgical Procedure/Technique:
Injectional and tissue modulation technology, RF treatment for:
– Selective nerve
blocks, epidural
block and cervical
sympathetic nerve
block
– Facet arthralgia
(medial branch of
posterior primary
rami)
– Spinal discogenic
pain (related to sinuvertebral nerve)
– Cervicogenic
headache
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ANESTHESIA – AECD Surgical Technique:
ANESTHESIA and Intra-operative neurophysiological monitoring (IOM)
•
Local anesthesia combined with
IV conscious sedation with
surface EEG monitoring optimize
anesthesia and reduce drug
requirement
•
The obvious challenge of MISS is
limited visualization and
exposure of the relevant anatomy
and direct visualization of the nerve
•
Continuous intra-operative
EMG/neurophysiological
monitoring in a digital operating
room (DOR) prevents undue neural
trauma
•
IOM of neural structure, direct
visualization with fluoroscopy and
endoscopy creates safer
endoscopic MISS procedures
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Intraoperative Neurophysiological
Monitoring - IOM
•
Trend of spinal surgery is toward less or
minimally invasive spine surgery (MISS)
•
MISS aims at being less traumatic, with less
morbidity and improved surgical outcome
•
The obvious challenge of MISS is limited
visualization and exposure of the relevant
anatomy in spite of fluoroscopy and endoscopy to
work with, and potentially placing the relevant
neural structures at increased risk of trauma
•
INTRAOPERATIVE NEUROPHYSIOLOGICAL
MONITORING (IOM) of neural structure, direct
visualization with fluoroscopy and endoscopy
creates safer endoscopic MISS procedures
•
Spontaneous EMG monitoring, at times SSEP
and MEP can provide the surgeon with useful
feedback to avoid neural trauma during MISS
•
Intra-operative surface EEG/neurophysiological
monitoring optimizes the anesthesia for MISS
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Surgical Technique - Step by Step
with Case Illustration
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Case Illustration I –
Large extruded C6-7 disc:
34 year old accountant suffering from intractable increasing
neck and left arm pain and weakness. MRI scan showed
large C6-7 extruded disc/osteophyte which was relieved by
endoscopic cervical discectomy and foraminoplasty.
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Endoscopic Anterior Cervical Discectomy
(AECD) Surgical Technique:
•
•
Patient Positioning and surgical portal of entry
Needle and stylette placement into the disc under Grid Position
System (GPS)
•
Supine position with
hyperextension of neck
•
Digital retraction of
trachea/esophagus, and the
carotid artery under the first
two fingers
•
Systolic arterial pressure
maintained at 130+ ephedrine
may be used to maintain BP
•
•
45°
Needle and stylette inserted
into the disc aided by GPS,
under fluoroscopy and EMG
20°
N/G tube is placed in the
esophagus to avoid injury
GPS
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AECD Surgical Technique:
•
•
•
•
•
•
•
Small 3mm skin incision
The spinal needle with a
thin stylette is introduced
into the center of the disk
Under fluoroscopy
Provocative discogram is
often done first
The working cannula/dilator
are passed over the stylette
gently (dilatation
technology)
Mechanical
microdecompressive
discectomy to follow
Completed with laser
thermodiskoplasty (LTD) to
shrink and to tighten the disc
besides sinu-vertebral
denervation
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AECD Surgical Technique:
Endoscopic/fluoroscopic/imaging monitoring to provide safe and precise
application of aggressive micro grasper forceps, drill, curette, discectome,
and bony ronguer for microdecompression
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Endoscopic Cervical Microdiscectomy and
Foraminoplasty Procedure – Step by Step - A
Discogram demonstrated double shadow of large extruded disc/osteophytes
Micro-drill and forceps for microdecompression of disc/osteophyte
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Endoscopic Cervical Microdiscectomy and
Foraminoplasty Procedure – Step by Step - B
Microdecompression along posterior spinal canal with safety ronguer, drill and forceps
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Endoscopic Cervical Microdiscectomy and
Foraminoplasty Procedure – Step by Step - C
Final removal of disc fragments/debris with ronguer, forceps, laser
thermodiskoplasty, irrigation and cleaning with a discectome
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AECD Surgical Technique:
“Fan Sweep Maneuver”
•
For maneuvering instrument to precisely increase the area
for microdecompressive discectomy
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AECD Surgical Technique:
Endoscopic Microdiscectomy – Laser Thermodiskoplasty (LTD)
•
•
•
Mechanical microdecompressive discectomy
Herniated disc fragment removal
Laser Thermodiskoplasty – disc shrinkage and tightening
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AECD Surgical Technique:
Cervical Foraminoplasty
Cervical Foraminal Decompression for Foraminal Disc and Stenosis
•
Mechanical decompressive discectomy foraminoplasty for
osteophytes/stenosis under fluoroscopy, endoscopy and IOM
Microdiscectomy forceps
Discectome
Micro cutting forceps
Micro curette
Trephine for osteophytectomy Burr for osteophyte
decompression
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AECD Surgical Technique:
• Endoscopic views of uncinate joint and nerve root
after disc decompression, and fissure in cervical
disc
LTD defect
Uncinate joint
Nerve root
Fissure
Disc
Disc
Intra operative
endoscopic view
of fissure in
cervical disc
Uncinate joint and
nerve root after
endoscopic
microdecompressi
on
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AECD Surgical Technique:
Protocols for laser thermodiskoplasty (LTD)
Level
Stage
Watts
Joules
Cervical
First Stage
8
300
Cervical
Second Stage
5
200
Holmium YAG laser with photo thermal effect and mechanism:
•
Absorbed by water
•
A pear shaped cavitation bubble formed by
vaporization of water molecules, undergoes
expansion and collapse - resulting in acoustic
and shock wave emission
•
Simultaneously a vapor channel is formed that
effectively conducts laser energy to the target
with a pressure effect
•
Continuous cold saline irrigation is necessary
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AECD Surgical Technique:
Surgical technique of LTD, fan sweep maneuver and
endoscopic views of disc shrinkage
Side fire laser probe
in action
“Fan sweep maneuver” of
instrument increased disc
removal and shrinkage
Laser used to shrink and
tighten the disc besides
“purse string” of the disc
defect
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AECD Post Operative Care:
•
Ambulatory usually in about one hour
and 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 are
required at times
•
Progressive spine exercise second
post operative day on
•
Rehabilitation compliments MISS and
motion preservation
•
Allowed to return to work in one to two
weeks (not for heavy work)
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AECD Surgical Outcome:
•
For 2169 patients, average follow-up
46 months (6-75 months)
•
Overall result: 1952(90%) patients with
good to excellent results, fair results
130(6%) patients (single level)
•
Various evaluations/tests of response to
treatment: modified Mac Nab criteria, Oswestry
disability score/index (ODI), visual analogue
pain scale (VAS), patient satisfaction scoring,
pain diagram and/or patient target achievement
score (PTA) for assessment were utilized
•
Average satisfaction score – 2309 (94% )
patients
•
98 (4.5%) patients had mild residual pain and
parasthesia, although overall their pain
lessened
•
Complication rate: less than 1%
•
Average return to work: ten days
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Case Illustration I –
Octogenarian w/herniated C5-6 disc/osteophyte:
81 yo NS Professor
underwent successful
laser endoscopic
cervical discectomy in
spite of transient extreme
bradycardia (30),
detected, monitored and
corrected with atropine
in the DOR. Discharged
on hour later
Intra operative monitor shows severe dropping of heart rate
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Case Illustration II –
JDHS C3, C4 & C6
•
54 year old female suffering post
fusion junctional disc herniation
syndrome (JDHS) (after C5 & C6
corpectomy, discectomy and bone
graft of C5-C6) at C3, C4 & C6
levels with severe radiculopathy
•
Complete relief of spinal
symptoms after AECD and
foraminoplasty at C3, C4 & C6
level
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Case Illustration III -
Herniated C5-6 disc:
50 yo female under went successful endoscopic microdecompressive
cervical discectomy for a large herniated C5-6 disc
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Case Illustration IV-
Large herniated C3-4 disc:
English rock star had successful endoscopic cervical discectomy C3-4 with hypoplastic odontoid process
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Case Illustrations V •
•
Large herniated C5-6 disc:
44 year old female with increasing intraticable neck and
upper extremity pain and numbness of fingers, mild
spastic gait and weakness of hand grip, mild hyper
reflexia, and hypoesthesia
AECM - post operatively rapid improvement and
disappearance of all symptoms
Pre operative MRI scan - Large 5 mm herniated C5-6
disc compressing spinal cord with myelopathic
changes of the spinal cord
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Case Illustration VI •
•
Large herniated C5-6 disc:
35 year old male rock star with increasing intraticable neck and
upper extremity pain and numbness of fingers, unable to perform
AECM and left C5-6 foraminal decompressive discectomy
and foraminoplasty gave immediate relief of all symptoms
Pre operative MRI scans - Large foraminal herniated C5-6 disc
compressing C6 nerve root
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Discussion:
•
New biotechnology, instrument advances and
accumulation of endoscopic spinal surgical
experience, make the procedure of AECD and
foraminal decompression (foraminoplasty)
possible
•
Open cervical spinal surgery/fusion results in
higher complication and morbidity besides longer
convalescence
•
Post cervical spinal fusion patient, has high as 25 –
52% of them developed Junctional Disc Herniation
Syndrome (JDHS) or Adjacent Segmental Disease
(ASD) within 3-4 years
•
AECD MISS is an effective alternative or
replacement for open spinal surgery for discectomy
and decompression of stenosis in degenerative spine
disease
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Discussion:
•
As demonstrated in a multi-center endoscopic cervical
spinal disc surgeries had an overall success rate 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 required only in 0.79%
•
Resuming usual activity in a few days and full active
lives in 2-6 weeks
•
These procedures can be extremely gratifying for
patients and surgeon
•
Soon spinal arthroplasty, spinal motion preservation
and dynamic stabilization can become an integral part
of all cervical spinal surgery
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AECD Discussion:
•
•
•
•
•
•
•
In order to perform AECD and to avoid
potential complications, one must have a
thorough knowledge of laser
endoscopic cervical spinal procedures
and the surgical anatomy
Endoscopic cervical MISS has its unique
surgical skill set
Requiring the surgeon to go through a
steep learning curve
Careful patient selection
Careful preoperative surgical planning
Fluoroscopy as “The 3rd Eye” or “Eye of
Wisdom” for confirmation of location of
instruments; endoscopy alone is not
enough
These surgical procedures must be
meticulously executed
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POTENTIAL COMPLICATIONS AND THEIR
AVOIDANCE
• Excessive sedation:
– Continuous conscious EEG monitoring with the new
computerized SNAP™ monitoring (SNAP index) improves
anesthesia and reduces drug requirement
– Local anesthesia with conscious sedation provides a
responsive patient to facilitate endoscopic MISS and
prevents potential complications
Surface EEG monitoring
(SNAP™)
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POTENTIAL COMPLICATIONS AND THEIR
AVOIDANCE
• Discitis:
– Prophylactic antibiotics
– Continuous irrigation of the
interspace
– Introduction of instruments
through a cannula without
contact with the skin
• Aseptic discitis:
– Aim the laser in a “bowtie”
fashion to avoid damaging the
endplates (at 6 and 12 o’clock)
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POTENTIAL COMPLICATIONS AND THEIR
AVOIDANCE
• Spontaneous
Cervical Fusion:
secondary to
using larger
working channel,
trephine (5mm or
more) and
trauma to the
endplate causes
spontaneous
fusion at C6-C7
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POTENTIAL COMPLICATIONS AND THEIR
AVOIDANCE
•
Neural Injury:
extremely rare
–
No spinal cord injuries reported
–
Nerve root and spinal cord injury,
though possible, but avoidable
–
With neurophysiologic monitoring
(EMG/NCV)
–
Root injury avoided by introducing
instruments in the “safety zone”
–
And direct endoscopic visualization
–
By frequent use C-arm fluoroscopy
–
Recurrent laryngeal nerve injury, is
extremely rare
–
Postoperatively one case of transient
hoarseness
–
One case with transient hiccough
Uncinate joint and nerve root after endoscopic
microdecompression
Continuous
intraoperative
neurophysiologic
monitoring (EMG/NCV)
Intra operative endoscopic view of
fissure in cervical disc
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POTENTIAL COMPLICATIONS AND THEIR
AVOIDANCE
•
•
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
Esophageal and trachea injury due to trauma or perforation
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 the esophagus aids in identifying and retracting
that structure by palpation.
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Conclusion:
•
•
•
•
•
AECD has proven to be safe, less
traumatic, easier, and efficacious
For treatment of intractable spinal pain
secondary to herniated cervical
discs, and degenerative cervical
spinal disease/foraminal stenosis
It preserves spinal segmental
motion, avoids JDHS, and provides an
excellent access for spinal
arthroplasty
Utilization of intraoperative
neurophysiological monitoring, IOM in a
DOR prevents neurological injury and
provides a safer MISS
With proper surgical training and
experience, it is a smart way to
perform cervical spinal surgery
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Hope you enjoyed this presentation!
“Gracias por su amable atención”
“Arigato”
“Danke schön”
“Cám ón”
“Thank you”
“Gracias”
“Merci”
John C. Chiu, M.D., FRSC (US), D.Sc.
California Spine Institute
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spinecenter.com