Chapters Transcript Endoscopic Decompression: Getting Through the Learning Curve Course: NYU Langone Orthopedics Webinar: Advances in Endoscopic Spine Surgery OK, good evening, everyone. Um, I'm sure that uh everyone that had logged into the room. The various degrees of experience with uh endoscopic spine surgery. Uh, some of you probably just heard about it. So maybe you might have done some cases, probably not only a master's at it, and if you are, you probably will be wasting your time looking at this webinar. Um, so let's, I'm gonna just assume that everyone's new, so forgive me if some of the uh topics that I cover are too basic. But I'm also gonna assume that most of you that have long on are spine surgeons or have some familiarity with the uh anatomy of the spine, OK? So I don't have to go to a uh basic uh stuff. So, evolution of minimally invasive invasive spine surgery. So, traditionally, the plants are used on the midline approach, right? whether it's cervical, thoracic, or lumbar, particularly if it's posterior approach, everything was the midline, cut the skin, get down to the bones, strip the muscle, and open everything. And then we realized, hey, we don't, maybe we don't have to do uh all that opening and stripping. Maybe perhaps we could just open small areas of the spine and do the same thing. Then they also realized even opening a little bit can also damage the muscle, ovate the muscle tissues. So then came the tubular approach where rather than stripping the muscle off the lamina, perhaps we could stick a tube in there and dilate the muscle, that lessening the uh trauma to the uh surrounding tissues. That along with improved microscopic uh techniques, really allowed us to do what we call a minimally invasive spine surgery. And they have become more of the go to surgery for most of the spine surgeons uh here in the United States. While we're very con while we were being content with what we have, however, the rest of the world were not content, and they were looking into other techniques to really, really minimize the tissue damage. So that included the attempt at percutaneous vasectomy, which, yeah, here in the United States, we have some degree of experience. Then also the endoscopic spine surgery. Again, I'm not saying that no one in the United States are doing endoscopic surgery, but unlike the rest of the world, it is not the mainstay of spinal surgery. And why is that? Well, as you know, endoscopic or arthroscopic surgery has been around for a long time. Those of you who are orthopedic trained, you know, a significant component of our training, uh, ears are spent on doing arthrocy of the knee, elbow, shoulders, whatnot. And do you have a joint with scope. Same thing with the neurosurgery. I'm sure you guys done your share of scopes. Uh, there's the picture, you know, to your right. Where you're taking a scope of the nostril and taking out a tumor in the I think it's the brain. Yes, in the brain, and then, you know, obstetric GUIN. And general surgery also use the scope too. So, what the common thing is that uh endoscopic surgery, these small scar, less postoperative pain, better recovery, and obviously less cancer infection given the fact that you're operating on a closed environment and oftentimes with significant amounts of irrigation. So, if you look at the adoption technology adoption curve, and this can be applied to individuals of the society, and if you look at endoscopic surgery, we are the United States surgeons in the United States are really here, and, you know, if you try to look to see why. And you look at this, this is the world and the bipolar endoscopic spine surgery at the society meeting last year, right? And you look who's there, and you see mostly Asians and some Europeans, there was none present from the United States. So, why are we still behind and I looked into why, and it feels like, you know, everyone kind of daunted by the uh the the learning curve. And there's also the significant misconception by the established surgeons. Surgeons have been doing this for a long time, and they're like, oh, I could do everything through the tube. My incisions just as small as yours. And they also feel that the indication for the surgery is limited, and I think that stems from all, you know, percutaneous vasectomy misconception of indications and what it could do. And they also feel that the, the feel the view that you get from endoscopic surgery is limited, which is not true. In fact, the view that you get from endoscopic surgery is much better than open surgery, and this is also, you know, that we were traumatized by the uh Laser spy Institute that went out of business, people, you know, uh going down to wherever that was, and coming back with band-aid, and yet the procedure itself was mostly a band-aid procedure. And more importantly, there's no financial incentive. You know, you learn the technique and you do technique and the RV that you're gonna get the reimbursement that you're gonna get is just as little as what you would get with endoscopic, I mean, uh, traditional open surgery. So why bother, right? And also, because it's endoscopic surgery, except for the unilateral unipotal surgery, the bipolar surgery that I'm gonna talk about. There is no hardware that needs to be bought, so it's not driven by the industry, so there's no industry training the doctors to use our stuff, telling, you know, to use their stuff, so lack of industry uh drive, and also, frankly speaking, there's really not that many opportunities for us to learn this and take, you know, courses in the lab, but this is changing. And there's been recently many opportunities, many uh symposium popping up all over the country, uh, with anatomy labs and things like that, uh, for us to uh learn the technique. So, some of the concerns I have discussed is the learning curve, right? It has a steep learning curve, and then for some of us who's very comfortable with traditional surgical technique, they just don't want to take the dive, right? Um, and then the question, what is the benefit? Look at my incision. This is a picture of an incision with a tubular approach, and this is a picture of an incision with bipolar endoscopic spine surgery. And if you're really good at UVA, this is what you do. You gotta say, hey, look, put it, you know, same to me if you add up those 24 incisions. Not true. So my past experience and observation was the percutaneous endoscopic surgery has been uh in the, I'm sure this procedure was around from the 80s and going into 90s, percutaneous to the procedure, introduction of percutaneous nucleotum, followed by some of the other techniques in the late 90s and early 2000s, including electrothermal uh therapy, in uh intradiscal. Electrothermal therapy and then came Arthur K with spine one where Pricky thing is putting this. Rotating device and are not rotate electrical RS device that you go in and out, in and out, zapping and uh evaporating the nucleus material and sinting down the annulus. And then came the abstractor decompressor again percutaneously not open, not visualizing, inserting the disc, inserting this probe, which is a rotating uh Uh, Ava, basically, and putting this in the center of the the space and sucking out the nucleus with very variable sets because you're taking a chance that you would by chance will fish out the fragment, but because you're not visualizing the herniated disc, oftentimes it led to incomplete decompression and poor outcome. So the, the true advancement was the uniportal endoscopic uh spine surgery championed by uh Tony Young, uh, and his wolf yes systems. Which really truly was the first time someone could actually visualize what they were doing by having a portal that had a camera attached to it, and then through the same portal, you can use uh operative equipment to perform the surgery. So that was that and then another uh company came out with their own system. And this allowed us to do um in laminar approach rather than transferrial approach. So this is a uh uh example of the unioral transparamal approach where you go from outside the foramen, as you can see here, and back in the uh scope into the postulate the space and doing the dissectomy. And this is the first generation uh optic, so the optic is terrible, right? It looks blue because oftentimes the surgeon would inject the disc with the methylene blue so you could see the disc material. Um, but the optics were limited. The field of view was really limited. So this really didn't really kick off in the United States, whereas someone where the rest of the world actually tried to really take this to a different uh level. Then came the um union uh portal incalainar approach with your Mac. And this one would improve optics. You could see this is the pre-op and post up MRI. You could see that, you know, the, the anatomy much clearer. You could see the dura being exposed by respecting the ligament and flabbum. And then by turning the scope around, you could work around the uh The canal and pull out the disk as you see on the uh view here. But again, Although you've could visualize the area of pathology, the whole field of view is very limited, you know, that leads to frustration, uh, difficulties, uh, a very steep learning curve. So although, you know, I went to Korea a couple times to really try to learn the technique. I, every time I came back, it it it really like. I could not jump, make that jump. Cause I still haven't found what I was looking for. So, just like how everyone in this world nowadays uh gets their information, I went on Facebook, and this is what popped up on the Facebook, because I guess they knew what my interest was, uh, so they kind of, I guess AI popped it up on my feet. And it was this, bipotal approach to endoscopic spine surgery. So, I said, sign me up. So I went to, I signed up, went to California. You see this yellow here? It's right here, that's me sitting there, and you could see how many people were there. Um, so this was a really an eye-opening experience for me, uh, seeing the endoscopic spine surgery, but done in a very different way. So, briefly history of bipolar endoscopic surgery, you know, as much as the South Koreans want to say they're the Mecca, it did not originate in South Korea. It was actually uh first developed by uh a person from Bahrain of all the uh uh places. So a couple of Korean guys visited the Professor Gaffar, and Professor Gaffa became the most uh famous Baharian in South Korea, and South Korean took this and really took it to a different level. So what is endoscopic biporal unilateral biporal endoscopic spine surgery? So you use two portals, right? Instead of using one photo, use two portal, one portal for the visualization, a second portal for doing the work. It's like doing the arthroscopy or the shoulder arthroscopy, that gives you greater flexibility, enhanced visualization, and increased versatility, and the equipment that we use is the stock equipment that we use for the knee scope of the shoulder scope. The way I compare unippoal endoscopic spine surgery to bipotal endoscopic spine surgery is riding unicycle versus bicycle. You get to point A from point A to point B, either on unic cycle or bicycle, what would you rather choose? So, The surgery that we do with bipolar endoscopic surgery is the exact same as what you would do for microscopic dectomy or laminectomy or tubular dectomy, uh. Decompression surgery. It's just that, you know, we're using different tool rather than using the air uh medium to visualize, we're using the water as the medium to visualizing. But every everything you do with the tube, you can do with the endoscope. So it's easy to start. You don't have to go to the hospital administrator and ask them to buy you a $150,000 power because every hospital has arthroscopic power, right? Every hospital has a scope, every hospital has arth direct equipment, so you don't need to buy anything. The only thing that you need to spend a few $100,000 buying a zero degree scope. So how do we do this case? Anatomy is very important. The starting point is very important. Where your center of action is just like how you would start your tubular decompression, distal end of the spinal land line. You want everything to end up there, right? So you make markings uh under a fluoroscopy, and then you create, uh, I'll go through that by step by step, but this is, you know, how you would set up APN lateral. Uh, and this line is where you want everything to converge onto. So your upper line, if you're doing a discectomy or just the uh decompression, you typically would make incision, a medial to the promal particle, and medial to the distal particle, and you will advance the tool onto the final laminar line here. So, although it is traditionally done with the fluoroscopy marking, what I have done in my institution is I have used navigation to do a marked the incision and also uh to confirm the levels. Uh, the advantage of intraoperative navigation is that those of you who are in training institutions, this is a great tool to uh teach the rotating so the rotating fellows, the anatomy, the topographic anatomy associated with endoscopic surgery, uh, with the putting the pointer and correlating what you see with the uh navigation system. So, and also, even though for a single level, it may take longer, you're doing 3 levels, intraoperative navigation can also save time cause you can just point and make the incision and point and make the incision rather than bringing your arm, wearing the lead, getting frustrated with AP and lateral and AP and lateral, right? So with intraoperative navigation, you're doing a 3 level. This is a scar for my 3 level full lamication, uh, it actually a pod. So this is how the interrupted navigation is used, going to a uh fellow where you think it's a spinal lambda line. Uh-huh. And then show me the medial aspect of the capsule. Did you ask for passage? And the inferior aspect of the facet. Very. Excellent, excellent. So you're getting some feedback, uh, and I think that really accelerates the learning, and also this can be taught to, you know, utilize to teach our colleagues as well. So, this is a quick video of how we, if we start the case, we make two separate incisions. And then once we cut the skin and the fascia, we introduce blunt dilator, just like the tubular approach. Um, but, you know, it's going up to only about 4 millimeters in diameter. And once the dilators are in place, uh, we strip the muscle utilizing uh like almost like a mini cob elevator stripping the uh muscle off the lamina. So this is what's happening. You're picking the uh minicab elevator, you're scratching the muscle of the lamina and the spinal faucet and exposing this area for us to visualize, and the arthroscope is inserted and your tool is inserted. And this is the space that's created. And this is, even though the skin incision made is small, we cut the fat a little bit bigger, which allows for better water flow, and that includes our visualization. So this is a little video of what you see when you initially. Insert the scope. You see the lamina, if we put the ninety-degree RF1 and start to bringing the tissue. You'll see a better uh picture uh on the uh subsequent slides. So I'm gonna show you a couple of uh case examples. This is the 43 year old male left by alpha 5 disc herniation. Um, This is high-speed diamondb. We're creating a small little blurry here, but creating a laminotomy defect, just like we would do on a tubula or open micro tape. We are reflecting the lateral aspect of the lamina, and then this allowed us to uh get to the ligamentum problem. We did the switching of the instruments just like we would do with the book. We're taking down the official distally, taking down the ligamentum fla distally, you can see the dura underneath. The carton, right? You can see the do right here. And then one Lateral recess is decompressed and visualized. The root is gently retracted, and the bit fragment underneath is extricated. And the this is the postop image. Um, this is a case, uh, the one with central disc herniation, uh, with neurogenic claudication. Same thing, uh, this one has a little bit oops. A better uh Video Again, The principle of the surgery is same as open surgery. take on the problem, you take on the overhang of the uh lamina. And the lad of you. I just went to the uh sorry, I apologize. OK, it is the same. So it is the next slide. So you could see the post-op um opening. I'm gonna, this is a one quick study I'm gonna show that compare the endoscopic portal surgery to the open technique and follow the patient for some months. And they all have similar outcomes except for the fact that patients had significantly less pain immediately for the first week post-op. So what is the take on? You mean the how then is what's the purpose? What's the use of endoscopic surgery, but at the end of the day everyone did the same and everyone did very well, well, you wanna have a baby with or without epidural. That's my statement, right? I mean, that first week of pain can be quite severe. Um, but anyways, um, so this is the, uh, some of the, uh, scores of VAS and ODI that showed that in the first immediate postop period, significant reduction in pain and the endoscopic spine surgery, but the pain scale mirroring each other. And no complication. The endoscopic one case the infection and microscopic tape. Uh, this is one more case, and then I'll be finishing up. This is the case of a very severe stenosis and you made the why you could do a scope with that. Sure, why not? So, again, same approach, you do, you drill out the lamina. You identify the midline rapid where the ligamentum problem detaches. And you go contralaterally, you drill out the contralateral lamina, follow that down to the inferior articulating process, and you do the same on both sides, and then you identify and dissect out the ligament and problem, and we use pituitary a lot and then theopic plan would be rather than the character because you could really grab the whole darn thing by itself and pull them out as a one big piece. So, at the end of the case, you'll see exile anatomy, you'll see the contralateral traversing nerve, you'll see ittilateral tra traversing ner you can see there. And at the end of the case, you, the degree of decompression that you will visualize is much, I dare to say, much better than tubular approach. So this is what we typically pull out when we do bilateral decompression, big side ligament and problem not input to the character but with pituitary and your. And this is what the dura looked like at the end of the case. And this this will be, this will be a typical post-op MRI. And also this technique is very helpful in morbidly obese patient as you, I'm sure all of us have experienced with people that have subcutaneous fat that's thicker than the longest tube. Well, you don't need to have the longest tube. You could just need to put a long sled down and this would be great for a morbidly obese patient and avoiding thick incisions and high rate of bone complication. So, the concern, however, regarding endoscopic spine surgery is real. Uh, the learning curve is there, uh, but it's not that bad. Your portal is not that bad. If I could do it, you could do it. And you just need to invest some time, um, you need to visit. Some people that had done this, uh, had some good experience, and then, you know, do a couple of cases on cadaver, and you could really get started, um, and I, I could tell you the, the visualization that you get and the The degree of versatility that you realize but endoscopic surgery is tremendous once you get the hang of it. Thank you. I went through over time. Published March 20, 2024 Created by Related Presenters Yong Kim, MD View full profile
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