Endoscopic Spine Surgery | Everything You Need To Know
There are only a few things in the world where “Less is Better”, but Spine Surgery has got to be one of them. The ultimate in “minimally invasive surgery” is Endoscopic Spine Surgery (without a fusion).
The term “minimally invasive” is really meaningless. The term doesn’t tell you the size of the tube that surgery is being performed thorough (usually 18-22mm) and now fusions are being performed with “minimally invasive” techniques. I would hardly describe a fusion as a minimally invasive procedure!
The size of the tube is what separates endoscopic techniques from the others. This surgery is performed through a 7-10mm tube, in a water environment (no air) without a fusion.
The goal of this type of procedure is to relieve your pain and give you back your life with the minimum of everything else. This means minimal incision size, minimal disturbance to soft tissues, minimal scar formation, minimal blood loss and complications, minimal anesthesia and recovery time, and outpatient surgery. It also means, No Fusion!
What is Endoscopic Spine Surgery?
Endoscopic Spine Surgery, also referred to as Minimally Invasive Spine Surgery (MISS), is a new and innovative approach to spinal surgery.
The method only requires a tiny incision in the lower back, without a pronounced dissection of the spinal nerves. The surgeon uses specialized surgical instruments to visualize the spinal structures and subsequently decompress the spinal nerves.
A camera (Endoscope) is used to transmit images to a monitor, and through the incision measuring less than 1 inch, the surgeon can view tiny structures using the Endoscope’s built-in magnification.
When the surgery is complete, the instruments are removed and the small incisions fixed using sutures.
It is important to have adequate information regarding a spinal cord surgery and the best approach to take. When weighing surgical options between Endoscopic Spine Surgery and Open Back Surgery, it is advisable to consult the doctor to help in the decision-making process.
Typical Conditions Endoscopic Spine Surgery Treats
Endoscopic Spine Surgery treats a wide variety of painful conditions in the spine that can be degenerative or acute in nature. These conditions can occur in the cervical, thoracic, or lumbar spine. Typical conditions that can be treated are:
- Spinal Stenosis
- Foraminal Stenosis
- Disc Herniations or Protrusions
- Facet Syndrome
- Annular Tears
- Some failed back surgeries
What surgical procedures can be performed on the spine?
Don’t be confused by all of the complicated terms and language surrounding spine surgery, there are only 4 operations.
- Disc Replacement
The goal of surgery is to relieve pressure or irritation of the affected nerve root(s) or to interrupt the sensation of pain from painful sensory nerves.
Patient selection and diagnosis are the first and most important first steps to success. These also determine if someone is a candidate. There are certain conditions that need to be treated with larger surgery and a fusion, so the first thing that must be determined is whether you are a candidate.
It’s best to have your symptoms of pain, numbness or weakness match the findings on the MRI scan, which can be likened to an “electrical wiring diagram”. If your pain is not “classical”, another approach (pain mapping) can be taken to determine the cause of the pain.
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Why should I avoid a fusion if possible?
There is well-documented long-term evidence that the discs above and/or below the fusion will degenerate prematurely. This problem (adjacent disc disease) will occur about 50% of the time in the lumbar spine and 25% of the time in the cervical spine after 10 years and continues on from there.
The adjacent disc disease is caused by the additional wear and tear occurring in the remaining discs that aren’t fused. Adjacent disc disease can result in the need for additional fusion surgery. Refuse to fuse when possible.
Pros and Cons of Endoscopic Spine Surgery
There are many benefits to choosing an endoscopic procedure and very few disadvantages.
- There is a smaller risk of infection as compared to Open Back Surgery.
- There is minimal loss of blood as only an incision less than 1 inch is made of the muscles.
- Minimal pain involved during and after the procedure.
- Recovery time is relatively quicker as the patient is only monitored for a few hours and released to resume a normal routine.
- Only a handful of surgeons are technically proficient enough to perform these procedures.
- Typically not an option for very severe back injuries from events such as auto accidents
How Is Endoscopic Spine Surgery Performed?
Surgeons use many different techniques to operate on the spine and see a patient’s internal anatomy. During an endoscopic spine surgery, both the operation and visualization are done through a small incision in the patient’s skin.
Below, you’ll read about why being able to see clearly during surgery is important. While it’s especially critical during spinal procedures, there no denying the fact that visualization is a good thing to have any time a person is being operated on! Understanding how this process works is a lot easier if you think about how a camera produces images. Obviously, you need light. Ever try taking a picture in the dark without your flash?
2 Ways Endoscopic Spine Surgery Can Be Done
The First Way
During any procedure, the surgeon has two ways to see a given problem. The first (and most ideal) is the direct method. You’re able to focus your eyes directly on an object, without any obstructions. Due to sterilization procedures, this is not always as easy as it seems.
First, you cannot stick your face directly into the area that’s being operated on; a little distance between the surgeon and the patient is necessary. Second, the instruments being used must be covered with a protective (and sterile) sheet of plastic.
When the body part that’s being operated on is large, these nuances don’t make much difference. With smaller anatomy, these precautions can hinder the surgeons ability to see clearly. Resolution can be increased (from 2.5-40x magnification, depending on the equipment). Clearly, the larger the instruments are, the larger the incision must be.
The Second Way
The second (and much more likely) way is considered indirect. With this method, a different approach is taken.
A surgeon can use a spinal endoscope, which is a small flexible tube equipped with a camera lens. The scope is tiny, so can get closer to the area of interest. Importantly, this let’s surgeons see objects even when they are obstructed by surrounding tissues/structures. It too, has magnification capabilities. High-definition images gathered from the scope’s camera can be uploaded (in real-time) to a monitor located next to the surgeon.
Both methods have something in common. What they both have is a light source. As you may recall, there is simply no way to create an image without it. One might even say that it is the amount of light that determines exactly how big an incision must be.
Let’s walk through a simple analogy that explains how light can be used to alter our visualization.
Sally is standing just outside of her bedroom and wants to find something very small that’s located inside. From the doorway, Sally will need a flashlight to look inside the room. Of course, the more Sally opened the door (compare this to the incision size), the more light would pour in, and the easier it would be for her to find the keys. If she kept the door mostly closed (a tiny incision), the light would only illuminate a small area and would need to be very bright to see extra far. Sally might even consider using a magnifying glass.
Another solution Sally could try is using a long pole (compare to endoscope). She could attach the flashlight and a small camera to the end. Now, she can keep the door mostly closed and it doesn’t matter how bright her flashlight is because she can get as close to the object as she wants. Her camera has a zoom feature, so she can enlarge the image to whatever magnification is needed.
Endoscopes are revolutionary because they let surgeons get away with making smaller incisions, while still affording them crystal-clear visibility. Physicians in the sports injury field recognized this more than three decades ago. Back then, it made knee and shoulder conditions much easier to treat. Patients recovered quicker because there was less disruption to healthy tissues and their surgeons could actually see what they were doing. There’s no reason spinal surgery should be any different.
Why Should you consider Endoscopic Spine Surgery?
Most important nerves operate from the spine, making it very vulnerable to open back surgery. Endoscopic Spine Surgery aims at eliminating tissue injury and trauma. This also requires precise diagnosis, sophisticated equipment, and top-notch neurosurgical expertise to perform.
Today, many types of spine surgery can be done using endoscopic procedures, with fewer risks of developing complications and quicker recovery time. My estimate is that 70-80% of fusions could be avoided if endoscopic spine surgery was done first. Whether Endoscopic or Open Back Surgery, many options would still need to be considered.
Why is it a good idea to start with an Endoscopic procedure?
If you have a problem that can be solved with a small procedure, wouldn’t that be the procedure of choice? Of course, you have to examine all the facts and decide for yourself, but if I could avoid a fusion with a small endoscopic procedure, I would. If the small endoscopic procedure was not satisfactory, then a fusion is an option, but it doesn’t work the other way around.
Why don’t all surgeons do endoscopic spine surgery?
There are several reasons:
- The learning curve is steep.
- The techniques have only recently been taught in a few fellowships.
- The German equipment is expensive.
- Three dimensional skills need to be exceptional.
- Not enough arthroscopy experience.
The pain interferes with sleep and the activities of daily living as well as recreational activities. Some people require the use of pain pills, which they don’t want to take. And then in desperation to get some relief, you take a trip to the surgeon, and he tells you that you need a fusion with a plate, screws and a bone graft!
Sometimes you will hear that if you don’t get it operated on immediately, that you run a significant risk of paralysis!
Since my early days in practice, I have always wanted people to retain as much range of motion as possible; I mean the body is meant to move.
If surgery is necessary then it should be performed through the smallest possible incision with the minimal disturbance of soft tissues And allow the natural motion to continue when possible. I think it’s also wise to operate directly on a problem, when possible, rather than restructure the surrounding anatomy, which is done with a fusion. I always struggled with the concept of creating “one problem” to solve another.
For more information or to see if you are a candidate, call us now for a free one-on-one consultation with Dr. Mork.
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If you’re currently a spine surgeon and looking for an endoscopic spine surgery course, check out our online video courses.