Endoscopic spine surgery cuts recovery time

[kkmalaysia]

The combination of high-frequency radiowave disc ablation, annulus modulation and manual nucleotomy/decompression in a single endoscopic-assisted surgery has more advantages than the single percutaneous technique, says an expert.

Compared with more invasive procedures, endoscopic spine surgery reduces the possibility of complications, in particular post-operative epidural scarring and fibrosis, orthopedic surgeon Dr. Stefan Hellinger, from Munich, Germany, said at a recent workshop in Petaling Jaya.

As a minimally invasive procedure, it also allows for faster rehabilitation, return to work and, thus, reduced cost of illness. "There is minimal surgical trauma [in] this approach as surgery is only carried out in the region of pathology," said Hellinger. In addition, it does not require general anesthesia, can be done on an outpatient basis and the patient can go home the same day.

Explaining the principles behind endoscopic surgery, Stefan listed the following requirements for surgeons to effectively perform and facilitate the procedure, and to avoid unexpected complications:

•Exact knowledge of the surgical procedure.
•Knowledge and understanding of the related anatomy.
•Knowledge of proper patient selection.
•Specific endoscopic spine surgery training.
•Previous hands-on experience.
•Meticulous pre-operative surgical planning.
Surgeons new to the technique should initially work closely with an experienced endoscopic surgeon to negotiate the first steep learning curve. Besides the usual surgical equipment, including suction and irrigation, endoscopic spine surgery requires an image converter with an optional video unit. In this regard, Hellinger highlighted the single-use Disc-FX® System by Elliquence that comes equipped with access cannulae, guide wires and a controllable radio-frequency probe. He also noted that the placement of the instruments requires a C-arm fluoroscope.

"The technical performance of the surgery is simple," assured Hellinger. Using a posterolateral access, a 16- or 18-gauge spinal needle is introduced transforaminally into the intervertebral disc, which is then used to place a guide wire. Normally, a 3 mm skin incision is sufficient for the introduction of the dilatator and working cannula. Free subligamentary material is removed with the rongeur, or the annulus is opened with a trepan, and additional disc material is then removed manually. "Our studies have shown that in this step, an average of 0.8 g of disc material is removed, with a corresponding reduction in intradiscal pressure," said Hellinger.

In a 2006/07 prospective controlled study of 66 patients, Hellinger (and Arnold Feldman) reported significant improvements (recorded by a visual analog scale) in back and leg pain at 6 weeks (8.5 to 3.5) and 6 months (3.3) post-operation. In addition, they wrote that "...all patients would undergo such a surgery again, if necessary, and recommend it."

To date, the procedure has not yielded major complications, and in comparison with other minimally invasive procedures of spinal surgery, the authors assumed the same low risk of less than 1/1000. [The Internet Journal of Minimally Invasive Spinal Technology 2007;1:1]

The decision for surgery should mainly be based on a thorough examination of case history and clinical symptomology. Patients with symptomatic, contained, lumbar disc herniations that have not responded to conservative treatment may experience relief from this procedure.

Before deciding on the procedure, all options for conservative therapy, including epidural injection (the gold standard of intervertebral disc treatment) should have been exhausted. Also, it is important to note that endoscopic spine surgery may not be beneficial for advanced degenerative disc disease or spinal fractures.