Key hole

Endoscopic Spine Surgery | |[pic]
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|Introduction |
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|Clear visualization of nervous tissue, the intervertebral disc and other surrounding structures is often the key to success in|
|any decompressive spine procedure. |
|The process of visualization in the past has meant open surgery with a translaminar access pathway that involvesextensive |
|muscle and ligament stripping, muscle and skin retraction, devascularisation, bony resection of normal parts of the spinal |
|canal including lamina resection as well as facet joint ligamentous, capsular and bony violation in order to gain access to |
|within the spinal canal. Once the spinal canal is reached, further exposure requires the need for dural and root retraction|
|with inherent risk of epidural scarring and fibrosis. The size area and magnitude of the surgical wound is disproportionate to|
|the size of the pathology, which is often measure in the magnitude of a few millimeters only. Realizing the above, in the late|
|1960’s Yasargil described microscopic discectomy utilizing the operating microscope[1]. The size of the surgical access wound |
|haddecreased but the problem of surgical trauma to the structures constituting the borders of the spinal canal was more or |
|less the same, with the same need for laminectomy followed by dural and nerve root retraction and the subsequent attendant |
|risk of development of epidural fibrosis and scarring. |
|Discalpathology is located ventral to the spinal canal, obviously an access pathway that would not require a translaminar |
|approach with breach of the dorsal column was required. In 1972 Kambin described a posterolateral approach for a limited |
|nucleotomy, defining the safe triangular working zone (Kambin’s triangle), being the site for safe surgical access to the disc|
|through aposterolateral approach (fig.1). |


[pic]
|Copyright © 2008 Spine Care Hong Kong |

|Fig.1 |
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[pic][pic][pic][pic]
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|Hijikata subsequentlydescribed percutanous manual discectomy for central nucleotomy[2] in 1975. Other reports were by Kambin |
|and Gellmann[3] in 1983. Onik and Helms[4] described Automated Percutaneous Lumbar Discectomy (APLD) with use of an automated |
|aspiration probe. The use of optics in the form of an endoscope was a breakthrough in visualization and it was Kambin [5] [6] |
|[7] [8] in the early 1990’s whofirst described Arthroscopic microdiscectomy. |
|Advantages of the Transforaminal Posterolateral Approach |
|The main advantages of the transforaminal posterolateral approach to the spine are that the erector spinae muscles are not at |
|all violated, therefore post operativelypatients do not have to rehabilitate and retrain their back muscles. Minimal fibrosis|
|around the epidural space results as there is minimal retraction or exposure of unaffected and adjacent neurological |
|structures, the only exposure if any is located at the site of pathology. In the presence of mild instability or |
|spondylolisthesis, a posterolateral transforaminal...