Evolving Minimally Invasive Endoscopic

Spine Surgery:
A Surgeon’s Perspective and Technological Considerations

• Chief, Neurospine Surgery, California Spine Institute

• Founding Chairman – President, the American Academy of Minimally
Invasive Spinal Surgery (AAMISMS).
• Immediate past President of the International Society for Minimally
Intervention in Spine Surgery (ISMISS)
• Internationally recognized pioneer and leader in minimally invasive
spinal surgery (MISS).
• Interests:
– Promoting interdisciplinary, inter-specialty and international education
– Research and Development in MIST
– Contribution in surgical informatics development of a “digital technological
convergence and control system” for DOR (digital OR)
– Authored and co-authored numerous peer reviewed articles, chapters
and textbooks, and appointed to editorial boards and an Editor-in-Chief
for medical, surgical, and research journals.
• Enjoys the practice of martial arts (Grand Master, Martial Arts Hall of Fame and
Martial Arts Legend Award)and its philosophy, playing Chinese classical musical
instruments, collecting Asian Art, tennis, skiing, traveling and social
John C Chiu, MD, DSc, FRCS (US) networking.
• Contact Information: www.spinecenter.com

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 Society for Progress and Innovations
for the Near East:
Updates and Cadaveric Bio-skills Workshop
Beirut, Lebanon
June 23 – 26, 2010

Evolving Minimally Invasive

Endoscopic Spine Surgery:
A Surgeon’s Perspective and Technological
Considerations

John C Chiu, MD, DSc, FRCS (US)

Chief, Neurospine Surgery
California Spine Institute
Thousand Oaks, California, USA

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What is Minimally Invasive Spine Surgery
(MISS)?

• Surgery is trending toward minimally

invasive surgery worldwide including
spine surgery

• Advancements in instrumentation,
fiber optics, laser technology,
fluoroscopic imaging, high resolution
video imaging endoscopy, along with
the accumulated experience in
endoscopic laser spine surgery made
MISS possible

• Minimally Invasive Spine Surgery

(MISS) requires more precise, delicate
and effective method for spinal
decompression
• MISS does not de-stabilize the
vertebral segments
• Can safely treat multiple level
symptomatic spinal discs, spinal stenosis
and high risk spinal patients

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Anatomical Basis for
MISS

Pathophysiology

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 Spinal Care and Treatment:
Current contemporary concept in minimally invasive
spine care

• Back pain is a result of modern lifestyle

including prolonged sitting, driving, computer
work, watching television, high speed vehicle
accidents, plane crashes, active sporting activities
causing spinal injury, overeating, obesity, lack
of exercise , and emotional stress and even
degenerative process
• There is frequent occurrence of back pain -
statistics
– 85% of Americans have some back pain
during their lifetime
– 5%-8% of Americans have back pain
affecting their lifestyle and work
– 3% or less may require some type of
procedural intervention
• The majority of back pain can be treated
conservatively with relief by self-care,
acupuncture, exercise, physiotherapy,
medication and at times injectional therapy

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 Introduction:

Anatomy and function of the spine

• The spine is a bony column in the center

of the body with the following functions:
– Supporting the body, keeping it straight
instead of being crooked as in scoliosis or
the hunchback of Notre Dame
– Providing the mechanism for bodily
leverage, bending, lifting and twisting
– Protecting the nervous system, spinal
cord, and nerves
– Preservation free spinal motion
• The disc serves as a cushion for the
vertebral bodies
• Like a jelly donut. The outer layer is
very firm and fibrous, nucleus fibrosis and
the inner layer gelatinous, jelly like,
nucleus pulposus
• If you have a bad back, you will have a
back pain

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 Introduction:

Herniated Lumbar Discs Causing Nerve Impingement

- Radiculopathy

• If conservative treatment fails,

and continue to have persistent
significant symptoms affecting their
daily activities and ability to work
this can lead to the need for
surgical decompression of the
disc

• In the past, the only method

was open traumatic lumbar
surgery with cutting of the muscle,
bone and the disc, and even spinal
fusion, which are associated with
long periods of recovery, wound
healing, blood loss, hospitalization,
and others

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Surgical Indications

Reason for Surgery

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MISS Surgical Indications:

– Herniated
discs/degenera
tive spine
disease
– Post fusion
Junctional
Disc
Herniation
Syndrome
(JDHS) or
Adjacent
Segment
Disease (ASD)
– Vertebral
compression
fracture
(Osteoporotic
and post-
traumatic)

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MISS Surgical Indications:
For treatment of:

– Lumbar spinal
stenosis and
spondylolisthesis
– Cervicogenic
headache and
discogenic pain
– Intraspinal
lesions
– Synovial cyst and
degenerative cyst
– Intraspinal tumor,
lipoma
– Others

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 MISS Surgical Indications:
As 3 legs for a bar stool –
supporting findings for
surgical indication:
• Intractable symptoms without
relief by conservative treatment,
exercise program, medication and
even injectional therapy
• Positive neurological findings
of reflex changes, muscular
weakness and/or decreased pain
and touch sensation
• Laboratory testing being
positive for MRI scan, CT Scan,
EMG and others
• Positive 3 legs of bar stool –
symptoms, physical findings,
EMG, imaging and provocative
discogram to support the
surgical indications

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 Challenges
Facing
Traditional -
Current Open
Spine
Surgery/Fusion

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Challenges Confronting Open Traditional Spine
Surgery/Fusion, Spinal Arthroplasty and Disc
Replacement
• Obvious challenges:

– Larger surgical incision – longer healing time

– More traumatic than MISS and more blood loss
– Often is performed under general anesthesia
– Higher risk and complication rate
– Long and painful recovery time
– Higher long term complication rate including
post fusion junctional disc herniation syndrome
(JDHS 19-49% after 4-5 years)
– Alarming high rate of “failed back syndrome”
– Long term benefit and outcome in question by
numerous studies published
– Disc replacement technology/arthroplasty is
yet to be proven – only time will tell (another 8-
15 years)
– More difficult in high risk patients with morbid
obesity, cardiac pulmonary disease, advanced
diabetes, elderly
– Affecting spinal segmental motion

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 Logical Evolution of
Spine Surgery

Endoscopic Laser MISS

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Logical Algorithm for Spine Care:

The modern concept - algorithm of

The last resort
spine care like walking up a staircase
Open Spinal Surgery
For treatment of degenerative and herniated Fusion
spinal discs, and spinal stenosis
Spinal Arthroplasty
Maybe Disc Replacement
Artificial Disc

Minimally Invasive
MISS and NFT (Laser) Spinal Surgery

Pain Management
Injectional Therapy and RF

Conservative
Treatment

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Advantages of Minimally Invasive Laser
Spine Surgery (MISS)
Obvious advantages of Laser MISS:
• An out patient or "same day surgery“, no hospitalization
• Less traumatic
• Small or tiny incision
• Costs less - approximately 40% less than a open spinal
surgery/fusion
• Economic savings for the employee and employer are significant
due to earlier return to work
• Done under local anesthesia
• Early post – op exercise one day after surgery
• Surgical triad approach and critical "fan-sweep maneuver" further
facilitate the disc decompression and improves surgical result
• Multiple level spinal discectomy can be performed at one sitting
with minimal risk
• Can be done for high risk anesthesia patients with morbid obesity,
emphysema, and cardiac conditions under local anesthesia/IV
sedation at much less risk
• Intra-operative neurophysiological/EMG monitoring, and direct
visualized endoscopic significantly reduces the chance of
inadvertent injury of neural structure
• Preserves spinal motion

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Surgical Procedure/Technique:

Preparing for MISS – Anesthesia

• Anesthesia: Local/IV
conscious Sedation
• Intra-operative
continuous monitoring
of vital signs (pulse
rate, blood pressure,
RR), pulse oxymetry
C02 content,
neurophysiological
monitoring – EEG,
EMG, on intra-operative
wave form
display/monitor
• To insure safety and
to facilitate MISS

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Types of Endoscopic Laser
Minimally Invasive Spine
Surgery (MISS)

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LUMBAR ENDOSCOPIC LASER MISS
TECHNIQUE:
Posterio-lateral and posterio–median surgical approaches

• Patient positioning and localization

– Patient in prone position
– Or in lateral decubitus position
– Localization – skin marking for portal of entry
and placement of needle
– Under fluoroscopic guidance

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Lumbar Endoscopic Laser MISS Technique:

Localization of skin incision and portal of entry

Provocative discogram

• Under fluoroscopic
guidance
• Provocative discography
to confirm the damaged
herniated disc
• Point of incision – by
placing the “bull’s-eye”
target device to determine
the portal of entry and
skin incision

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Surgical Plane/Approach/Technique:

Right posterolateral
approach - prone
position

for endoscopic lumbar

MISS

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Surgical Plane/Approach/Technique:

Left lateral
decubitus position

for right posterolateral

endoscopic lumbar MISS

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Surgical Plane/Approach/Technique:

Left lateral
decubitus
position

for right
posterolateral
endoscopic lumbar
MISS

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Surgical Plane/Approach/Technique:
With GPS

• Extreme obese patient had left

posterolateral endoscopic
lumbar disectomy with
geometric line/plane and GPS
system

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GPS (Grid Position System) for Endoscopic Laser Lumbar MISS

Fluoroscopic monitoring to provide safe and precise lumbar spine

surgery by using GPS

Subarticular
3 pedicle • Lumbar spine has neuro
Extraforaminal 2 foramen and intra-lamina
Foraminal 1 disc foramen openings
restricting MISS at a portal
A BC
D of entry
• Critical structures within
the foramen – DRG,
neural structure
• GPS provides a precise
and safe path to reach
the lesion and to avoid
trauma to the nerve
vessels, DRG, dura and
even the spinal cord
• The grid – the GPS
System – Zones (in A,B,C,
D and 1,2,3) provides a
accurate navigation map
for MISS surgeons

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GPS (Grid Position System) for Laser Endoscopic Lumbar
MISS

Mini Endoscopic Spinal Surgical Instruments for MISS

Close up view

• Duck bill tubular

retractor with dilator to
enter the GPS for lumbar
disc surgery to protect
dural and neuro
vascular injury
• Under endoscopy and
fluoroscopy, spinal
instruments of trephine
forceps, curette, rasp,
knife, discectome, and
laser can safely be
utilized for MISS
surgery and laser
thermodiskoplasty

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GPS (Grid Position System) for Endoscopic Laser Lumbar
MISS
Fluoroscopic/imaging and endoscopy to provide safe and precise
lumbar MISS and foraminoplasty

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Lumbar Endoscopic Laser MISS Technique:

Application of Tissue Modulation Technology in

Endoscopic Laser MISS

• Holmium YAG laser equipment for Laser Thermodiskoplasty

(LTD)

Trimedyne Right angle (side

Holmium YAG firing) laser
laser generator probe

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Lumbar Endoscopic Laser MISS Technique:
step by step

Fluoroscopic/imaging and endoscopic monitoring to provide safe and

precise application of endoscopic microdiscectomy and laser
thermodiskoplasty

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Lumbar Endoscopic MISS Technique:
Additional advanced MISS surgical instruments

• Small spinal
discectome for rapid
disc removal

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Lumbar Endoscopic MISS Technique:
Posterio-lateral approach vs. posterio–median aproach

• Under fluoroscopy -
With dilatation
technology
• Introduction of dilator
and then a tubular
retractor/working
cannula are passed
over the stylette
• Foraminoplasty and
decompressive
discectomy performed
with trephines, forceps,
ronguers, discectome
and Holmium laser

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Lumbar Endoscopic MISS Technique:
Endolumbar paramedium approach

For larger extruded herniated lumbar discs (red arrows)

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Surgical Instruments and Equipment:

Tissue Modulation Technology

laser, radio frequency and cryogenic are utilized in MISS, spinal
injection and spinal denervation

Holmium YAG laser generator Radiofrequency generator

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Illustration Case I Lumbar MISS

• 26 yo “Extreme Athlete”,
Motorcycle, Rally car X-
games gold medalist
• Severe posttraumatic
L4-5 disc herniation
• Excellent relief from
outpatient endoscopic
MISS
• Return to rally car racing
in two weeks

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Illustration Case II Lumbar MISS

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CERVICAL ENDOSCOPIC LASER MISS
TECHNIQUE:
Illustrated with

Anterior Endoscopic Cervical Laser

Microdiscectomy
• Cervical discectomy– begins with anterior medial
approach for needle and stylette insertion into the disc
under monitoring (fluoroscopy, EMG) aided by GPS System

45°

20°

Cervical GPS

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Cervical Endoscopic Laser MISS Technique:
Endoscopic/fluoroscopic/imaging monitoring to provide safe and precise
application of provocative discogram, aggressive micro grasper forceps,
drill, discectome, and bony ronguer for microdecompression

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Illustration Case – Cervical Laser MISS

English rock star had successful endoscopic cervical discectomy C3-4 with hypoplastic odontoid and C3-4 disc
herniation

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 THORACIC ENDOSCOPIC LASER
MISS TECHNIQUE:

POSTEROLATERAL ENDOSCOPIC THORACIC

DISCECTOMY

• Due to tight and confined Portal of entry

anatomical relationship at
thoracic spine of the spinal cord
and spinal canal, the use of
laminectomy, and various thoracic
spinal surgical approaches for the
treatment of herniated thoracic discs
has been associated with an
unacceptable high rate of
pulmonary and neurological
complications
• Therefore, spinal surgeons have
long sought to find a better
procedure to treat thoracic disc
herniations effectively and less
traumatically

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 THORACIC ENDOSCOPIC LASER
MISS TECHNIQUE:

Fluoroscopic/imaging monitoring to provide safe and

precise Posterolateral Endoscopic Thoracic Discectomy
• Patient Positioning, localization and portal of entry
– PETD is performed under local anesthesia and conscious sedation

Portal of entry

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Thoracic Endoscopic Laser MISS Technique:

GPS (Grid Position System)

Fluoroscopic/imaging monitoring to insure safe and precise endoscopic

thoracic discectomy via GPS within the grid

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Thoracic Endoscopic Laser MISS Technique:

POSTEROLATERAL ENDOSCOPIC THORACIC

DISCECTOMY

Herniated Thoracic Disc

disc fragments
Removed

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Illustration Case – Thoracic Laser MISS
Endoscopic Thoracic MISS for F-22 Fighter Pilot

T7 herniated disc

27yr old F-22 fighter

pilot suffered severe
T7 herniated disc
symptoms as a
result of
tremendous G-Force
successfully treated
with endo-MISS

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New Digital Technology to
Facilitate Endoscopic Laser
MISS (Digital OR – DOR)

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 Image view boxes
Video Endoscopy Image Manager - Report MRI Image - PACS
Monitor

MD’s

Staff
RN,
Tech

Teleconferencing -
telesurgery C-Arm Images

Left side of OR
C-Arm Fluoroscopy

EEG Monitoring

Laser
generator

Current Digital Endoscopic DOR suite facility

Courtesy of : Dr. John Chiu, California Spine Institute EMG Monitoring

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 DOR - Surgical ePR Control System
SurgMatix® TO FACILITATE MISS

With Image acquisition, Display, Manipulation and Document

Historical and Live Data on two Opposite Large Screens

133 Video
143 Selected 137 Authoring 100
Mixing Imaging/ dictation document
system module
Equipment

Circulator
132 Surgical
Intra-op 52” LCD Video 136 Endoscope - C-ARM
134 Pre-OP 52” LCD
Fluoroscopic 133 Fluid
Camera / Display / Intake/
Display
Display /
Storage Output
Storage

139 Vital
signs and 140 1Large screen
120 Large screen EMG/ Pre-op
Display
intra-op Operating Table Display image/data
Anesthe-
image/data siologist
138 EEG/
Display

135
Assistant Surgeon Scrub Surgical
141 EKG/ Pt Biom ID
Nurse Instrument
Display table

131 142 Laser

Neuro Generator
Physio
(SSEP)
2800 mm .

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 SurgMatix® IN MISS DOR

• SurgMatix® was created by an innovative team for seamless

connectivity and teamwork in a MISS DOR
• It provides not only digital connectivity but also integration
of all OR systems including, sophisticated surgical
instruments, equipment, complex high tech systems for “digital
technological convergence, and efficient DOR control
system”
• In order to facilitate and to perform a safer and better MISS

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2nd Generation Integrated (SECS) SurgMatix®

Schematic diagram of
2nd generation of
SurgMatix® integrated
SECS, two types: in a
mobile unit, or in a tower

SurgMatix® mobile unit

SurgMatix® tower

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Goals of SurgMatix® integration system
to facilitate and control MISS

• Provides a complete picture of the patient’s medical

history and status by consolidating data from multiple
IT and OR systems – patient transparent
• Improves patient safety by converging pre-op, intra-
op and post-op data and OR control – patient centric
• Offers a complete “real-time” picture of the
patient’s medical status, including vital signs, wave
form and biosensor data
• Promotes workflow efficiency in the DOR, reducing
personnel and other costs, leading to a significant
economic saving in an “organized control instead
of an organized chaos” environment
• Enhances quality of patient care by providing
information available to all OR staff and facilitating
communication in the DOR
• Facilitates post-surgical care and trend analysis
through increased data collection during surgery

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DOR Technology Convergence and Control
System - SurgMatix®
Technological data convergence To facilitate and to insure safe
and precise MISS

INTRAOPERATIVE MONITOR with live data/”real time” image/data

- vital signs, 02 sat , EMG, laser, endoscopic and fluro images

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Potential Complications and their Avoidance:
With SurgMatix® monitoring in DOR

• Excessive sedation:
– By continuous conscious EEG and vital
signs monitoring

• Neural injury:
– Avoidance of n. injury by fluoroscopic
monitoring, imaging studies and anatomic
knowledge

• Sympathetic nerve injury:

– Avoidance of n. injury by fluoroscopic
monitoring, imaging studies and anatomic
knowledge

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Potential Complications and their Avoidance:
With SurgMatix® monitoring in DOR

• Operation at the wrong level:

– A major complication of all spine surgery
– Avoided by using digital C-arm fluoroscopy for accurate anatomic
localization
– Provocative discogram verifies level

1 1
2 2

4 CASE I CASE II 4

6 6

8 8

T10 10
10
12
12 T12
13
13

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Post Surgical Care and
Surgical Outcome

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 Post Operative Care:

• Ambulatory within one

hour and discharged
subsequently
• May shower the following
day
• May use a cervical collar in
a vehicle or on a flight as
needed (for cervical AECD)
• Ice pack is helpful Spinal motion measurement (spine Advanced exercise
mouse)
• Mild analgesics and muscle
relaxant are required at times
• Progressive spine exercise
second post operative day on
• Postoperatively on average,
resumed usual activity in a
few days and in 2-5 weeks
resumed full active lives,
providing no heavy work

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 Surgical Outcome:
Minimally Invasive Laser Endoscopic Spine Surgery (MISS)

• 5336 patients (10,255 discs),

average age 44.8 (16-94)
• Average follow-up 46.5 months
Lumbar
(6 to 75 months)
• Response to treatment evaluated
by using: MacNab, modified Mac
Nab criteria, Oswestry disability
score/index (ODI), visual
analogue pain scale (VAS),
patient satisfaction scoring, pain
Cervical
diagram and/or patient target
achievement score (PTA)
• Average satisfactory score
5024 (93.5%) patients
• Good to excellent results in
4889 (91%) patients (for single
level), fair result in 215 (4%)
Thoracic
patients
• 269 (5%) patients with
persistent residual pain and
paresthesia although overall
their pain lessened PRE-OP POST-OP

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 Surgical Outcome:
(symptomatic improvements) 5336 patients

Minimally Invasive Endoscopic Laser Spine Surgery (MISS)

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 RESEARCH AND
DEVELOPMENT IN EVOLVING
MISS

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 R&D for MISS:
Robotic aided endoscopic spine surgery and image guided
technology on the horizon

Microphone headset

Voice activated Image guided endo-MISS

• Advanced 3D
Image guided
system is being
developed and
will be applied
to enhance and
navigationally to
• Surgical robotics can guide the
improve endo-MISS with better surgical robot
surgical precision and minimal
trauma

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New innovations are on the horizon
for minimally invasive spinal technology
Spinal Arthroplasty – Biologic Product – Genome RX

Prodisc - L Bryan Cervical Disc

Charite’
Maverick

ceramic
implants

Biologic Product - Genome RX

Prodisc - C

Prestige SMART Disc

Dascor DNR
NR - b
NR - a NuCor

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