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8 Endoscopy inSpinal Surgery

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television camera is mounted at its tip and allows an image to be transmitted to a monitor.

• Chromoendoscope and zoom endoscope A chromoendoscope allows cells to be stained. In gastroenterology, for example, areas of mucous membranes can be sprayed with a harmless pigment such as indigo carmine. This is actually not relevant for spine surgery. Endoscopic spinal surgery requires coordination of the

following:

• Endoscopic surgical access Using different thoracoscopic or laparoscopic portals or serial tubular dilators

• Operative guidance Intraoperative uoroscopy is essential to conrm the working level.

• Endoscopic visualization Digital imaging, endoscopic considerations and illumination

• Endoscopic surgical instruments Dissection tools, retractors, irrigation, suction, haemostasis, cautery and endoscopic drills

• Spine implants for endoscopic use

8.4 Endoscopy inSpine Surgery

8.4.1 Anterior Cervical Spine

8.4.2 Posterior Cervical Spine

The approach and the surgical technique are similar to traditional surgery but are performed using a working tube of varying diameters and the typical endoscopic instruments mentioned for the anterior approach. Fessler and Khoo [7] have reported on minimally invasive cervical microendoscopic foraminotomy in 25 patients.

8.4.3 Anterior Thoracic Spine

With the aid of thoracoscopy and mediastinoscopy, and using specially adapted trocars and instruments, spine operations can be carried out either entirely endoscopically or with endoscopic assistance. Using thoracoscopy, for example, it is possible to carry out decompression in cases of thoracic disc prolapse or instrumented procedures with additional ventrolateral plating. In 1994, Rosenthal etal. [3] reported the rst excision of a herniated thoracic disc by thoracoscopic surgery. Video-assisted thoracoscopic surgery can be used for a variety of spinal indications [8, 9]. The nerve roots and the spinal cord can be decompressed, bone grafts can be placed for interbody fusion and vertebral body reconstruction and internal xation can be applied to stabilize the thoracic spine [10] (Figs.8.5 and 8.6).

Endoscopically assisted transoral surgery represents an alternative to standard microsurgical techniques for transoral approaches to the anterior cervicomedullary junction [6].

The anterior approach is very similar to the traditional

microsurgical approach, with the neurovascular sheath being positioned lateral to the working channel and the visceral structures medial to the working channel. The tip of the working sleeve is positioned against the anterior longitudinal ligament and the edge of the anterior part of the adjacent vertebral bodies. The disc space can then be passed without performing a discectomy, which is not possible with traditional microsurgery. Herniectomy and, if necessary, removal of osteophytes are carried out with suitable instruments including burrs, trephines, microresectors, various types of forceps, drills, hooks and bipolar microelectrodes. Using this approach, the foraminal areas and the spinal canal can be reached with excellent control of the operating eld, but the interpedicular space is not accessible. In the cervical spine— more than in the other segments of the spine—an anterior endoscopic approach facilitates the effective anatomical decompression of the spinal canal and/or the nerve roots (plus in select cases, even the vertebral artery) without requiring replacement of the disc by fusion or arthroplasty.

There is usually no need for a drain or for post-operative

immobilization.

8.4.4 Posterior Lumbar Spine

Interlaminar Approach

This approach is very similar to the traditional microsurgical approach. Access to the spinal canal is via a limited avotomy, and the risks of damaging the dura or neural structures are similar to those applying to the microsurgical approach. Depending on the angle of entry into the interlaminar window in the sagittal plane and the level treated, it may be easy or difcult to actually reach the posterior aspect of the disc. The interpedicular region is very difcult to reach if at all, as is the contralateral side of the ventral epidural space. If the interlaminar window is very small, this approach may not be feasible without resection of the laminar edge and/or the medial aspect of the facet joint, especially with some of the more modern endoscopes that have a larger working channel but also a larger outer diameter.

One clear advantage is the easy convertibility to an open

approach.

Posterolateral Approach

This is the best known foraminal approach to the lumbar spine and can be used for foraminal and extraforaminal disc herniations as well as for intradiscal procedures. It uses an angle of about 60deg to the sagittal plane and approaches the

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Fig. 8.5 Special long-stemmed instruments for the thoracoscopic preparation of prevertebral structures, discs and the bone (Miaspas TL, Aesculap)

(with permission of Aesculap AG, Tuttlingen, Germany)

Fig. 8.6 Operating room

set-up for endoscopic spine surgery with arrangement commonly used for thoracoscopy. The video monitors are in the surgeon’s direct line of sight (with permission of Aesculap AG, Tuttlingen, Germany)

Assistant

Camera assistant

U. Vieweg

Fluoroscopy monitor

Surgeon

Instruments

Video-Endoscopy tower

C-arm

8 Endoscopy inSpinal Surgery

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Fig. 8.7 Selective

percutaneous endoscopic cervical decompression (PECD) by Dr. Hellinger (with permission of KARL STORZ Endoskope, Germany)

foramen at the level of the disc. It can be performed with the patient either prone or in a lateral decubitus position. The main intraoperative risks are damage to the exiting nerve root (especially where there is advanced loss of disc height) and to blood vessels. To gain adequate access, it is often necessary to ream the lateral aspect of the superior articular process, especially in patients with short pedicles and even without the presence of osteophytes at the facet joint. The ventral epidural space can only be reached in its lateral aspect.

Far or Extreme Lateral Approach

This approach is a more recent development and has largely been pioneered by Ruetten etal. [4]. Using this approach, it is possible to reach the ventral epidural space (with the exception of the interpedicular area) and the foraminal and extraforaminal areas. The foramen is approached at an angle of slightly less than 90deg to the sagittal plane. The skin is penetrated at about the level of the facet joints in the coronal plane. The patient should be placed in a prone position. This ensures that there is less interference with the facet joint that occurs with the posterolateral approach, but short pedicles and a large bulging disc can still make it difcult to reach the ventral epidural space. The operative risks are much the same as those applying to the posterolateral approach. There is a higher risk of injury to the dura and the added risk of injury to retroperitoneal organs at the upper lumbar levels. The retroperitoneal anatomy at the level of interest therefore needs to be examined using CT or MRI prior to performing this approach at higher lumbar levels.

Fig. 8.8 ENDOSPINE operating tube (with permission of KARL

STORZ Endoskope, Germany)

8.4.5 Anterior Lumbar Spine

Laparoscopy makes it possible to carry out various surgical procedures on the ventral spine. In 1991, Obenchaim [11] performed a laparoscopic L5–S1 discectomy followed, in 1992, by Bohlmann and Zdeblick’s [2] L5–S1 fusion with laparoscopic placement of an interbody cage. Anterior arthrodesis has been performed by laparoscopic insertion of cages at the L4/L5 and L5/S1 levels [10]. Laparoscopic retroperitoneal techniques have been used for anterior plating to xate the anterior column rigidly to restore stability [12].

The spinal endoscopy can be divided in percutaneous-

(see Figs.8.7, 8.8, 8.9 and 8.10, selective percutaneous endo-

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Fig. 8.9 Thoracoscopic spine

surgery—set according to Rosenthal (with permission of KARL STORZ Endoskope, Germany)

U. Vieweg

scopic cervical decompression (PECD); ENDOSPINE operating tube; thoracoscopic spine surgery, set according to Rosenthal; percutaneous lumbar transforaminal endoscopy, KARL STORZ Endoskope) or endoscopic-assisted (EASYGO!, KARL STORZ Endoskope) techniques.

8.5 Tips andTricks

• Endoscopes are precision instruments and must be handled with care. Any damage to the shaft or excessively hard knocks can cause the lenses to become loose or slip inside the instrument. A typical sign of this is clouding of the eyepiece which can lead to a

complete breakdown if the endoscope is subjected to further damage.

• The end of the shaft containing the prism must be protected from high temperatures. All manufacturers give their own recommendations, but an upper limit between +65°C and +70°C is common. Some manufacturers achieve upper limits between +150°C and +200°C.

• If the glass bres in a exible endoscope are damaged or subjected to extreme bending, the individual glass bres may break. This causes small black dots to appear in the endoscopic image.

• To learn these techniques, it is essential that surgeons receive adequate training. This includes practice with cadaver and invivo models, preceptorships and proctor-

8 Endoscopy inSpinal Surgery

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Fig. 8.10 Percutaneous

lumbar transforaminal endoscopy (with permission of KARL STORZ Endoskope, Germany)

ship training and, ultimately, teaching in residency and spinal fellowship programmes.

References

1. Beisse R, Potulski M, Beger J, et al. Entwicklung und klinischer Einsatz einer thorakoskopisch implantierbaren Rahmenplatte zur Behandlung thorakolumbaler Frakturen und Instabilitäten. Orthopade. 2002;31:413–22.

2. Bohlmann H, Zdeblick T.Anterior excision of herniated thoracic discs. J Bone Joint Surg Am. 1988;70:1038–47.

3. Rosenthal D, Rosenthal R, De Simone A.Removal of protruded thoracic disc using microsurgical endoscopy. Spine. 1994;19: 1087–91.

4. Ruetten S, Komp M, Merk H, etal. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine. 2008;33:931–9.

5. Ruetten S, Meyer O, Godolias G.Endoscopic surgery of the lumbar epidural space (epiduroscopy): results of therapeutic intervention in 93 patients. Minim Invasive Neurosurg. 2003;46:1–4.

6. Frempong-Boadu A, Faunce W, Fessler R.Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction. Neurosurgery. 2002;51:60–6.

7. Fessler RG, Khoo LT. Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery. 2002;51:37–45.

8. Raju S, Balabhadra V, Kim DH, et al. Thoracoscopic decompression and xation (MACS-TL). In: Kim DH, Fessler RG, Regan JJ, editors. Endoscopic spine surgery and instrumentation. NewYork: Thieme; 2005.

9. Waisman M, Saute M.Thoracoscopic spine release before posterior instrumentation in scoliosis. Clin Orthop. 1997;336:130–6.

10. Kim DH, Jaikumar S, Kam AC.Minimally invasive spine instrumentation. Neurosurgery. 2002;5:15–25.

11. Obenchaim TG. Laparoscopic discectomy: case report. J Laparoendosc Surg. 1991;1:145–9.

12. Mack MJ, Regan JJ, Bobechko WP.Application of thoracoscopy for diseases of the spine. Ann Thorac Surg. 1993;56:736–8.

Equipment forFull Endoscopic Spinal

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Surgery

SebastianRuetten

9.1 Introduction and Core Messages

Minimally invasive techniques can reduce tissue damage. Endoscopic operations have advantages which have raised these procedures to the standard in various areas. In arthroscopy, working with rod-lens optics under continuous uid irrigation has proven valuable. In addition to reduced traumatization, improved visual and light conditions are achieved. Full endoscopic operations on the lumbar spine can usually be performed uniportal via trans-/extraforaminal or interlaminar approaches. Analogous to the arthroscopy, there is a continuous intraoperative irrigation. Since usually only one access is used, the instruments must be inserted through an intraendoscopic working canal. These days, the equipment available offers operation technical possibilities comparable to those known from microscope-assisted surgery.

9.2 Denition ofSpinal Endoscopy

Full endoscopic technique is the term for a relatively newly developed method for endoscopic uniportal operations of the lumbar spinal canal and adjacent structures under constant visual control and continuous intraoperative irrigation via a minimally traumatizing access using rod-lens optics with an intraendoscopic working canal. On the lumbar spine, there are existing two different surgical approaches: the trans-/ extraforaminal approach through or outside the intervertebral foramen and the interlaminar approach through the interlaminar window.

S. Ruetten (*) Department of Orthopädic Surgery, Center for Spine Surgery and Pain Therapy, Center for Orthopaedics and Traumatology, St. Anna-Hospital, Herne, Germany e-mail: spine-pain@annahospital.de

9.3 Basic Equipment ofSpinal Endoscopy

In addition to standard surgical accessories and small parts, the following basic equipment of the instruments we use (Richard Wolf GmbH, Knittlingen, Germany) are necessary for full endoscopic operations of the lumbar spine:

• Rod-lens optics

The oval rod-lens optics have an outer diameter of maximal 6.9mm and contain an eccentric working canal with a diameter of 4.1mm. Moreover, the light source system and an irrigation canal are in the optics unit. The visual angle is 25deg. The optics for trans-/extraforaminal and interlaminar accesses differ in their usable length (Fig.9.1).

• Access instruments

Access is made bluntly in the dilator technique. For the trans-/extraforaminal approach, the following instruments are necessary:

– Spinal needle: for puncture of the target area in or out-

side the spinal canal

– Target wire: for subsequent control of the dilators after

removal of the spinal needle

– Dilator creates the access for the nal operation

sheath

– Operation sheath: for insertion of the optics after

removal of the dilators For the interlaminar approach, the following instruments are necessary:

– Dilator creates the access for the nal operation

sheath.

– Operation sheath: to insert the optics after removal of

the dilators. The operation sheaths have a beveled opening which creates a eld of vision and work area in an area without clear anatomically preformed hollows. The irrigation uid is drained off between the oval optics and round operation sheath. The operation sheaths for trans-/extraforaminal and interlaminar accesses differ in their usable length (Fig.9.2).

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Fig. 9.1 Rod-lens optics with

intraendoscopic working canal (with permission from Wolf Endoscope, Knittlingen, Germany)

Fig. 9.2 Dilator and

operation sheath (with permission from Wolf Endoscope, Knittlingen, Germany)

S. Ruetten

• Manual instruments The instruments are inserted through the intraendoscopic working canal of the optics. There is a wide variety of punches, shears, rongeurs, and other supplies with diameters from 2.5 to 4mm. The manual instruments for the trans-/extraforaminal and interlaminar approach differ in their usable length (Fig.9.3).

• Motor-driven burrs and shavers The burrs and shavers are also inserted via the working canal so that visualization is guaranteed at all times. For bone resection, there are various diamond and normal burrs in ball or oval shapes with various soft tissue protec-

tors. The diameter ranges from 2.5 to 4mm. The shavers for nucleus resection have a diameter of 4mm (Fig.9.3).

• Bipolar coagulation and preparation For intraoperative coagulation and soft tissue preparation, there are semiactive exible, bipolar ball electrodes. They are used with radiofrequency current which can reduce tissue damage in the immediate vicinity of neural structures.

• Basic unit for endoscopic operations In addition to the operation instruments and the optics, general instruments for endoscopic operations under uid ow are needed, such as monitor, camera unit, light

9 Equipment forFull Endoscopic Spinal Surgery

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Fig. 9.3 Instruments and burrs (with permission from Wolf Endoscope, Knittlingen, Germany)

source, documentation system, uid pump, shaver system, and radiofrequency generator. Some of the instruments available for arthroscopy or endoscopy can be used (Fig.9.4).

• Technical setup in the operating theater An X-ray permeable, electrically adjustable operating table and a C-arm are needed. Positioning of the basic units and instruments is made individually and corresponding to the procedure in arthroscopy or endoscopy.

Transforaminal [1–4]

– In consideration of abdominal structure performance of a

lateral approach to reach the spinal canal sufciently under constant visualization

– Performance of the approach strictly to the caudal part

of the disc level to avoid damaging of the exiting nerve root

– Performance of the extraforaminal approach in cases of

intra-/extraforaminal disc herniations or foraminal stenosis

– In cases of insufcient mobility in the spinal canal

9.4 Tips andTricks

resection of the ventral bony aspect of the ascending facet

• Observance of the general indications for the surgical procedure (decompression due to radicular or neurogenic symptoms)

• Observance of the specic indication criteria for the utilization of each approach (trans-/extraforaminal or interlaminar)

Interlaminar [2–5]

– Performance of the skin incision as medial as possible to

facilitate introducing of the endoscope in the spinal canal

– Preparation and identication of the lateral margin of the

neural structures before mobilization to avoid damaging of the dura

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Fig. 9.4 Endoscopy tower

with basic equipment (with permission from Wolf Endoscope, Knittlingen, Germany)

S. Ruetten

– Avoidance of immoderate retraction for a long time of the

neural structures

– In cases of insufcient mobility in the spinal canal or dur-

ing the approach resection of bony aspect

References

1. Ruetten S, Komp M, Godolias G.An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach. Technique and prospective results of 463 patients. Spine. 2005;30:2570–8.

2. Ruetten S, Komp M, Merk H, Godolias G.Use of newly developed instruments and endoscopes: full-endoscopic resection of lumbar

disc herniations via the interlaminar and lateral transforaminal approach. J Neurosurg Spine. 2007;6:521–30.

3. Ruetten S, Komp M, Merk H, Godolias G.Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine. 2008;33:931–9.

4. Ruetten S, Komp M, Merk H, Godolias G.Recurrent lumbar disc herniation following conventional discectomy: a prospective, randomized study comparing full-endoscopic interlaminar and transforaminal versus microsurgical revision. J Spinal Disord Tech. 2009;22:122–9.

5. Ruetten S, Komp M, Merk H, Godolias G. Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique: a prospective, randomized, controlled study. J Neurosurg Spine. 2009;10:476–85.

Electrosurgery

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UweVieweg

10.1 Introduction and Core Messages

In electrosurgery, a high-frequency electric current is applied to the biological tissue as a means to cut, coagulate, desiccate or fulgurate the tissue. When a current is passed through the tissue, the cell liquid expands and evaporates, and the cell explodes, which causes the cutting or coagulation effect. This technique underlies many modern surgical procedures. It is therefore important for spine surgeons to be familiar with its basic physical principles and safety measures.

U. Vieweg (*) Department of Conservative and Surgical Spine Therapy with Interdisciplinary Spinal Deformities Centre and Rummelsberg Sectional Center, Hospital Rummelsberg, Schwarzenbruck, Germany e-mail: uwe.vieweg@sana.de

10.2 Denition

Electrosurgery uses high-frequency energy for cutting, cutting with simultaneous coagulation and coagulation procedures on the human tissue (synonyms: HF surgery, diathermia, electrocauterisation, electrosurgery). Today, high-frequency surgery or electrosurgery is an established feature in the different surgical disciplines. Most highfrequency surgical devices now work with frequencies of about 300–600kHz (see Fig.10.1). The advantages of highfrequency surgery are that bleeding is minimal, the high working temperature prevents contamination with microorganisms and the surgical procedure requires only a small skin incision.

10.3 Procedures andDevices

• Haemostasis and tissue cutting with high-frequency currents alone (e.g. MBC 200 Söring GmbH)

• Haemostasis and tissue cutting with high-frequency currents and additional helium gas as a carrier for the electric current (e.g. CPC 1000–1500–3000 cold plasma coagulation, Söring GmbH)

• Haemostasis and devitalisation of the tissue with highfrequency currents and additional ionised argon gas (e.g. VIO-APC 2 argon plasma coagulation, Erbe Elektro medizin GmbH)

• High-frequency-induced thermotherapy (tissue ablation) with high-frequency currents and hollow insulated shaft

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