Sebastian Ruetten discusses the techniques and benefits of full-endoscopic procedures
Degenerative constrictions of the spinal canal with compression of neural elements arise as a result of bony, disk, capsular, or ligament structures. The most frequent causes are disk herniations and spinal stenoses. The lumbar and cervical spine is the most prominent cause. After conservative treatments have been exhausted, surgical intervention may be necessary. Today, microsurgical, microscopically assisted decompression is regarded as the standard procedure for disk herniation and spinal stenosis in the lumbar region, while in the cervical spine microsurgical, microscopically assisted anterior decompression and fusion are standard. Both procedures demonstrate good clinical results but can present problems associated with the operation.
Full-endoscopic lumbar surgery describes an operating technique for the spinal canal and neighbouring structures carried out under continuous visual control and irrigation using an approach causing minimal trauma. This is not an endoscopic-assisted procedure through a tubular retractor but a uniportal technique using endoscopes with intraendoscopic working channels. Apart from reduced trauma, it yields the benefits of arthroscopic procedures, such as improvement in visualisation and light conditions.
Decompressions in the area of the spine must be carried out under continuous visualisation and must entail the possibility of adequate bone resection. Taking this into account, completely new endoscopes and instrument sets were developed for full-endoscopic operations in tandem with the development of the lateral transforaminal and interlaminar approaches for the lumbar spine and the posterior and contralateral anterior approaches for the cervical spine. The possibilities and results of comparable, established standard procedures were used as a benchmark in the course of clinical validation. The development of surgically created approaches and the new rod lens endoscopes combined with appropriate instrument sets have laid the technical foundations for full-endoscopic operation in the lumbar spine on all primary and recurrent disk herniations inside and outside the spinal canal and on spinal stenoses. This development has also permitted resection of soft disk herniations and foraminal stenosis in the cervical spine. The use of the relevant approaches depends on anatomical and pathological inclusion and exclusion criteria.
The clinical results of standard procedures are achieved, which must be regarded as a minimum criterion for the introduction of new technologies. On the basis of evidence based medicine criteria, it can be established that using the full-endoscopic techniques developed, adequate decompression is achieved in the defined indications with the following advantages:
- facilitation for the surgeon due to excellent visualization, good illumination, and expanded field of vision with 25˚ endoscopes
- cost-effective procedure due to short operating time, rapid rehabilitation, high rate of return to earlier activity levels and low postoperative costs of care
- reduced traumatisation and the resultant consequences for the surrounding tissue, the stabilising structures of the spinal canal and the epidural space
- facilitated revision operations
- reduced complication rate, such as dural injury, bleeding, infections, etc.
- monitor image as training basis for assistants
- high level of patient acceptance
- The challenging learning curve should be assessed as disadvantageous.
Today, full-endoscopic operations may be regarded as an adequate, safe supplement and expansion within the overall concept of spinal surgery. But surgeons should also be able to perform open procedures, not simply so that they are in a position to offer patients the most appropriate procedure for their particular circumstances but also to enable them to deal safely with any problems and complications that emerge.
Sebastian Ruetten, Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St Elisabeth Group – Catholic Hospitals Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital, Herne University Hospital/Marien Hospital Witten, Germany