Key Features of Endoscopic Spine Surgery Are Exciting

Endoscopic spine surgery (ESS) is a relatively modern development that allows for the treatment of spinal pathology with minimal damage to surrounding tissue. Instead of using large open incisions under general anesthesia for traditional back surgery, ESS uses specialized instruments along with an endoscope in small incisions to perform delicate operations involving and surrounding the spine. Often, these operations can be performed under local anesthesia. Endoscopy allows for excellent visualization of anatomy without extensive exposure and results in faster recovery, minimal blood loss, and reduced scar formation. This operative technique minimizes tissue trauma and postoperative pain. Endoscopic surgery can be a beneficial alternative to open procedures, especially in higher-risk patients, such as those with medical comorbidities.

ESS was developed as a less invasive procedure to treat spine disorders. At first, the technique was utilized primarily for diskectomy in the lumbar spine. However, in recent years, endoscopic surgery has been used to treat an increasing number of spinal pathologies involving the cervical, thoracic, or lumbar spine. Instrumentation and technical advances have allowed successful endoscopic application in many spine pathologies. Current surgeries performed under endoscopy include lumbar decompression, foraminotomy, facet rhizotomy, and foraminoplasty, among others. This technique can also be used for removal of extradural tumors and in trauma surgery of the spine. Surgery can be performed through interlaminar or transforaminal approaches. Endoscopic lumbar decompression can be used to treat herniated nucleus pulposus even in challenging scenarios when the herniation has migrated vertically.

As the elderly population grows, there is a rising incidence of degenerative disk disease. Older patients often present with additional health issues (e.g., high blood pressure, heart disease, diabetes), and surgery for such patients can be complex and riskier due to their multiple health conditions. ESS may be a preferable option for such individuals, offering a safer alternative by avoiding the potential side effects of general anesthesia. Additionally, the small incisions lower the risk of infection and help the patient heal more quickly. Endoscopic surgery can also be a safer option for those who are frail, immunocompromised, or at high risk of blood loss.

Benefits of ESS
ESS can be beneficial even for patients with average to low risk of complications. The minimally invasive nature of these procedures allows for faster recovery and return to work. These surgeries can be performed at an outpatient surgery center, resulting in lower costs compared with hospitalization. This option is often more convenient and less stressful because many patients can return home for recovery on the same day as surgery. The rapid recovery and return to work may provide secondary benefits, such as greater patient satisfaction and potentially less reliance on opioid pain medication following surgery.

Because of the smaller incisions and reduced tissue trauma, surgeons can conduct spine surgeries without disrupting structures and tissues that provide spinal stability. Minimizing muscle weakness or instability can improve patient outcomes from surgery. Robotics, virtual reality, and 3D visualization are new innovations that can further expand and improve ESS procedures.

Disadvantages of ESS
Endoscopic surgery has potential drawbacks. There is a steep learning curve for surgeons as they become adept at using the novel technology and equipment. At the beginning of the learning curve, common complications include incomplete decompression or iatrogenic nerve root damage. Surgeons inexperienced in the technique may require more time to perform the surgeries, as well.

Traditional operative risks such as infection, bleeding, or nerve damage still exist. Hospitals and surgical centers must invest in endoscopic surgical equipment, which is costly. Furthermore, insurance reimbursement for ESS is often lower than reimbursement for traditional open spine surgical procedures. Moreover, due to the substantial number of disposable items used during surgery, endoscopic procedures can be more expensive than open procedures. However, patients undergoing open surgery often stay longer in the hospital and may have higher rates of complications depending on the specific procedure.

Case presentation
The following case presentation illustrates the utility and positive outcome of an ESS patient.

A female patient aged 67 years with a history of diabetes and bilateral total knee arthroplasty presented to the clinic for evaluation of low-back pain and radiculopathic pain in the right leg (rated 8–9 out of 10). She reported numbness, tingling, and burning sensations below the kneecap down her shin. She reported significant weakness and difficulty balancing while ambulating and climbing stairs; she required the use of a rolling walker. She failed conservative treatment, consisting of 2 weeks in physical therapy and NSAIDs without improvement. Pain management included hydrocodone and acetaminophen, as well as cyclobenzaprine, which provided moderate relief. Her physical exam was notable for weakness (rated 2–3 out of 5) of her right iliopsoas and quadriceps, milder weakness of the tibialis anterior and extensor hallucis longus, absent right patellar reflex, and a positive straight leg sign. MRI confirmed a right L4–L5 far lateral extraforaminal herniated nucleus pulposus causing foraminal and central stenosis. The physician proceeded to perform a right L4–L5 microscopic diskectomy with unilateral biportal endoscopy. Six weeks after right L4–L5 microdiskectomy, the patient stated that she is doing well and reported pain as 0 out of 10, with resolution of her radiculopathy and full motor recovery. At the follow-up visit, she was very pleased with her surgical outcome.

Future role of ESS
With continuing advancements in technology and equipment, ESS is allowing surgeons to address a wider range of spine pathologies with precision and efficiency. At the same time, this technique often proves to be safer and less invasive, helping patients to reach their surgical goals and have a speedier recovery. Innovative technology and improvements in endoscopes, optics, pumps, drills, shavers, and multiport endoscopes are overcoming previous limitations. Because of this, ESS can be employed for a broader spectrum of spine pathologies. As instrumentation and endoscopic surgical techniques continue to improve, this procedure may become the surgical treatment of choice for many patients with spinal diseases.

Kern Singh, MD, is a professor of orthopaedic surgery at RUSH University Medical Center in Chicago. He currently serves as the vice chair of clinical affairs in the Department of Orthopaedic Surgery, professor and director of the Division of Spine Surgery, codirector of the Minimally Invasive Spine Institute, and founder and president of the Minimally Invasive Spine Surgery Study Group.

References

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