EVOLVING METHODOLOGY IN ARTHROSCOPIC AND ENDOSCOPIC SPINAL SURGERY

P. KAMBIN ( USA)

 

In the mid sixties Lyman Smith introduced the concept of chemical nucleolysis for the treatment of herniated lumbar disc. The surgical technique required radiographic confirmation for proper positioning of the needle in the nucleus prior to the injection of chymopapain.

Kambin in the early seventies and Hijikata in the mid seventies experimented with mechanical nuclear debulking for the management of a contained disc herniation. The concept of nuclear debulking was further advanced by Onik, et al in the mid eighties who developed a small caliber automated device for nuclear resection.

Ascher and coworkers in the late eighties reported satisfactory outcome with laser nuclear ablation for the treatment of herniated lumbar disc. Since its introduction a variety of laser lights have entered the armamentarium which are used in the field of minimally invasive spinal surgery.

In an attempt to access and retrieve the herniated disc fragments that were dislodged adjacent to the spinal canal, Kambin in the early eighties utilized a larger diameter cannula with a 6.4-mm OD that accommodated both an up biting and flexible tip forceps. (Ref. 2) The use of a larger diameter cannula in the US, Switzerland. Belgium and France met with certain resistance. The concern of causing an inadvertent neural injury altered the concept of localization of the instrument in the center of the intervertebral disc at the onset of the operative procedure. Following a number of cadaveric studies, a safe zone on the posterolateral annulus for lodging of the instruments was identified (Ref:3, 4).

The idea of docking of the instruments on the annulus prior to entering the intervertebral disc was promoted.

 

The availability of a small caliber rigid rod discoscope in the late eighties (Ref.3) forever altered the concept of blind nucleotomy to disc fragment resection under arthroscopic or endoscopic magnification and illumination. (Ref: 5)

The surgical approaches  to the spinal column also have evolved during the last 10 years. Selection of a surgical approach to a give disc herniation by in large is dependent to the nature and location of the herniation and the experience of the operating surgeon.

Schreiber, Suczawa. and Leu (Ref.7) introduced the principals of bilateral biportal access to the intervertebral disc.

Kambin (Ref.6) used dual portal unilaterally for the retrieval of a contained or non-migrated sequestered disc herniation via an intradiscal or subligamentous access. Transforaminal approach also may be used for retrieval of sequestered disc fragments.

Among all minimally invasive spinal procedure, arthroscopic or endoscopic approaches stand-alone by providing access and the capability of visualizing the structures that were previously hidden from the naked eye, loops or a microscope. Although minimally invasive technology has been commonly used for the decompression of herniated intervertebral disc, its horizon has expanded to include retrieval of sequestered herniated disc fragments, retrieval of recurrent disc herniations, decompression of lateral  recess stenosis, and the potential use of an expandable cage or disc prosthesis.

Recent advancement in gene coding of desired bone proteins would certainly enhance our ongoing efforts in the field of anterior column stabilization under arthroscopic magnification and illumination.

 

 

 

 

Finally thoracoscopic and laparoscopic approaches to the pathological conditions of the thoracic and lumbar spine has opened a new window of opportunity for the management of a variety of spinal disorders.

Efficacy of arthroscopic and endoscopic surgery for the treatment of contained and non-contained disc herniations has been impressive and the subject of numerous publications in peer review journals. (Ref. 1, 5, 8).

 

 

References

 

1. Hermantin FU, Peters T, Quartararo L. and Kambin P: A prospective, randornized study

comparing the results of open discectomy with those  video-assisted arthroscopic

microdiscectomy. The Journal of Bone and Joint Surgery, Vol. 8I-A. No. 7, July 1999-

2. Kambin P, Gellman H: Percutaneous Lateral Discectomy of the lumbar spine: a preliminary report. Clin. Orthop. 174:127-132,1983.

3. Kambin P: Arthroscopic Microdiscectomy Minimal Intervention in Spinal surgery. Text, P Kambin (Ed) Urban & Schwarzenberg Baltimore, MD 67-100, 1991.

4. Kambin P: Percutaneous Lumbar discectomy: Current Practice. Surgical Rounds for Orthopaedic, pp 31-35, December 1988.

5. Kambin P, O'Brien E,  Zhou L and SCHAFFER JL:  Arthroscopic Microdiscectomy and Selective Fragmentectomy. CORR, No 347, 150-167, Feb. 1998.

6. Kambin P: Chapter 94 Arthroscopic Microdiscectomy in Frymoyer.J (Ed-in-chief): the Adult  Spine Principles and Practice Second Edition. New York, Raven Press, July 1996.

7. Schreiber A, Suezawa Y, and Leu  H: Does percutaneous nucleotomy with discoscopy rep1ace conventional discotomy. Clin Orthop 238:35-42. 1989.

8. Yeung AT , Tsou PM: Posterolateral endoscopic excision for lumbar disc herniation, surgical technique. Outcome and complications in 307 consecutives cases. Spine 27: 722-31.2002.