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My 16 Year Evolving Clinical Experience in Endoscopic Lumbar

Surgery

John C Chiu, MD, FRCS (US), DSc Chief, Neurospine Surgery California Spine Institute

Thousand Oaks, California, USA President AAMISMS

COLEGIO MEXICANO DE ORTOPEDIA Y TRAUMATOLOGÍA A.C.

September 5, 2012 Mexico City, Mexico

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California Spine Institute Medical Center, Inc

Calif. Center for Minimally Invasive Spine Surgery

“Guten Tag!”

“Bonjour”

“Buenos Dias”

“Ciao”

“Konnichi wa”

Kinh Môi

“Bienvenida del CSI”

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Overview:

1. MISS being disruptive technology with dilatation technology e.g. microdecompressive endoscopic lumbar discectomy

2. MISS with limited visualization requires GPS for navigation

3. DOR facilitates MISS by “technology convergence and control”

4. Patient centric IOM

5. Clever micro spinal instruments

6. Important of education, technology training, surgical anatomy, hands on training, meticulous imaging planning preoperatively

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Introduction:

• 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

• 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

What is Minimally Invasive Spine Surgery (MISS)?

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Introduction:

• 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

Herniated Lumbar Discs Causing Nerve Impingement - Radiculopathy

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Surgical Indication for MISS

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MISS Surgical Indications:

– Herniated discs/degenerative 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:

– Lumbar spinal stenosis and spondylolisthesis

– Cervicogenic headache and discogenic pain

– Intraspinal lesions

– Synovial cyst and degenerative cyst

– Intraspinal tumor, lipoma

– Others

For treatment of:

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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:

For treatment of degenerative and herniated spinal discs, and spinal stenosis

Pain Management Injectional Therapy and RF

Conservative Treatment

Minimally Invasive (Laser) Spinal Surgery

Spinal Arthroplasty Disc Replacement

Artificial Disc

Open Spinal Surgery Fusion

MISS and NFT

The last resort The modern concept - algorithm of spine care like walking up a staircase

Maybe

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Advantages of 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 except occasional brief general 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

Obvious advantages of Endoscopic MISS:

Obviously “less is better – less is more” for MISS

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MISS Surgical Procedure:

• Anesthesia: Local/IV conscious Sedation

• INTRA-OPERATIVE NEUROPHYSIOLOGICAL MONITORING (IOM) ,– EEG, EMG of vital signs (pulse rate, BP, RR), pulse oxymetry C02 content, on intra-operative wave form display/monitor

• To insure safer and to facilitate MISS

Preparing for MISS – Anesthesia (requiring technological monitoring and precision)

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Types of Endoscopic MISS (Requiring precision, navigation and monitoring)

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LUMBAR ENDOSCOPIC MISS TECHNIQUE:

• 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

Posterio-lateral and posterio–median surgical approaches

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Lumbar Endoscopic MISS Technique:

• 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

Localization of skin incision and portal of entry Provocative discogram

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Surgical Plane/Approach/Technique: With GPS

• Extreme obese patient had successful left posterolateral endoscopic lumbar discectomy with application of geometric line/plane and GPS system

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Grid Position System (GPS) in Endoscopic Lumbar MISS

Fluoroscopic monitoring to provide safer and precise lumbar spine surgery by using GPS

Subarticular

Extraforaminal Foraminal 1 disc

2

3 pedicle

B C D A

• Lumbar spine has neuro foramen and intra-lamina foramen openings restricting MISS at a portal 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 an accurate navigation map for MISS surgeons

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Surgical Instrument and Equipment

Mini Endoscopic Spinal Surgical Instruments for MISS

• 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

Close up view

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Surgical Instrument and Equipment

• For bony decompression: – Round ball tip drill

avoids neural and tissue trauma

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Surgical Instrument and Equipment

• Holmium YAG laser equipment for Laser Thermodiskoplasty (LTD)

Trimedyne Holmium YAG laser generator

Right angle (side firing) laser probe

Application of Tissue Modulation Technology in Endoscopic Laser MISS

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GPS (Grid Position System) for Endoscopic Lumbar MISS

Fluoroscopic/imaging and endoscopy to provide safe and precise lumbar MISS and foraminoplasty

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Lumbar Endoscopic MISS Technique:

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:

• Small spinal discectome for rapid disc removal

Additional advanced MISS surgical instruments

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Lumbar Endoscopic MISS Technique:

• 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

Posterio-lateral approach vs. posterio–median aproach

(Requiring precision, navigation and monitoring)

SMART Endoscopic System

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Lumbar Endoscopic MISS Technique:

For larger extruded herniated lumbar discs (red arrows)

Endolumbar paramedium approach (SMART Endo System)

(Requiring precision, navigation and monitoring)

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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:

• 45 year old male firefighter for Anchorage Alaska Fire and Rescue

• Suffered from an extremely large L4-5 paracentral extruded disc, extending upward measuring 18 mm x 10 mm towards the left, neuro foramen and also towards the right

• Microdecompressive lumbar L4-5 laminectomy, exploration and meticulous removal of the sequestrated disc fragment with endoscope gave him immediate relief of his symptoms, returned to work in a few weeks

• Incidentally adjoining L4 – L5 vertebra showed prior post laser thermodiskoplasty - subchondral vertebral/bone marrow asymptomatic changes/artifact

Extremely large extruded/herniated lumbar disc

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Severe lumbar stenosis

• 73 yo with severe rapid progressive (in 6 mos.) neurogenic claudication, leaning on grocery cart syndrome

• Successfully treated with endoscopic microdecompressive discectomy and interspinous spacer Coflex-f with facet fusion

• One hour post op able to stand and walk unassisted and straight

Case Illustration III LUMBAR MISS COMBINED WITH INTERSPINOUS

PROCESS/LAMINA SPACER FIXATION/FUSION (COFLEX-F)

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Digital Technology in the DOR

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Introduction:

• Endoscopic MISS is a technologically dependent surgery, requiring utilization of advanced endoscopic surgical instruments, imaging-video technology and tissue modulation technology, in a digital operating room (DOR)

• It requires seamless connectivity and control to perform the surgical procedures in a precisely orchestrated manner.

• Therefore a new integrated technological convergence and control system (SECS) SurgMatix® was created by myself and Professor HK Huang, USC MC to facilitate MISS

• This system facilitates MISS with “organized control instead of organized chaos” in an endoscopic DOR suite and enables a safer, precise and more effective surgery

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Current Digital Endoscopic DOR suite facility Courtesy of : Dr. John Chiu, California Spine Institute

MD’s

Staff

RN, Tech

EMG Monitoring

C-Arm Fluoroscopy

MRI Image - PACS

C-Arm Images

Image Manager - Report Video Endoscopy Monitor

EEG Monitoring

Left side of OR

Image view boxes

Teleconferencing - telesurgery

Laser generator

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DOR - Surgical ePR Control System (SECS) SurgMatix® was invented TO FACILITATE MISS, (by Professor HK

Huang and Dr. John C. Chiu)

With Image acquisition, Display, Manipulation and Document Historical and Live Data on two Opposite Large Screens

Pre-OP 52” LCD Intra-op 52” LCD

Operating Table

136 Endoscope Display / Storage

142 Laser Generator

138 EEG/ Display

2800 mm .

120 Large screen intra-op image/data

143 Selected Imaging/ dictation system

133 Video

Mixing Equipment

132 Surgical Video

Camera / Display

141 EKG/ Display

139 Vital signs and

Display

137 Authoring document module

Fluoroscopic

Display / Storage

134 C-ARM -

Surgical Instrument

table

Assistant Surgeon Scrub Nurse

Anesthe- siologist

Circulator

1Large screen Pre-op image/data

140 EMG/ Display

135 Pt Biom ID

100

131 Neuro Physio (SSEP)

133 Fluid Intake/ Output

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SurgMatix® SECS IN MISS DOR

• SurgMatix® SECS 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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Goals of SurgMatix® SECS 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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Post Operative 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 • 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

Spinal motion measurement (spine mouse)

Advanced exercise

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Results:

• Average follow-up 47 months (7-68 months)

• Overall result: 3710 (90%) patients with good to excellent results, fair results 165 (4%) patients (single level)

• Various evaluations of response to treatment: modified Mac Nab criteria, Oswestry disability score/index (ODI), visual analogue pain scale (VAS), patient satisfaction scoring, pain diagram and/or patient target achievement score (PTA) for assessment were utilized

• Average satisfaction score – 3875 (94%) • 165 (4%) patients had mild residual pain

and parasthesia, although overall their pain lessened

• Complication rate: less than 1% • Average return to work: 10-14 days

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Results (symptomatic improvements)

296176

2438

68

119874

4122157

150143

28415

0 500 1000 1500 2000 2500 3000 3500 4000 4500

Persistent Numbness

Muscle Spasm

Muscle Weakness

Required Analgesics

Mild Spine Pain

Severe Spine Pain

Pre-Op Post-Op

Lumbar disc patients (2858)

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RESEARCH, DEVELOPMENT, EDUCATION AND TRAINING IN

MISS

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R&D for MISS:

Microphone headset

Voice activated

Robotic aided endoscopic spine surgery and image guided technology on the horizon

• Advanced 3D Image guided system is being developed and will be applied to enhance and navigationally to guide the surgical robot

• Surgical robotics can improve endo-MISS with better surgical precision and minimal trauma

Image guided endo-MISS

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Education/Training for Endoscopic MISS:

– Thorough knowledge of the surgical anatomy and the surgical procedure

– Specific endoscopic MISS training – Hands-on experience in a laboratory

including cadaveric – Meticulous pre-operative surgical

planning – Working closely with an experienced

endoscopic spine surgeon through the steep surgical learning curve

– Fluoroscopy as “The 3rd Eye” or “Eye of Wisdom” for confirmation of location of instruments; endoscopy alone is not enough

– Use of digital imaging system PACS, enhanced 3D visualization, and use of SurgMatix® -in DOR

• Endoscopic MISS has numerous obvious advantages but requires:

• Training is critical in order to perform endoscopic MISS effectively, safely and avoid potential complications

Computer assisted endoscopic MISS trainer

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Conclusion:

• The convergence, utilization and control of science and technology is a must for furthering MIST and MISS

• Endoscopic MISS has advanced as a result of the past spinal surgical experience, advancement of bio-technology and new MISS instruments

• MISS performed in a patient centric, seamless DOR is an effective, safe, less traumatic and easier spine surgery

• MISS is a smart way to perform spine surgery

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Hope you enjoyed this presentation!

“Danke schön”

“Merci” “Gracias”

“Cám ón”

“Arigato”

“Thank you”

John C. Chiu, M.D., FRSC (US), D.Sc.

California Spine Institute

“Gracias por su amable atención!”

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References: 1. Chiu J, Surgeon’s Perspective and Consideration: OR Digital Technology Convergence and Control System for Minimally Invasive Spine

Surgery, Presented at Special Session, Minimally Invasive Spine Surgery, CARS 2008, Computer Assisted Radiology and Surgery 22nd International Congress and Exhibition, Barcelona, Spain, Proceedings, P. 8 June 23-28, 2008.

2. Chiu J, Digital Technology Convergence and Control System: Minimally Invasive Spine Surgeon’s (MISS) Perspective and Technological Consideration, “Interdisciplinary PACS” The Second Iranian Imaging Informatics Conference Syllabus, pp 30-31, Tehran, Iran, 2008

3. Chiu J, Therapeutic Application of Surgical ePR Control System Beyond Radiology PACS, presented at the SPIE Medical Imaging Advanced PACS Based Imaging Informatics and Therapeutic Applications, Orlando, Fl, February 8-12, 2009.

4. Huang, H.K., Utilization of medical imaging informatics and biometrics technologies in healthcare delivery in: Image Processing and Informatics laboratory (IPI), University of Southern California (USC), Annual Progress Report, pp 76-88 February 2009.

5. Heinz U Lemke and Leonard Berliner, IT Architecture and Standards for a Therapy Imaging and Model Management System (TIMMS), Chapter 31, in “Principles and Advanced Methods in Medical Imaging and Image Analysis” AP Dhawan, HK Huang, and DS Kim, Ed. Chapter 31, 29-62. World Scientific Publications, NJ, London, Singapore. 783 – 827, 2008.

6. Chiu J, Prototyping an IT infrastructure in the Digital Operating Room (DOR) - Clinical and technical considerations, “Interdisciplinary PACS” The Second Iranian Imaging Informatics Conference Syllabus, pp 28-29, Tehran, Iran, 2008

7. Chiu J, Surgical Informatics for Minimally Invasive Spinal Surgery Practice, “Interdisciplinary PACS” The Second Iranian Imaging Informatics Conference Syllabus, pp 32-33, Tehran, Iran, 2008

8. Documet J, Le A, Liu BJ, Huang HK, Chiu J, An image-intensive ePR for image-guided minimally invasive spine surgery applications including real-time intra-operative image acquisition, archival, and display, Proceedings of SPIE Medical Imaging 7264:72640E, 2009.

9. Evolving Minimally Invasive Spinal Surgery (MISS) a Surgeons Perspective and Technological Considerations, Chiu J, presented at the Minimal Invasive Spinal Therapy – SPINE, Seminar, Session; CARS 2009 Computer Assisted Radiology and Surgery 23rd International Congress, Berlin, Germany, June 23 - 27, 2009

10. Chiu J, Maziad, A. Rappard, G.et al Evolving Minimally Invasive Spine Surgery: a Surgeon’s Perspective on Technological Convergence and Digital OR Control System, In, Szabo Z, Coburg AJ, Savalgi R, Reich H, Yamamotto M, eds. Surgical Technology International XIX, UMP, San Francisco, CA 2009 p.211-222.

11. Chiu J, Maziad, A., Innovative Grid Positioning System (GPS) Guidance for Minimally Invasive Spinal Surgery, In, Szabo Z, Coburg AJ, Reich H, Yamamotto M, Brem, H., Harwin, S., eds. Surgical Technology International XX, UMP, San Francisco, CA 2010 p.363-372

12. Savitz MH, Chiu JC, Yeung AT. History of Minimalism in spinal medicine and surgery. In: Savitz MH, Chiu JC, Yeung AD (eds), The practice of minimally invasive spinal technique. Richmond, VA: AAMISMS Education, LLC; pp 1-12, 2000.

13. Chiu J, Endoscopic Assisted Lumbar Microdecompressive Spinal Surgery with a New Smart Endoscopic System. In, Szabo Z, Coburg AJ, Savalgi R, Reich H, Yamamotto M, eds. Surgical Technology International XV, UMP, San Francisco, CA 2006: p.265-275

14. Chiu J. Endoscopic Lumbar Foraminoplasty In: Kim D, Fessler R, Regan J, eds. Endoscopic Spine Surgery and Instrumentation. New York: Thieme Medical Publisher; 2004: Chapter 19, pp 212-229.

15. Hijikata S. Percutaneous nucleotomy: A new concept technique and 12 years’ experience. Clin Orthop 1989;238:9-23. 16. Ascher PW, Choy, D. Application of the laser in neurosurgery. Laser Surg Med 1986;2:91-7.

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References: 17. Kambin P, Saliffer PL. Percutaneous lumbar discectomy: reviewing 100 patients and current practice. Clin Orthop 1989;238:24-34. 18. Schreiber A, Suezawa Y, Leu HJ. Does percutaneous nucleotomy with discoscopy replaces conventional discectomy? Eight years of

experience and results in treatment of herniated lumbar disc. Clin Orthop 1989;238:35-42. 19. Destandau J. Endoscopically assisted microdiscectomy. In: Savitz MH, Chiu JC, Yeung AD (eds), The practice of minimally invasive spinal

technique. Richmond, VA: AAMISMS Education, LLC; pp 187-92, 2000. 20. Chiu J, Evolving Transforaminal Endoscopic Microdecompression for Herniated Lumbar Discs and Spinal Stenosis: In, Szabo Z, Coburg AJ,

Savalgi R, Reich H, eds. Surgical Technology International XIII, UMP, San Francisco, CA 2004: pp. 276-286 21. Chiu J, Clifford T, Princenthal R. The new frontier of minimally invasive spine surgery through computer assisted technology. In: Lemke

HU, Vannier MN, Invamura RD (eds), Computer assisted radiology and surgery, CARS 2002. Berlin: Springer-Verlag, pp 233-7, 2002. 22. Chiu J, Clifford T. Microdecompressive percutaneous discectomy: Spinal discectomy with new laser thermodiskoplasty for non extruded

herniated nucleus pulposus. Surg Technol Int 1999;VIII:343-51. 23. Chiu J, Stechison M, Percutaneous Vertebral Augmentation and Reconstruction with an Intervertebral Mesh and Morecelized Bone Graft:

In, Szabo Z, Coburg AJ, Savalgi R, Reich H, Yamamotto M, eds. Surgical Technology International XIV, UMP, San Francisco, CA 2005: p.287-296

24. Chiu JC, Hansraj K, Akiyama C, et al. Percutaneous (endoscopic) decompressive discectomy for non-extruded cervical herniated nucleus pulposus. Surg Technol Int 1997;VI:405-11.

25. Kambin P, Casey K, O’Brien E, et al. Transforaminal arthroscopic decompression of lateral recess stenosis. J Neurosurg 1996;84:462-7. 26. Chiu JC, Clifford T. Multiple herniated discs at single and multiple spinal segments treated with endoscopic microdecompressive surgery. J

Minim Invasive Spinal Tech 2001;1:15-9. 27. Knight M, Goswami A. Endoscopic laser foraminoplasty. In: Savitz MH, Chiu JC, Yeung AD (eds), The practice of minimally invasive spinal

technique. Richmond, VA: AAMISMS Education, LLC; pp 337-40, 2000. 28. Clifford T, Chiu JC, Rogers G. Neurophysiological monitoring of peripheral nerve function during endoscopic laser discectomy, J Minim

Invasive Spinal Tech 2001;1:54-7. 29. Chiu J, SMART Endolumbar System for Microdecompression of Degenerative Disc Disease, presented at the Practical Course on Minimally

Invasive Technique in Spinal Surgery, Russian Spinal Cord Society, Moscow Russia - April 26-29, 2007 30. Chiu J, Complications and Avoidance in Endoscopic Spine Surgery, presented at the North American Spine Society Minimally Invasive

Spine Technique: Hands-on Course, Barrow Neurological Institute (BNI), Phoenix, AZ 31. Chiu J, Evolving Minimally Invasive Spinal Surgery (MISS) and Future Perspectives, presented at the Minimal Invasive Spinal Therapy –

SPINE, Seminar, Session; CARS 2007 Computer Assisted Radiology and Surgery 21st International Congress, Berlin, Germany. June 27-30, 2007

32. Chiu J, Digital Endoscopic OR Suite, In: Ed. Kyoko Yoshida, Views Radiology (Japanese), Tokyo, Japan: Medical Tribune, Inc., Vol 9-No. 3, 2007, ISSN 1881-1388, pp 20

33. Chiu J, Interspinous Process Decompression (IPD) System (X-STOP) For the Treatment of Lumbar Spinal Stenosis. In, Szabo Z, Coburg AJ, Savalgi R, Reich H, Yamamotto M, eds. Surgical Technology International XV, UMP, San Francisco, CA 2006: p.265-275