Advanced Technologies

The utilization of spinal endoscopic surgery techniques is on the rise in routine clinical practice and treating painful annular tears, herniated disc, and spinal stenosis. Over the past ten years, we have witnessed an increasing number of surgeons recognizing spinal endoscopy's value. Many of them had difficulty finding access to adequate training while facing reimbursement and acceptance problems. In this chapter, the authors describe the implementation issues at play that they perceive as relevant in the discussion between the healthcare equation's stakeholders. Included in this chapter on the forward-looking perspective of spinal endoscopy is the first author's involvement in the role and value of laser and electrothermal therapy, which is still pertinent but has evolved with advancements in technology and endoscopes and instrumentation.

Runaway cost for surgical spine care has led to increased scrutiny on its medical necessity. Consequently, the beaurocracy involved in determining coverage for these services has grown. The call for high-grade clinical evidence dominates the debate on whether endoscopic surgery has a place in treating painful conditions of the aging spine. The cost-effectiveness and durability of the endoscopic treatment benefit are questioned every time technology advances prompt an expansion of its clinical indications. The authors of this chapter introduce the concept of early-staged management of spine pain and make the case for personalized spine care focused on predominant pain generators rather than image-based necessity criteria for surgery often applied in population-based management strategies. The authors stipulate that future endoscopic spine care will likely bridge the gap between interventional pain management and open spine surgery. This emerging field of interventional endoscopic pain surgery aims to meet the unanswered patient demand for less burdensome treatments under local anesthesia and sedation. The very young and old patients often are ignored because their conditions are either not bad enough or too advanced for a successful outcome with traditional spine care. In this watershed area of spine care, the authors predict endoscopic spine surgery will thrive and carve out accepted surgical indications in direct competition with pain management and traditional open spine fusion protocols.

Endoscopic spinal surgery affords the patient simplified and less burdensome spine care. Its superiority over open decompression surgeries has been long debated, and the current evidence is incomplete. The innovators and proponents of this procedure carry the burden of proof. The targeted endoscopic treatment of common spinal pain generators produces higher perioperative patient satisfaction than traditional spine surgery. This chapter discusses conventional spine surgery research's pros and cons of employing patient-reported outcome measures (PROM). They offer an alternative approach to establishing a better value proposition with the endoscopic versus open spinal surgery - the concept of durability analysis.

 Identifying pain generators in multilevel lumbar degenerative disc disease focuses on artificial intelligence (AI) applications in endoscopic spine care to assure adequate symptom relief with the targeted endoscopic spinal decompression surgery. Artificial intelligence (AI) applications of deep learning neural networks to analyze routine lumbar MRI scans could improve clinical outcomes. One way to accomplish this is to apply AI management of patient records using a highly automated workflow, highlighting degenerative and acute abnormalities using unique three-dimensional patient anatomy models. These models help with the identification of the most suitable endoscopic treatment protocol. Radiology AI bots could help primary care doctors, specialists including surgeons and radiologists to read the patient's MRI scans and more accurately and transcribe radiology reports. In this chapter, the authors introduce the concept of AI applications in endoscopic spine care and present some initial feasibility data validating its use based on intraoperatively visualized pathology. This research's ultimate objective is to assist in the development of AI algorithms predictive of the most successful and cost-effective outcomes with lumbar spinal endoscopy by using the radiologist's MRI grading and the grading of an AI deep learning neural network (Multus Radbot™) as independent prognosticators.

Best management practices of complications resulting from outpatient transforaminal endoscopic decompression surgery for lumbar foraminal and lateral recess stenosis are not established. Recent advances in surgical techniques allow for endoscopically assisted bony decompression for neurogenic claudication symptoms due to spinal stenosis. These broadened indications also produced a higher incidence of postoperative complications ranging from dural tears, recurrent disc herniations, nerve root injuries, foot drop, facet and pedicle fractures, or infections. Postoperative sequelae such as dysesthetic leg pain, and infiltration of the surgical access and spinal canal with irrigation fluid causing spinal headaches and painful wound swelling, as well as failure to cure, are additional common postoperative problems that can lead to hospital readmissions and contribute to lower patient satisfaction with the procedure. In this chapter, the authors focus on analyzing the incidence of such problems and, more importantly, how to manage them. While the incidence of these problems is recogniz-ably low, knowing the art of managing them in the postoperative recovery period can make the difference between a flourishing endoscopic outpatient spinal surgery program and one that will continue to struggle with replacing traditional open spinal surgeries.

Lasers have been popular in spine surgery for decades. Patients frequently ask about laser spine surgery when looking for simplified ways to treat spine pain related to a herniated disc. Percutaneous interventional non-visualized needle-based laser treatments have been replaced with visualized endoscopic decompressions. This chapter reviews the fundamental physics of laser technology applications in spine surgery. Guidelines for safe laser use in the operating room and avoidance of complications are discussed in detail. Lasers suitable for spinal decompressions and their respective tissue interactions are described. The clinical evidence of percutaneous versus the hybridized use with the visualized endoscopic decompression is examined in detail.

 High-frequency coagulation, cutting, and coblation technology have long been applied during endoscopic spine surgery. Endoscopic visualization devices and high-frequency surgical devices can be found in almost every surgical subspecialty. During surgical HF applications, electrical energy is converted into heat, used to cut biological tissue and stop bleeding. This technology works with high voltages in cutting and coagulation mode. The difference is in the creation of arcs, which have a cutting effect. In simplified terms, voltages of ≤ 200 Volts are generated during coagulation and > 200 Volts during cutting. The interaction of HF with biological tissue can be explained by the faradic, electrolytic, and thermal effect. A frequency of over 400 kHz has no harmful effect on body tissue. Frequencies over 1MHz have a “cold cutting effect” allowing for safe bipolar applications and minimizing thermal damage. This chapter reviews how modern high-frequency generators work and how to minimize risk during clinical applications, including electrode bonding and burns by applying automatic power metering, two-part neutral electrode, and bipolar techniques. During spinal endoscopy, the effects of HF treatment can be directly assessed under very high magnification factors. This complementary overlap of the videoendoscopic and HF technique in modern endoscopic spine surgery is the key to superior clinical outcomes compared to non-visualized percutaneous procedures performed under fluoroscopic control.

The commonly used preoperative lumbar MRI grading lags behind modern patient selection criteria to prognosticate favorable outcomes with the endoscopic decompression for lumbar herniated disc and foraminal and lateral recess stenosis. Since its utilization has evolved into a primary medical necessity criterion for surgical intervention, surgeons often find themselves with clinical symptoms whose treatment is not supported by the MRI report. Therefore, this chapter's authors established the need to determine the MRI's accuracy and positive predictive value for successful postoperative pain relief after endoscopic transforaminal decompression. Using the transforaminal endoscopic technique, the authors performed a critical retrospective analysis of 1839 patients who had surgery for herniated disc and stenosis in the foramina or lateral spinal canal. They calculated the sensitivity, specificity, accuracy, and positive predictive value of preoperative MRI grading, correctly identifying the symptomatic surgical level by correlating it with the directly visualized pathology during surgery and clinical improvements. The lumbar MRI verbal report's sensitivity was calculated at 68.34%, the specificity at 68.29%, the accuracy at 68.24%, and the positive predictive value at 97.38%. The use of surgical MRI criteria for nerve compression detailed within this manuscript improved the calculated sensitivity to 87.2%, specificity to 73.03%, and accuracy to 86.51%. The likely explanation lies in the lack of consensus between radiologists and spine surgeons when grading compression syndromes of the exiting and traversing nerve root. The grading of a preoperative MRI scan for lumbar foraminal and lateral recess stenosis may significantly differ between radiologists and surgeons. The authors conclude that the endoscopic spine surgeon should read and grade the lumbar MRI scan independently.

Successful implementation of endoscopic spinal surgery programs hinges on reliable performance and case cost similar to traditional decompression surgeries of the lumbar spine. Spinal endoscopes used during routine lumbar decompression surgeries for herniated disc and spinal stenosis should have an estimated life cycle between 150 to 300 surgeries. However, actual numbers may be substantially lower. Abusive use by surgeons, mishandling by staff, and deviation from prescribed cleaning and sterilization protocols may substantially shorten the life cycle. Contingency protocols should be in place to readily replace a broken spinal endoscope during surgery. More comprehensive implementation of endoscopic spine surgery techniques will hinge on technology advancements to make these high-tech surgical instruments more resistant to the stress of daily use and abuse of expanded clinical indications' surgery. The regulatory burden on endoscope makers is likely to increase, calling for increased reimbursement for facilities to cover the added expense for capital equipment purchase, disposables, and the cost of the endoscopic spine surgery program's maintenance. In this chapter, the authors review such maintenance programs' cornerstones in the current regulatory environment that one should implement when attempting to run an endoscopic spinal surgery program at their healthcare facility. 

Regenerative medicine is a subspecialty of medicine that seeks to recruit and enhance the body's own inherent healing armamentarium in the treatment of patient pathology. In regenerative spine care, the intention is to assist in the repair and potentially replace or restore damaged tissue through autologous or allogenic biologics. In the authors' opinion, future spine care will likely evolve into a blend of prevailing strategies from interventional pain management and minimally invasive spine surgery. This form of spine care nowadays is commonly called interventional pain surgery. The interest in regenerative medicine in general and in interventional pain surgery of the spine is growing given the high patient awareness of problems with traditional spine surgery, whose focus is on decompression of pinched nerves and correction of spinal instability and deformity. However, reoperation- and complication rates are high with those open corrective spine surgeries as many of the spine's degenerative conditions are being only treated surgically when the disease has progressed to its end-stage. The sole application of image-based medical necessity criteria for surgical intervention in the spine seems slightly out of step with the growing demand for less aggressive and burdensome procedures that could perhaps be instituted earlier in the disease process where the goal is to heal the spinal injury or repair damage from the degenerative process more naturally. In this chapter, the authors review and discuss the current state of the art in regenerative biologic therapies and interventional pain care of the spine from their perspective as endoscopic spine surgeons. Simplifying therapeutic measures and strategies are at the heart of what patients request of us as surgeons. This field's applications in modern spine care are clearly in their infancy, except for fusion. The authors will discuss potential applications of select advanced biologics technologies and their attempts at integrating them into their endoscopic spinal stenosis surgery program to treat degenerative spinal disease and instability-related symptomatic end-stage degenerative vacuum disc disease in the elderly.

Among different causes of chronic low back pain, Modic changes of the endplates have been identified as an MRI-image representation of end stage degenerative disc disease. Painful innervation of these degenerative endplates from within the vertebral body by arborization of the basivertebral nerve towards these endplates has been demonstrated. Ablation of the basivertebral nerve has been identified as one possible way to treat chronic low back pain. This chapter describes the transforaminal epiduroscopic laser ablation of the basivertebral nerve and its associated clinical outcomes.

Combining the percutaneous transforaminal endoscopic decompression (PTED) with interspinous process distraction systems (ISP) may offer additional benefits in treating spinal stenosis in patients who have failed conservative treatment. We retrospectively investigated the medical records of 152 patients who underwent transforaminal endoscopic decompression with simultaneous ISP placement through the same incision. Patients were operated on from January 2008 to June 2016 and included 80 males, and 72 patients were females. Clinical data analysis was done on 142 patients two years postoperatively since ten patients were lost in follow-up. Primary outcome measures were pre-and postoperative visual analog scale (VAS) criteria and the Oswestry Disability Index. Only patients with a minimum follow-up of 2 years were included. The analysis included 224 patients who underwent interspinous spacers during the transforaminal endoscopic decompression. Of the 152 patients, 84 complained of axial facet-related pain syndromes versus the remaining 68 patients who chiefly complained of radicular symptoms. The postoperative VAS reduction at twoyear follow-up for the low back was 6.4. The patient-reported ODI reductions were of a similar magnitude at 40.4%. According to Macnab criteria, the percentage of patients who graded their surgical results as excellent or good was 90%. At two-year follow-up, 5 percent of patients required another operation to deal with failure to cure or recurrent symptoms due to implant subsidence. The authors concluded that adding an interspinous process spacer to the endoscopic decompression in patients treated for lateral lumbar stenosis and foraminal stenosis with low-grade spondylolisthesis might improve clinical outcomes by stabilizing the posterior column.

The transforaminal interbody fusion (TLIF) is a time-tested procedure for treating various lumbar degenerative pathologies. This approach leverages an access route through Kambin's triangle that typically requires a partial or total facetectomy for access to the disc space and neural decompression. Since its first published description in the early 1980s, the procedure has undergone extensive refinements concomitant with technology and technique advancements. Traditional open TLIF is effective but associated with adverse perioperative effects due to the amount of muscle dissection necessary for exposure, including increased blood loss, hospital length of stay, and extended recovery times. The transition to more minimally invasive, paramedian approaches has sought to reduce the burden of these consequences. Spinal endoscopy has witnessed a resurgence over the past decade paralleled by advancements in higher resolution optical systems along with more robust and enduring endoscopic instrumentation. This development, combined with increased awareness of healthcare economic costs, problems with narcotic dependency surrounding open spine surgery, and admission restrictions to hospitals during pandemic times, has fueled a push for “ultra” minimally invasive variants of the traditional TLIF. Patients, payors, and hospitals alike expect shorter inpatient stays, earlier mobilization and discharge from the hospital, as well as narcotic independence faster than ever before. To this end, awake endoscopic TLIF has recently been described with efficacious results to comply with these broader factors. In this chapter, the authors explain their awake endoscopic TLIF step-by-step and demonstrate the clinical advantages and the noninferiority data to traditional MIS TLIF based on their clinical series's one-year outcomes data. 

 Endoscopic spinal fusion is on the horizon. Many surgeons have offered various endoscopically assisted decompression and fusion surgeries that consist of an interbody device and posterior supplemental screws. Stabilization of the spine via an anterior column fusion implant has excellent advantages of improving the fusion rate via bone graft containment. It can enhance spinal alignment and assist in direct and indirect decompression of neural elements via restoring normal lumbar curvature and neuroforaminal height. However, further use of posterior supplemental fixation has the disadvantage of adding to the operation's complexity in blood loss, time, equipment needs, and complications. Therefore, a simplified standalone anterior interbody fusion procedure to be carried out through the transforaminal approach via a small posterolateral skin incision was of interest to the authors of this chapter, who are introducing the complete endoscopic implantation of a threaded expandable cylindrical fusion cage. This fusion system was developed to mitigate subsidence and migration problems seen with non-threaded lumbar interbody fusion cages, many of which require posterior pedicle screw fixation. This chapter describes step-by-step transforaminal decompression fusion technique suitable for an outpatient ambulatory surgery center setting.

Spinal endoscopy allows creating access to areas of the spine that are ordinarily difficult to reach, thereby reducing the collateral damage from extensive exposure to treat common degenerative or traumatic conditions of the spine. In this chapter, the authors present a case of endoscopic spinal canal decompression in a patient who sustained a burst fracture near the thoracolumbar junction. The endoscopic decompression technique was employed, which resulted in removing bone fragments, causing compression of the neural elements. The burst fracture was then stabilized with a percutaneous short pedicle screw construct. The patient did well with the hybridized endoscopic and minimally invasive decompression and stabilization technique. The authors are making a case for considering the endoscopic spinal surgery platform other than the traditionally accepted indications in the interest to diminish further blood loss, pain, and complication rates associated with spinal fracture surgeries.

The authors present a case of a 25-year old female patient who presented to their facility with a chief complaint of low back pain and discomfort for the previous two months. The symptoms gradually worsened. The patient denied any fever, night sweats, and other aches. Symptoms worsened when standing up. They were also aggravated by changing the body position. In particular, bending forward was restricted. There was no radiating pain in the lower extremities. An MRI of the lumbar spine revealed a lesion raising suspicions of tuberculosis of the spine, which was later confirmed with biopsy and cultures. The patient was placed on oral multi antituberculosis antibiotic treatment but responded poorly to this treatment without much clinical improvement. Therefore, endoscopic access was chosen to debride and irrigate the paraspinal tuberculous abscess, which successfully treated the infection. The authors report the case details to illustrate that a combination of antibiotic treatment and endoscopic debridement may resolve the lumbar spine's complicated infection adequately. Minimally invasive endoscopic irrigation and lavage of paraspinal tuberculous abscesses can be considered an alternative to open surgery.

 Deformity correction is an integral part of spinal surgery. For patients with painful coronal and sagittal plane deformity, correction to restore lumbar lordosis and scoliosis is the surgical treatment goal. Traditional open spinal surgery techniques are associated with wound problems, long-recovery times, high blood loss, and many other disadvantages compared to their more modern minimally invasive counterparts. While the minimally invasive percutaneous placement of pedicle-screw-rod constructs has been tried, anterior column release and fusion techniques to facilitate deformity correction often require excessive surgical exposures to gain access to the anterior column. This chapter presents a percutaneous transforaminal endoscopic interbody decompression and fusion technique to release the anterior column and facilitate deformity correction with the posterior column pedicle screw constructs. When combined with percutaneous minimally invasive screw placement, the patient's overall burden by the long-segment spinal fusion procedure can be significantly lowered by simplifying the entire procedure and carrying it out through small percutaneous incisions. An illustrative case is presented to demonstrate the utility of endoscopically assisted interbody fusion in scoliosis patients. 

 Extramedullary benign tumors of the spine may cause spinal cord compression. Patients may present with motor weakness and sensory loss in the extremities causing gait abnormalities. Surgical treatment is indicated when symptoms are no longer manageable. In this chapter, the authors present an 87-year-old female's case as an illustrative example of how the spinal endoscopy platform can be safely and effectively deployed in the treatment of such lesions. The example patient suffered from spinal cord compression from a large meningioma at the T7 level. The tumor was successfully removed via an endoscopic working cannula. The patient's symptoms improved, and a nine-month follow-up MRI scan showed adequate and maintained spinal cord decompression. This case example demonstrates that spinal endoscopy may be applied to an increasing number of surgical indications beyond the scope of degenerative disease. Further clinical investigation will need to show this technology's limits when treating benign tumors of the spine. 

Cervical endoscopic unilateral laminotomy for bilateral decompression (CEULBD) is an applicable surgical method in cases of central canal stenosis, usually associated with myelopathy. Other authors have shown the feasibility, safety, and efficacy of this method. They could also demonstrate more favorable perioperative benchmark data of this procedure than anterior cervical discectomy and fusion (ACDF) in terms of duration of surgery, blood loss, and hospital stay. In this chapter, the authors focus on the technological advances making this surgery possible. Moreover, the authors review the relevant surgical anatomy to enable the aspiring endoscopic spine surgeon to safely and successfully perform the CE-ULBD procedure. Experience in advanced endoscopic surgery in other areas of the spine is recommended before imparting on the posterior endoscopic decompression of the stenotic central cervical spinal canal. The authors have implemented CE-ULBD in formalized and wellstructured Endoscopic Spine Academy (Espinea®) training programs, intending to provide high educational standards to achieve favorable outcomes with the CE-ULBD procedure reproducibly.