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None of the Traditional Spinal SurgeryAnterior Endoscopic Cervical Discectomy and Foraminal
Decompression
Chief, Neurospine Surgery, California Spine Institute Founding Chairman President, the American Academy of Minimally
Invasive Spinal Surgery (AAMISMS). Immediate past President of the International Society for Minimally
Intervention in Spine Surgery (ISMISS) Internationally recognized pioneer and leader in minimally invasive spinal
surgery (MISS).
Interests: Promoting interdisciplinary, inter-specialty and international education
Research and Development in MIST
Contribution in surgical informatics development of a digital technological
convergence and control system for DOR (digital OR)
Authored and co-authored numerous peer reviewed articles, chapters andtextbooks, and appointed to editorial boards and an Editor-in-Chief formedical, surgical, and research journals.
Enjoys the practice of martial arts (Grand Master, Martial Arts Hall ofFame and Martial Arts Legend Award)and its philosophy, playing Chineseclassical musical instruments, collecting Asian Art, tennis, skiing, travelingand social networking.
Contact Information: www.spinecenter.com
John C Chiu, MD, DSc, FRCS (US)
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None of the Above:
Here is How I Do It!
Society for Progress and Innovationsfor the Near EastBeirut, Lebanon
June 23 26, 2010
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Anterior Endoscopic CervicalDiscectomy (AECD) and Foraminal
Decompression
John C Chiu , MD, FRCS (US), DScChief, Neurospine SurgeryCalifornia Spine Institute
Thousand Oaks, California, USAPresident AAMISMS
Society for Progress and Innovationsfor the Near EastBeirut, Lebanon
June 23 26, 2010
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What is Minimally Invasive Spine Surgery (MISS)?
Surgery is trending toward minimallyinvasive surgery worldwide includingAECD cervical spine surgery
Advancements in instrumentation,fiber optics, laser technology,fluoroscopic imaging, high resolutionvideo imaging endoscopy, along with
the accumulated experience inendoscopic laser spine surgery madeMISS possible
Minimally Invasive Spine Surgery (MISS)requires more precise, delicate andeffective method for spinaldecompression
MISS does not de-stabilize thevertebral segments
Can safely treat multiple levelsymptomatic spinal discs, spinal stenosisand high risk spinal patients
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AECD Surgical Indications:
Neck with arm pain(radicular pain) associatedwith paresthesia, sensoryloss, muscle weakness and/ordecreased reflexes
Intractable cervicogenicheadache
Discogenic pain
At least 12 weeks ofconservative therapy
MRI or CT scan positive fordisc herniation
Positive provocativediscogram
Positive EMG
Multiple discs can be treatedat one sitting
Post fusion junctional discherniation syndrome
Positive 3 legs of bar stoolsymptoms, physical findings,EMG, imaging andprovocative discogram
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42
1%
1502
40%
847
23%
303
8%
46
1%
990
27%
C2
C3
C4
C5
C6
C7-T1
AECD Demographics of HerniatedCervical Discs (3730)
Since 1995, 2066patients with 3730herniated cervical discs
Average age of 43.3 (21 to80) with symptomatic
cervical, single andmultiple herniatedintervertebral discs
Males: 1059 - Females:1007
Each failed at least 12
weeks of conservativecare
Post operative follow up:7 to 75 mos. (average 46months)
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AECD Surgical Instruments and Equipment:
Endoscopic surgical instruments for anterior endoscopic
cervical discectomy (AECD)
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Surgical Instruments and Equipment:
Advanced endoscopic micro flexible forceps, bone ronguerand navigable dissecting probe
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AECD Surgical Procedure/Technique:
Local anesthesia combinedwith IV conscious sedation withsurface EEG monitoringoptimize anesthesia and reducedrug requirement
The obvious challenge of MISSis limited visualization andexposure of the relevantanatomy and direct visualizationof the nerve
Continuous intra-operativeEMG/neurophysiologicalmonitoring in a digital operating
room (DOR) prevents undueneural trauma
IOM of neural structure, directvisualization with fluoroscopy andendoscopy creates saferendoscopic MISS procedures
Anesthesia and Intra-operative neurophysiological monitoring (IOM)
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AECD Surgical Procedure/Technique:
Positioned in the supineposition with mild
hyperextension of neck Digital retraction of
trachea/esophagus, and thecarotid artery under the firsttwo fingers (systolic arterialpressure maintained at 130+ephedrine may be used tomaintain BP)
Needle and stylette insertedinto the disc aided by GPSSystem , fluoroscopy and EMG
N/G tube is placed in theesophagus to avoid injury
Patient Positioning and surgical portal of entry for AECD
Surgical Technique for needle and stylette placement into the discwith GPS
45
20
GPS
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AECD Surgical Procedure/Technique:
Small 3mm skin incision
The spinal needle with a thinstylette is introduced into thecenter of the disk
Under fluoroscopy
Provocative discogram is
often done first The working cannula/dilator
are passed over the stylettegently (dilatationtechnology)
Mechanicalmicrodecompressivediscectomy to follow
Completed with laserthermodiskoplasty (LTD) toshrink and to tighten the discbesides sinu-vertebraldenervation
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Cervical Endoscopic AECD Technique:
Endoscopic/ fluoroscopic/ imaging monitoring to provide safe and precise
application ofaggressive micro grasper forceps, drill, curette, discectome,and bony ronguer for microdecompression
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AECD Surgical Procedure/Technique:
Mechanical microdiscectomy decompression Herniated disc fragment removal
Endoscopic Microdiscectomy
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AECD Surgical Procedure/Technique:
Mechanical decompressive with GPS guidance forforaminoplasty for osteophytes/stenosis
Cervical Decompression Foraminoplastyfor Foraminal Disc and Stenosis can be safely performed
20-35
20-35
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AECD Surgical Procedure/Technique:
Mechanical decompressive discectomy foraminoplasty forosteophytes/stenosis under fluoroscopy, endoscopy and IOM
Cervical Foraminoplasty
Cervical Foraminal Decompression for Foraminal Disc and Stenosis
Microdiscectomy forceps Micro curette
Trephine for osteophytectomy Burr for osteophytedecompression
Micro cutting forceps
Discectome
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AECD Surgical Procedure/Technique:Fan Sweep Maneuver
For maneuvering instrument to precisely increase the area formicrodecompressive discectomy
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AECD Surgical Procedure/Technique:
Level Stage Watts JoulesCervical First Stage 8 300
Cervical Second Stage 5 200
Holmium YAG laser - photo thermal effect on the disc shrinking and tightening
Protocols for laser thermodiskoplasty (LTD)
LTD
Fan sweep
maneuver
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AECD Post Operative Care:
Ambulatory usually in about one hourand discharged subsequently
May shower the following day
May use a cervical collar in a vehicle or
on a flight as needed Ice pack is helpful
Mild analgesics and muscle relaxant arerequired at times
Progressive spine exercise second postoperative day on
Rehabilitation compliments MISS andmotion preservation
Allowed to return to work in one to twoweeks (not for heavy work)
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AECD Surgical Outcome:
For 2066 patients, average follow-up 46months (7-75 months)
Overall result: 1859 (90% ) patients withgood to excellent results, fair results124 (6% ) patients (single level)
Various evaluations of response to treatment:
modified Mac Nab criteria, Oswestry disabilityscore/index (ODI), visual analogue pain scale(VAS), patient satisfaction scoring, pain diagramand/or patient target achievement score (PTA) forassessment were utilized
Average satisfaction score 1942 (94% )patients
93 (4.5%) patients had mild residual pain andparasthesia, although overall their pain lessened
Complication rate: less than 1%
Average return to work: ten days
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AECD Surgical Outcome: (symptomaticimprovements)
206683
124033
68065
206681
590
89
14760
0 500 1000 1500 2000 2500
Persistent Numbness
Muscle Spasm
Muscle Weakness
Required Analgesics
Mild Neck Pain
Severe Neck Pain
Pre-Op Post-Op
AECD Cervical disc patients(2066)
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AECD Case Illustration I:
English rock star had successful endoscopic cervical dis cectomy C3-4, one hour post surgery
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AECD MISS Case Illustration II:
81 yo NS Professorunderwent successfulendoscopic cervicaldiscectomy in spite oftransient extremebradycardia (30),detected, monitored andcorrected with atropine
in the DOR. Dischargedon hour later
Intra operative monitor shows severe dropping of heart rate
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AECD Discussion:
As demonstrated in the recent multi-center(20) study of 32,100 cases includtng AECDspinal disc surgeries with an overall successrate of 91% (single level)
With a complication rate of less than 1%,zero mortality, satisfaction score, over 90%
(for single and multi-levels) Second operation only required in 0.79%
Resuming usual activity in a few days and fullactive lives in 2-6 weeks
These procedures can be extremelygratifying for patients and surgeon
Soon spinal arthroplasty, spinal motionpreservation and dynamic stabilization willbecome an integral part of all cervical spinalsurgery
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AECD Discussion:
In order to perform AECD and toavoid potential complications, onemust have a thorough knowledgeof endoscopic cervical spinalprocedures and the surgicalanatomy
Endoscopic cervical MISS has itsunique surgical skill set
Requiring the surgeon to gothrough a steep learning curve
Patients must be carefully selected
Careful preoperative surgicalplanning
Fluoroscopy as The 3rd
Eye orEye of Wisdom forconfirmation of location of
instruments; endoscopy alone isnot enough
These surgical procedures mustbe meticulously executed
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AECD Discussion:Potential Complications and their Avoidance
Esophageal and tracheainjury due to trauma orperforation can occur:
But are avoided by careful surgical
technique and by identifying and
retracting these structures
By careful digital palpation and
retraction at the site of needle insertion
By placing a nasogastric tube into theesophagus aids in identifying and
retracting that structure by palpation.
Sympathetic nerve injury: Rare but can occur from injury to
cervical sympathetic and Stellate
Ganglions
One post-operative transient Horner
syndrome or oculo sympathetic
dysfunction occurred
Spontaneous Cervical Fusion: secondary to using larger workingchannel, trephine (5mm or more) and
trauma to the endplate causes
spontaneous fusion at C6-C7
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Conclusion:
AECD has proven to be safe, lesstraumatic, easier, and efficacious
For treatment of intractable spinal painsecondary to herniated cervical discs,and degenerative cervical spinal
disease/ foraminal stenosis It preserves spinal segmental motion,
avoids JDHS, and provides an excellentaccess for spinal arthroplasty
Utilization of intraoperative neurophysiologicalmonitoring, IOM in a DOR preventsneurological injury and provides a safer MISS
With proper surgical training andexperience, it is a smart way to performcervical spinal surgery
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Hope you enjoyed this presentation!
Danke schn
Merci Gracias
Cm n
Arigato
Thank you
John C. Chiu, M.D., FRSC (US), D.Sc.
California Spine Institute