Chiu Evolving

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spinecentercom spinecentercom Evolving Minimally Invasive Endoscopic Spine Surg ery: A Surgeon’s P erspective and Technological Considerations Chi ef , Neuros pin e Surgery , Ca lif orn ia Spine Insti tut e Founding Cha irman President, t he American Aca demy of Minima lly Invasive Spinal Surgery (AAMISMS). Immediat e pa st President of the Inter natio nal Societ y for Minimall y Intervention in Spine Surgery (ISMISS) Inter nationally recognized pioneer and leader in minimally i nvasi ve spinal surgery (MISS). Interests:  Promoting interdisci plina ry , int er-special ty a nd international education   Research and Development in MIST   Contribution in surgical informatics development of a “digital technological converg ence and control system” for DOR (digital OR)  Aut hor ed and co -authored nu mer ous pe er rev iew ed arti cle s, chap ter s and textbooks, and appointed to e ditorial boards and an Editor-in-Chief for medical, surgical, and research journals. Enjoys the practice of martial arts (Grand Master, Martial Arts Hall of Fame and Martial Arts Legend Award)and its philosophy , playing Chinese c lassical musical instruments, collecting Asian Art, tennis, skiing, traveling and social networking. Contact Information: www.spinecenter.com John C Chiu, MD, DSc, FRCS (US)

Transcript of Chiu Evolving

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Evolving Minimally Invasive EndoscopicSpine Surgery:

A Surgeon’s Perspective and Technological Considerations

• Chief, Neurospine Surgery, California Spine Institute

• Founding Chairman – President, the American Academy of MinimallyInvasive Spinal Surgery (AAMISMS).

• Immediate past President of the International Society for MinimallyIntervention 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, chaptersand textbooks, and appointed to editorial boards and an Editor-in-Chief

for medical, surgical, and research journals.• Enjoys the practice of martial arts (Grand Master, Martial Arts Hall of Fame and

Martial Arts Legend Award)and its philosophy, playing Chinese classical musical

instruments, collecting Asian Art, tennis, skiing, traveling and social

networking.

• Contact Information: www.spinecenter.comJohn C Chiu, MD, DSc, FRCS (US)

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Society for Progress and Innovationsfor the Near East:

Updates and Cadaveric Bio-skills WorkshopBeirut, Lebanon

June 23 – 26, 2010

Evolving Minimally Invasive

Endoscopic Spine Surgery:A Surgeon’s Perspective and Technological

Considerations

John C Chiu , MD, DSc, FRCS (US)

Chief, Neurospine Surgery

California Spine Institute

Thousand Oaks, California, USA

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What is Minimally Invasive Spine Surgery(MISS)?

• Surgery is trending toward minimallyinvasive surgery worldw ide includingspine surgery

• Advancements in instrumentation,fiber optics, laser technology,fluoroscopic imaging, high resolution

video imaging endoscopy, along withthe accumulated experience inendoscopic laser spine surgery madeMISS possible

• Minimally Invasive Spine Surgery(MISS) requires more precise, delicateand effective 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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Anatomical Basis for

MISSPathophysiology

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Spinal Care and Treatment:

• Back pain is a result of modern lifestyleincluding prolonged sitting, driving, computerwork, watching television, high speed vehicleaccidents, plane crashes, active sporting activitiescausing spinal injury, overeating, obesity, lackof exercise , and emotional stress and even

degenerative process

• There is frequent occurrence of back pain -statistics

– 85% of Americans have some back painduring their lifetime

– 5%-8% of Americans have back painaffecting their lifestyle and work

– 3% or less may require some type of procedural intervention

• The majority of back pain can be treatedconservatively with relief by self-care,acupuncture, exercise, physiotherapy,medication and at times injectional therapy

Current contemporary concept in minimally invasive

spine care

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Introduction:

• The spine is a bony column in the centerof the body with the following functions:

– Supporting the body, keeping it straightinstead of being crooked as in scoliosis orthe hunchback of Notre Dame

– Providing the mechanism for bodilyleverage, bending, lifting and twisting

– Protecting the nervous system, spinalcord, and nerves

– Preservation free spinal motion

• The disc serves as a cushion for thevertebral bodies

• Like a jelly donut. The outer layer isvery firm and fibrous, nucleus fibrosis andthe inner layer gelatinous, jelly like,nucleus pulposus

• If you have a bad back, you will have aback pain

Anatomy and function of the spine

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Introduction:

• If conservative treatment fails,and continue to have persistentsignificant symptoms affecting theirdaily activities and ability to workthis can lead to the need forsurgical decompression of thedisc

• In the past, the only methodwas open traumatic lumbar

surgery with cutting of the muscle,bone and the disc, and even spinalfusion, which are associated withlong periods of recovery, woundhealing, blood loss, hospitalization,and others

Herniated Lumbar Discs Causing Nerve Impingement- Radiculopathy

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Surgical Indications

Reason for Surgery

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MISS Surgical Indications:

– Herniateddiscs /degenerative spinedisease

– Post fusionJunctional

DiscHerniationSyndrome(JDHS) orAdjacentSegmentDisease (ASD)

– Vertebralcompressionfracture(Osteoporoticand post-traumatic)

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MISS Surgical Indications:

– Lumbar spinalstenosis andspondylolisthesis

– Cervicogenic

headache anddiscogenic pain

– Intraspinallesions

– Synovial cyst anddegenerative cyst

– Intraspinal tumor,lipoma

– Others

For treatment of:

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MISS Surgical Indications:

• Intractable symptoms withoutrelief by conservative treatment,exercise program, medication andeven injectional therapy

• Positive neurological findingsof reflex changes, muscularweakness and/or decreased painand touch sensation

• Laboratory testing beingpositive for MRI scan, CT Scan,

EMG and others• Positive 3 legs of bar stool –

symptoms, physical findings,EMG, imaging and provocativediscogram to support thesurgical indications

As 3 legs for a bar stool –

supporting findings forsurgical indication:

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ChallengesFacing

Traditional -Current Open

Spine

Surgery/ Fusion

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Challenges Confronting Open Traditional SpineSurgery/ 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 includingpost 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 bynumerous studies published

– Disc replacement technology/ arthroplasty isyet to be proven – only time will tell (another 8-15 years)

– More difficult in high risk patients with morbidobesity, cardiac pulmonary disease, advanceddiabetes, elderly

– Affecting spinal segmental motion

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Logical Evolution of 

Spine SurgeryEndoscopic Laser MISS

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Logical Algorithm for Spine Care:

For treatment of degenerative and herniatedspinal 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 resortThe modern concept - algorithm of spine care like walking up a staircase

Maybe

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Advantages of Minimally Invasive LaserSpine Surgery (MISS)

• An out patient or "same day surgery“, no hospitalization

• Less traumatic

• Small or tiny incision

• Costs less - approximately 40% less than a open spinalsurgery/ fusion

• Economic savings for the employee and employer are significantdue to earlier return to work

• Done under local anesthesia

• Early post – op exercise one day after surgery

• Surgical triad approach and critical "fan-sweep maneuver" furtherfacilitate the disc decompression and improves surgical result

• Multiple level spinal discectomy can be performed at one sittingw ith minimal risk

• Can be done for high risk anesthesia patients w ith morbid obesity,emphysema, and cardiac conditions under local anesthesia/ IVsedation at much less risk

• Intra-operative neurophysiological/ EMG monitoring, and directvisualized endoscopic significantly reduces the chance of inadvertent injury of neural structure

• Preserves spinal motion

Obvious advantages of Laser MISS:

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Surgical Procedure/ Technique:

• Anesthesia: Local/ IVconscious Sedation

• Intra-operative

continuous monitoringof vital signs (pulserate, blood pressure,RR), pulse oxymetryC02 content,neurophysiologicalmonitoring – EEG,EMG, on intra-operative

wave formdisplay /monitor

• To insure safety andto facilitate MISS

Preparing for MISS – Anesthesia

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Types of Endoscopic LaserMinimally Invasive Spine

Surgery (MISS)

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LUMBAR ENDOSCOPIC LASER MISSTECHNIQUE:

• Patient positioning and localization

– Patient in prone position

– Or in lateral decubitus position

– Localization – skin marking for portal of entryand placement of needle

– Under fluoroscopic guidance

Posterio-lateral and posterio–median surgical approaches

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Lumbar Endoscopic Laser MISS Technique:

• Under fluoroscopicguidance

• Provocative discography

to confirm the damagedherniated disc

• Point of incision – byplacing the “bull’s-eye” target device to determinethe portal of entry andskin incision

Localization of skin incision and portal of entryProvocative discogram

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Surgical P lane/ Approach/ Technique:

Right posterolateralapproach - proneposition

for endoscopic lumbar

MISS

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Surgical P lane/ Approach/ Technique:

Left lateraldecubitus position

for right posterolateral

endoscopic lumbar MISS

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Surgical P lane/ Approach/ Technique:

Left lateraldecubitusposition

for rightposterolateralendoscopic lumbarMISS

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Surgical P lane/ Approach/ Technique:With GPS

• Extreme obese patient had left

posterolateral endoscopiclumbar disectomy withgeometric line/plane and GPSsystem

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GPS (Grid Position System) for Endoscopic Laser Lumbar MISS

Fluoroscopic monitoring to provide safe and precise lumbar spinesurgery by using GPS

Subarticular

Extraforaminal

Foraminal 1 disc

2

3 pedicle

BCD

A

• Lumbar spine has neuroforamen and intra-laminaforamen openingsrestricting MISS at a portalof entry

• Critical structures withinthe foramen – DRG,neural structure

• GPS provides a preciseand safe path to reachthe lesion and to avoidtrauma to the nervevessels, DRG, dura andeven the spinal cord

• The grid – the GPSSystem – Zones (in A,B,C,D and 1,2,3) provides aaccurate navigation mapfor MISS surgeons

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GPS (Grid Position System) for Laser Endoscopic Lumbar

MISS

Mini Endoscopic Spinal Surgical I nstruments for MISS

• Duck bill tubularretractor with dilator toenter the GPS for lumbardisc surgery to protectdural and neurovascular injury

• Under endoscopy andfluoroscopy, spinalinstruments of trephineforceps, curette, rasp,

knife, discectome, andlaser can safely beutilized for MISSsurgery and laserthermodiskoplasty

Close up view

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GPS (Grid Position System) for Endoscopic Laser Lumbar

MISS

Fluoroscopic/ imaging and endoscopy to provide safe and precise

lumbar MISS and foraminoplasty

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Lumbar Endoscopic Laser MISS Technique:

• Holmium YAG laser equipment for Laser Thermodiskoplasty(LTD)

TrimedyneHolmium YAGlaser generator

Right angle (sidefiring) laserprobe

Application of Tissue Modulation Technology inEndoscopic Laser MISS

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Lumbar Endoscopic Laser MISS Technique:step by step

Fluoroscopic/ imaging and endoscopic monitoring to provide safe andprecise application of endoscopic microdiscectomy and laser

thermodiskoplasty

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Lumbar Endoscopic MISS Technique:

• Small spinaldiscectome for rapiddisc removal

Additional advanced MISS surgical instruments

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Lumbar Endoscopic MISS Technique:

• Under fluoroscopy -With dilatationtechnology

• Introduction of dilatorand then a tubularretractor /workingcannula are passedover the stylette

• Foraminoplasty anddecompressive

discectomy performedwith trephines, forceps,ronguers, discectomeand Holmium laser

Posterio-lateral approach vs. posterio–median aproach

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Lumbar Endoscopic MISS Technique:

For larger extruded herniated lumbar discs (red arrows)

Endolumbar paramedium approach

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Surgical Instruments and Equipment:

Tissue Modulation Technology

laser, radio frequency and cryogenic are utilized in MISS, spinalinjection and spinal denervation

Holmium YAG laser generator Radiofrequency generator

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I llustration 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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I llustration Case II Lumbar MISS

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CERVICAL ENDOSCOPIC LASER MISSTECHNIQUE:

Anterior Endoscopic Cervical LaserMicrodiscectomy

• Cervical discectomy– begins with anterior medialapproach for needle and stylette insertion into the discunder monitoring (fluoroscopy, EMG) aided by GPS System

I llustrated w ith

Cervical GPS

45°

20°

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Cervical Endoscopic Laser MISS Technique:

Endoscopic/ fluoroscopic/ imaging monitoring to provide safe and preciseapplication of provocative discogram, aggressive micro grasper forceps,

drill, discectome, and bony ronguer for microdecompression

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I llustration Case – Cervical Laser MISS

English rock star had successful endoscopic cervical discectomy C3-4 with hypoplastic odontoid and C3-4 discherniation

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THORACIC ENDOSCOPIC LASERMISS TECHNIQUE:

POSTEROLATERAL ENDOSCOPIC THORACICDISCECTOMY

• Due to tight and confinedanatomical relationship atthoracic spine of the spinal cord

and spinal canal, the use of laminectomy, and various thoracicspinal surgical approaches for thetreatment of herniated thoracic discshas been associated with anunacceptable high rate of pulmonary and neurological

complications• Therefore, spinal surgeons have

long sought to find a betterprocedure to treat thoracic discherniations effectively and lesstraumatically

Portal of entry

O C C OSCO C S

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THORACIC ENDOSCOPIC LASERMISS TECHNIQUE:

• Patient Positioning, localization and portal of entry– PETD is performed under local anesthesia and conscious sedation

Fluoroscopic/ imaging monitoring to provide safe andprecise Posterolateral Endoscopic Thoracic Discectomy

Portal of entry

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Thoracic Endoscopic Laser MISS Technique:

Fluoroscopic/imaging monitoring to insure safe and precise endoscopicthoracic discectomy via GPS within the grid

GPS (Grid Position System)

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DiscfragmentsRemoved

Herniated Thoracicdisc

Thoracic Endoscopic Laser MISS Technique:

POSTEROLATERAL ENDOSCOPIC THORACIC

DISCECTOMY

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I llustration Case – Thoracic Laser MISS

27yr old F-22 fighterpilot suffered severeT7 herniated discsymptoms as aresult oftremendous G-Forcesuccessfully treatedwith endo-MISS

T7 herniated disc

Endoscopic Thoracic MISS for F-22 Fighter Pilot

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New Digital Technology to

Facilitate Endoscopic LaserMISS (Digital OR – DOR)

Image view boxes

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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 - ReportVideo EndoscopyMonitor

EEG Monitoring

Left side of OR

Teleconferencing -telesurgery

Lasergenerator

DOR S i l PR C t l S t

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DOR - Surgical ePR Control SystemSurgMatix ® TO FACILI TATE MISS

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

Pre-OP 52” LCDIntra-op 52” LCD

Operating Table

136 Endoscope

Display /

Storage

142 LaserGenerator

138 EEG/

Display

2800 mm.

120 Large screenintra-opimage/data

143 SelectedImaging/ dictationsystem

133 Video

Mixing

Equipment

132 Surgical

Video

Camera /

Display

141 EKG/

Display

139 Vital

signs and

Display

137 Authoringdocumentmodule

Fluoroscopic

Display  /Storage

134 C-ARM-

SurgicalInstrument

table

Assistant Surgeon ScrubNurse

Anesthe-siologist

Circulator

1Large screenPre-opimage/data

140EMG/Display

135Pt Biom ID

100

131NeuroPhysio(SSEP)

133 FluidIntake/Output

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SurgMatix ® IN MISS DOR

• SurgMatix ® was created by an innovative team for seamless

connectivity and teamwork in a MISS DOR

• It provides not only digital connectivity but also integrationof  all OR systems including, sophisticated surgicalinstruments, equipment, complex high tech systems for “digitaltechnological convergence, and efficient DOR controlsystem” 

• In order to facilitate and to perform a safer and better MISS

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2nd Generation Integrated (SECS) SurgMatix ®

Schematic diagram of 

2nd

generation of SurgMatix ® integrated

SECS, two types: in amobile unit, or in a tower

SurgMatix ® mobile unit

SurgMatix ® tower

G l f S M i ® i t ti t

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Goals of SurgMatix ® integration system

to facilitate and control MISS

• Provides a complete picture of the patient’s medicalhistory and status by consolidating data from multipleIT 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 thepatient’s medical status, including vital signs, waveform and biosensor data

• Promotes workflow efficiency in the DOR, reducingpersonnel and other costs, leading to a significanteconomic saving in an “organized control insteadof an organized chaos” environment

• Enhances quality of patient care by providinginformation available to all OR staff and facilitatingcommunication in the DOR

• Facilitates post-surgical care and trend analysisthrough increased data collection during surgery

DOR Technology Convergence and Control

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DOR Technology Convergence and Control

System - SurgMatix®

INTRAOPERATIVE MONITOR with l ive data/” real t ime” image/data

- vital signs, 02 sat , EMG, laser, endoscopic and fluro images

Technological data convergence To facilitate and to insure safe

and precise MISS

Potential Complications and their Avoidance:

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Potential Complications and their Avoidance:With SurgMatix® monitoring in DOR

• Excessive sedation:

– By continuous conscious EEG and vitalsigns monitoring

• Neural injury:

– Avoidance of n. injury by fluoroscopicmonitoring, imaging studies and anatomicknowledge

• Sympathetic nerve injury:

– Avoidance of n. injury by fluoroscopicmonitoring, imaging studies and anatomicknowledge

Potential Complications and their Avoidance:

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Potential Complications and their Avoidance:With SurgMatix® monitoring in DOR

• Operation at the wrong level:– A major complication of all spine surgery

– Avoided by using digital C-arm fluoroscopy for accurate anatomiclocalization

– Provocative discogram verifies level

2

4

6

8

10

12

13

1

T10

T12

2

4

6

8

10

12

13

1

CASE I CASE II

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Post Surgical Care andSurgical Outcome

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Post Operative Care:

• Ambulatory within onehour and dischargedsubsequently

• May shower the followingday

• May use a cervical collar in

a vehicle or on a flight asneeded (for cervical AECD)

• Ice pack is helpful

• Mild analgesics and musclerelaxant are required at times

• Progressive spine exercisesecond post operative day on

• Postoperatively on average,resumed usual activity in afew days and in 2-5 weeksresumed full active lives,providing no heavy work

Spinal motion measurement (spine

mouse)

Advanced exercise

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Surgical Outcome:

PRE-OP POST-OP

Lumbar

Cervical

Minimally Invasive Laser Endoscopic Spine Surgery (MISS)

Thoracic

• 5336 patients (10,255 discs),average age 44.8 (16-94)

• Average follow-up 46.5 months(6 to 75 months)

• Response to treatment evaluatedby using: MacNab, modified Mac

Nab criteria, Oswestry disabilityscore/index (ODI), visualanalogue pain scale (VAS),patient satisfaction scoring, paindiagram and/or patient targetachievement score (PTA)

• Average satisfactory score5024 (93.5% ) patients

• Good to excellent results in4889 (91% ) patients (for singlelevel), fair result in 215 (4%)patients

• 269 (5%) patients withpersistent residual pain andparesthesia although overalltheir pain lessened

S i l O t

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Surgical Outcome:(symptomatic improvements) 5336 patients

Minimally Invasive Endoscopic Laser Spine Surgery (MISS)

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RESEARCH AND

DEVELOPMENT IN EVOLVINGMISS

& f

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R&D for MISS:

Microphone headset

Voice activated

Robotic aided endoscopic spine surgery and image guidedtechnology on the horizon

• Advanced 3DImage guidedsystem is beingdeveloped and

will be appliedto enhance andnavigationally toguide thesurgical robot

• Surgical robotics canimprove endo-MISS with bettersurgical precision and minimaltrauma

Image guided endo-MISS

N i i h h i

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New innovations are on the horizon

ceramic

implants

Spinal Arthroplasty – Biologic Product – Genome RX

for minimally invasive spinal technology

Bryan Cervical Disc

Prodisc - C

Prestige

MaverickCharite’ 

Prodisc - L

Dascor DNR

NR - a

NR - b

NuCor

Biologic Product - Genome RX

SMART Disc

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