Bridging Endoscopic and Conventional Spinal Surgery

SMART® Endoscopic Spine System for Lumbar Microdecompressive Surgery

John C. Chiu, M.D., F.R.C.S., D.Sc.
Director, Department Neurospine Surgery
California Center for Minimally Invasive Spine Surgery
California Spine Institute Medical Center
Thousand Oaks California USA

Citation:

John C. Chiu: SMART® Endoscopic Spine System for Lumbar Microdecompressive Surgery . The Internet Journal of Minimally Invasive Spinal Technology. 2007. Volume 1 Number 1.

Introduction

Low back pain secondary to lumbar disc herniation is a relatively common occurrence, resulting in approximately 300,000 lumbar procedures in the United States each year and 600,000 in the rest of the world. Because conventional posterior laminectomy and discectomy with or without fusion are more traumatic and potentially destabilizing, the development of minimally invasive spinal surgery (MISS) has been of particular interest to surgeons and patients alike. ¹ , ² , ³ , ⁴ , ⁵ , ⁶ Not long ago MISS was thought to be impossible and impractical. The MISS revolution has virtually impacted every surgical specialty with the same objective as the traditional open spinal surgery for neurodecompression but with the benefits of smaller incisions, less tissue trauma, enhanced illumination and visualization, and as an outpatient procedure with faster recovery and significant economic savings. ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ MISS has rapidly come of age as a result of improved endoscopic and microspinal surgical instruments, the explosive development of biocomputer technology, digital video imaging, ultrafast spinal scans, and tissue modulation technology.

A less-traumatic MISS approach can be viewed as being essentially spinal motion preservation surgery compared with open fusion surgery, after which a patient's condition often became worse. ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ It may not be the final step in some patient's spinal treatment regimen. Rather, it can be an effective middle stage leading to recovery and follow-up therapy. ⁷

Evolution and progress in developing innovative endoscopic surgical instruments for MISS — spinal endoscopes, intra-operative digital fluoroscopy systems, and digital video systems, as well as a range of laser technologies (tissue modulation technology) — have all demonstrated their clinical usefulness and are advancing MISS techniques. ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ MISS procedures have in fact progressed to the point where they are now commonly performed either in an office-based or freestanding surgical center. ⁶ , ⁷ , ⁸ , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ In the future, various computer-aided innovations such as surgical robotic systems and image-guided technology will offer new surgical advantages and enhancements to patient care. ⁷

Thus far, a significant percentage of spinal surgeries has already been modified or replaced with MISS techniques. ¹⁴ , ¹⁵ In view of this development, a new algorithm for the treatment of degenerative spinal disease is needed, as illustrated in Table 1. ⁷ A patient's treatment begins conservatively with physical therapy and exercise, which may continue for 8 to 24 weeks. If no improvement is found after at least 12 weeks, the patient is considered to be showing signs of possible nerve damage. Physical findings should suggest continuing nerve damage. Proof of those findings can include lab testing, electromyography (EMG), or x-ray studies. The next step is then to determine the appropriate type of surgery to be performed. ⁶ , ⁷ , ⁸ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁶ , ¹⁷

Bridging Endoscopic and Conventional Spinal Surgery

Currently, endoscopic spine surgery often uses small incisions through which instruments of less than 3 mm are used. Percutaneous approaches using these small instruments work well for many simple nerve decompression procedures. Some MISS requires a larger access than that offered by pure endoscopic techniques. The new SMART® Endoscopic Spine System (Karl Storz GmbH & Co., Tuttlingen, Germany) tubular access set for posterior approaches to the spine is designed to provide the necessary bridge between traditional and endoscopic spine surgical techniques. ²¹ , ²² This system allows MISS procedures to be performed at various sized tubular access openings, thus providing the spine surgeon with both selection of access size and imaging type. Because of the unique features of the SMART® endoscopic tubular access set, the surgeon can take advantage of microscopic, endoscopic, or direct-vision imaging during spinal surgery.

Progressive sequential dilators allow the use of muscle-sparing dilatation techniques that gently spread the muscle fibers, rather than cutting them, with traditional microsurgical techniques. Because the surgeon can choose the size of the access, many procedures can be done using minimal access to arthroplasty techniques. A full range of strong Kerrison forceps, aggressive tissue-cutting forceps, trephines, microcurettes, and strong curettes provide the surgeon with the tools necessary to remove the cause of nerve decompression. Bipolar forceps provide a means of coagulation if bleeding should occur.

The SMART® endoscopic tubular access set also allows procedures in a continuous fluid irrigation mode, for laser and thermal therapies, and a dry well mode for manual tissue removal.

Advantages

This SMART® Endolumbar spine tubular access surgery offers a range of benefits and advantages in spine procedures. First and foremost, it offers true minimal access and can be used in outpatient procedures using conscious sedation, as well as more complicated spinal procedures under general anesthesia. Using the SMART® endoscopic tubular access set, MISS offers the patient reduced postsurgical pain and a quicker recovery. Using the SMART® endoscopic tubular access system preserves muscle tissues, resulting in a faster recovery and allowing patients to begin postsurgical physical therapy sooner. The main advantages are:

• Small skin incision
• Atraumatic dilation using sequential dilators
• Integral visualization and illumination of the operative field through the endoscope
• Accommodates the use of direct visualization, loops, operative microscope, endoscopic, or hybrid surgical techniques
• Stable triangulation between the cannula and endoscopic sheath removes the need for a separate holding system and frees up space in the surgical field
• Minimally invasive spinal surgery
• Faster recovery ²¹ , ²²
• Using the SMART® endoscopic tubular access set, surgeons are able to remove larger spinal lesions and decompress nerves with visual confirmation using minimal access techniques.

Surgical Procedure

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