Introduction: The history and development of endoscopic spine surgery (PELD) in China is reviewed. Its significance and effect is predicted to have great implications for advancing spine care in China’s working and aging population. Percutaneous spine technology was introduced simultaneously from Japan and the United states by Hijikata and Kambin in the early 1980s. It was called Arthroscopic Microdiscectomy (AMD). The access portal was called “Kambin’s Triangle, with the discectomy technique through a “safe” puncture portal through an anatomical triangular zone in the foramen bordered by the facet and foraminal ligament dorsally, the exiting nerve ventrally, and the endplate of the caudal margin of the triangle.
Method: An expanded indication for the transforaminal Kambin technique was introduced to China by Anthony Yeung in 1998, and its evolution and contribution to modern minimally invasive spine care, called the Yeung Endoscopic Spine System (YESSTM) technique, is reviewed. The percutaneous technique has been adopted by surgeons as well as non-surgeons who also undergo surgical training in their rehabilitation programs who integrate the technique through their various affiliations in China for painful degenerative conditions of the spine.
Results: The efficacy of the endoscopic technique has evolved significantly since Kambin, with additional contributions by Chinese surgeons and key opinion leaders of surgical and non-surgical Chinese associations that have co-existed, but are focused on providing treatment options for the Chinese population for centuries. Western Medicine has provided great influence on Chinese medicine, but a significant percentage of the Chinese population still cling to traditional treatment, embracing both Old and New methods. With respect to modern surgical techniques, surgeons and no surgeons are cooperative, and focus on results while working together. They recognize that with endoscopic spine surgery, it is important to maintain a success rate comparable to traditional western open surgery with less surgical morbidity utilizing the endoscope. Peer reviewed papers are emerging from China, using the EBM guidelines of Western Journals.
Conclusion: A rapidly increasing number of surgeries along with improving results will continue to drive this minimally invasive surgical method to China that bridges the gap between non-surgical pain management, physical medicine, and surgical intervention that focuses on the patho-anatomy and patho-physiology of spinal conditions of pain. This will be known as “surgical pain management, a term coined by Dr Anthony Yeung. Future developments will continue to drive the adoption of endoscopic surgery as a significant advancement for Chinese medicine and surgery.
Abstract: The role of robotics is gaining prominence as the technology of the future. In traditional spine surgery, accuracy of hardware placement, selection of ideal size and length of implanted screws and hardware for segmental fixation is desired and important even for experienced surgeons. Hardware placement in tight spaces is especially critical in the cervical and thoracic spine. Robotics will enhance patient safety as well as surgical results, for the protection of patients.
By reducing surgical radiation exposure, it also protects patients as well as the surgeon and OR personnel. In endoscopic surgery, improving the accuracy of endoscopic trajectories with image guidance will also bring this aspect of MIS surgery to the surgical mainstream. Robotic techniques are evolving rapidly. Even in their current State of the Art, robotics offer significant advantages to the outpatient spinal surgeon by precise reproducible placement of hardware and endoscopes for minimally invasive approaches.
If the current Health Care system in the USA remains the law of the land, Health Care of the future will be on life support. The free market may be the last chance for the entitlement mentality to survive. New Regulations and politics will play a key role.
Introduction: The ability to identify and treat pain generators in the lumbar spine is helped by incorporating diagnostic and therapeutic injections, followed by visualizing the pain generator with an endoscope. Although improvements in imaging are getting very sophisticated, visualization of the source of the pain generators is currently only possible with an endoscope. This has opened the door to more options for cost effective surgical treatment in staged manner by treating the pain source.
Materials and methods: An FDA approved system endoscopic system and technique developed by A. Yeung in 1997, using a multichannel endoscope for the transforaminal approach to visualize the disc and foramen, is featured. After anesthetizing the disc foramen, and targeting the axilla of the foramen in the vicinity of the exiting and traversing nerve, known to spine surgeons as the “hidden zone” of MacNab, the technique has evolved to surgically provide pain relief for stratified conditions for patient selection. The standard translaminar approach to the disc and the spinal segment will usually miss visualizing the patho-anatomy of pain in this “hidden zone”, an area harboring common causes of “failed back surgery syndrome”. Recent minimally invasive techniques of decompression and fusion may help resolve the pain source, but fusion has its surgical morbidities and high costs. A less invasive highly successful transforaminal endoscopic method with 25-year data supports this technique.
Discussion: Transforaminal Endoscopic Spine Surgery, the YESS™ technique, is effective using mobile cannulas to visualize and target the pain source. New instrumentation, techniques, specially configured endoscopes with different size working channels; facilitate effective surgical treatment of the pain generator. Incorporating visualization of the disc cavity to treat painful annular tears adds to the effectiveness of the procedure. The surgeon can also treat spinal stenosis with foraminoplasty by decompressing the ventral facet of the superior articular process as well as the axilla containing the exiting and traversing nerve. The purpose of this study is to demonstrate that the physiology of pain can be visualized as a pain generator. Patho-anatomy is identified and surgically decompressed. Diagnostic and therapeutic injections also aid in identifying pain generators by epidurography performed with the transforaminal approach.
Conclusion: Interventional pain management, often the first line of minimally invasive treatment, provides pain relief only by targeting injections to block nerves. Visualizing the patho-anatomy with an endoscope targeting the patho-anatomy by the same interventional needle trajectories, however, provides a surgical option to decompress and ablate the pain generators.
Almost all spine surgeons tout minimally invasiveness in spine surgery as a beneficial focus. The meaning of minimally invasiveness, however, is actually a concept with different meanings for each surgeon. To some, it is the use of smaller incisions using standard surgical approaches, the use of tubular retractors, and/or the use of surgical magnification with a microscope, or an endoscope. Minimally invasiveness often advertises the use of lasers as a sexy and high tech surgical tool to tout their state- of- the- art surgical technique in minimally invasiveness, but it is not used as a needed part of the surgery unless visually used with endoscopes under irrigation.
Studies published in peer reviewed journals promote microscopic surgery, different types of MIS fusion, robotics guided fusion, and minimally invasive lumbar decompression as beneficial and cost effective. All tout less surgical morbidity using the measured parameters of less intra-operative blood loss, less surgical time after a short learning curve, faster recovery, decreased pain, and faster ambulation.
The obvious overall conclusion is that while all spine surgeons support minimally invasive spine surgery, the surgeons are mainly focused on their area of surgical experience and expertise in minimally invasiveness, which takes many forms.
