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.

What We Know

• Chronic back pain afflicts hundreds of millions of people worldwide
• The most common early cause is deterioration of the intervertebral disc from trauma or aging
• Current therapies to treat back pain from nonsurgical techniques (ie. Physical medicine + pain management and oral analgesics) are followed by various techniques of MIS and traditional disc surgery, but PREMATURELY ending in fusion.

There are viable minimally invasive technologies and minimally invasive surgical procedures that make it feasible to move away from fusion as an early surgical option for treating chronic low back pain if non-surgical methods fail. Surgeons who are familiar with and who have training in endoscopic spine surgery are able to utilize the transforaminal endoscopic approach to the lumbar spine and use these endoscopic techniques to identify and treat the pain generators with the least invasive, most effective methods available.