Introduction: Endoscopic spine surgery has attracted both surgeons and nonsurgeons in increasing numbers as endoscopic spine systems, a variety of spine endoscopes, and new and evolving surgical instrumentation are developed. The procedure, using fluoroscopically guided percutaneous techniques, are getting more standard, easier, safer, readily reproducible, and more cost effective. It has also been an avenue for surgeons and a few appropriately trained and certified non-surgeons to participate in a minimally invasive, procedure oriented health care delivery platform that provides cost effective results after failure of nonsurgical methods. Such a multidisciplinary team has been established at the University of New Mexico through a donation to the University by the first author.
Discussion: Asia, especially China and Korea, has seen adoption of endoscopic spine surgery grow exponentially in the past few years, recognizing that endoscopic spine surgery may be the answer to delivering cost effective spine care to their working and aging population. Two basic methods are the mainstay of current endoscopic techniques. The least invasive techniques in the lumbar spine are transforaminal, but translaminar endoscopic approaches are better accepted and easier for endoscopic surgeons to grasp.
Conclusion: Endoscopic spine surgery has great promise in countries with looking for cost effective delivery of health care to its population. Endoscopic surgery is the least minimally invasive surgical platform that will facilitate a move away from fusion as a first line of surgical treatment, delaying or eliminating fusion for patients who may have indications for decompression and fusion, but do well with an earlier and staged procedure that will mitigate the need for open decompression and fusion by 75%, derived by large individual and group databases known to this author.
Background/purpose: Operating under local anesthesia allows the patient to respond and provide feedback during surgery that is invaluable for patient safety and for the assessment of the pain generators and ultimately understanding of the source of pain that the surgeon is targeting. Over 10,000 case studies make up the database for information gleaned from patients reporting the pain experienced and relieved during translaminar and transforaminal endoscopic decompression.
Method: The patient is provided mild sedation with versed and fentanyl unless no sedation is requested. Patients requesting no sedation are usually anesthesiologists and other spine surgeons who opt for decompressive surgery, but wanted some measure of surgical participation and control. The anesthesiologist titrates the patient with 1-2 cc of fentanyl and versed pre-op with titration during surgery. The average total amount is 4-5 cc for most procedures. 1% lidocaine is utilized for the local anesthetic. An average of 10-20 cc is used for local anesthesia, titrated as needed during surgery.
Results: The results of decompression can be predicted by a combination of pain relief reported during, immediately after, and augmented by visualization of the targeted patho-anatomy. Such visualized pathology visualized includes annular tears, decompressed spinal nerves, and visualization of the axilla between the traversing and exiting nerve.
Conclusion: Observations provides level 5 EBM (Expert opinion) for surgical intervention. Evidence based medicine usually starts with level 5 “expert” opinions. With the ability to evoke pain in conscious surgical patients, with endoscopic images of the patho-anatomy that correlates evoked pain production with subsequent pain resolution following visualized endoscopic decompression. Along with comparison of pre-and post op images, a new and different and level of EBM may emerge and need to be considered in addition to the traditional Levels 1-5 EBM guidelines.
