This Clinician’s View opinion piece is written by Saeed Sadrameli, MD, neurosurgeon at the AdventHealth Neuroscience Institute.
For many years, microscopic discectomy, spinal fusion, and recently total disc replacement have been the surgical approaches utilized for addressing disc herniations or recurrent herniations. Unfortunately, all three approaches require open surgery involving dissevering of posterior multifidus muscle group and significant bony removal, which can result in long recovery times and need for further operations in the future. Spinal fusion surgery, in particular, can result in degenerative changes including disc herniation or joint disease above or below the previously fused segment. This concept is known as adjacent segment disease (ASD).
In August 2022, AdventHealth Celebration became the first facility in Central Florida to perform endoscopic spine surgery, the most minimally invasive approach to surgical correction of spinal disc pathologies, offering many patients symptom relief and an alternative to spinal fusion. To date, we have performed more than 50 cases including two thoracic disc herniation with spinal cord compression, which traditionally were addressed through an open 5-inch shark-bite incision.
How Endoscopic Spine Surgery Works
We perform endoscopic spine surgery in an outpatient setting. A high-definition camera incorporated within an endoscope and connected to a 4k monitor is inserted through an 8 mm incision (size of a #2 pencil) instead of the 1-inch incision typically required for a microdiscectomy or much larger for spinal fusion. This endoscopic approach allows us to arrive right at the pathology, avoiding disruption of the bone and muscle in the posterior elements, thereby decreasing chances of future accelerated degeneration due to muscle atrophy and bony resection. Once pathology is displayed on the 4k monitor attached to the endoscope and with the use of endo-surgical instruments, such as a laser or radiofrequency probe, the disc fragments can be removed, and the nerve can be decompressed. After surgery, patients are ambulatory and usually discharged within two hours and can expect to return to work with light duty within 72 hours.
An Effective Surgical Alternative that Improves the Patient Experience
The endoscopic approach to spine surgery offers patients several advantages:
- Immediate improvement of symptoms and quick discharge from the surgical facility
- Minor blood loss
- Minimal post-operative pain that does not require narcotic use -- most patients treat their surgical pain with Tylenol, Robaxin and Gabapentin.
- Expeditious return to normal activity and work -- typically within 72 hours
- Very low risk of infection or wound complication (0.001%)
A recent systemic review and meta-analysis published in the European Spine Journal found that compared with microdiscectomy, endoscopic discectomy has a lower risk of overall complications as well as a lower risk of complications requiring conservative treatment. Another meta-analysis that included 1,092 patients across nine clinical trials compared the effectiveness and safety of endoscopic discectomy with open discectomy for the treatment of symptomatic lumbar disc herniation. It found similar clinical outcomes between the two methods but higher patient satisfaction and fewer complications with the endoscopic approach. Finally, a prospective randomized study of 100 endoscopic versus 100 open discectomies with two-year follow up found that while improvement of pain and function was similar between the two techniques, significantly more patients with open discectomies suffered from progressive back pain. In addition, five of the microscopic cases went on to require a fusion surgery compared to only one of the endoscopic cases.
Clinical Advantages and Applications
At AdventHealth Celebration, we have identified the following clinical applications for using the ultra-minimally invasive endoscopic approach to spine surgery:
- Removal of disc herniation with minimal bony resection and no muscle disruption through an 8 mm incision.
- Treatment of patients with recurrent disc herniation who otherwise would undergo a spinal fusion.
- Treatment of far lateral disc herniations at L5-S1 that otherwise would need to undergo spinal fusion or total disc replacement.
- Treatment of adjacent segment disease above or below a previous fusion without extension of the fusion.
- Treatment of thoracic disc herniation that otherwise would require a large incision and thoracotomy to access and treat the pathology.
- Treatment of cervical disc herniation that otherwise would undergo total disc arthroplasty or cervical fusion.
Improving Patients’ Quality of Life
The data are certainly supportive of the endoscopic approach for certain cases, but it is the individual patient success stories that I find most encouraging. A 64-year-old veteran with prior lumbar spinal fusion, Freddie Clarke came to my clinic earlier this year after 9 months of suffering lower back and right leg pain so severe that he could not sleep. Traditionally a spine surgeon would offer extension of his fusion to L3-4. However, I decided to utilize spinal endoscopy and on March 13, 2023, performed an ultra-minimally invasive endoscopic right L3-4 transforaminal discectomy to relieve pressure off the nerve with the least amount of collateral damage and bony removal, thereby preventing or prolonging the need for yet another spinal fusion.
Freddie recently shared that with his previous spine surgeries, it took him 3-4 weeks just to get back to walking whereas with his latest surgery, he not only was walking immediately, but he is already back to an active lifestyle, riding his stationary bike and using his elliptical machine. He is also actively engaged in physical therapy to maximize his flexibility, strength, and range of motion. Freddie reported that his pain has decreased significantly and that he is feeling “tenfold better” than he was before the surgery.
While endoscopic spine surgery requires an additional level of training and commitment to acquire the necessary skills, Freddie and the other patients I have had the privilege to treat reinforce my commitment to offering this innovative surgical approach when appropriate.
