Ricardo Ruiz-López MD1, Ovidiu Palea MD, FIPP2, and Teodor Cristea MD3 1 Clinica Vertebra, Spine and Pain Surgery Centers, Barcelona / Madrid, Spain Percutaneous spinal endoscopy (PSE) was first reported by Kambin [1–3] and Hijikata [4], more than 50 years ago. This technique has evolved since then due to major technologic improvements in optics, high-resolution cameras, as well as the imaging modality. Even although initial indications were about disc herniations, nowadays, PSE covers a wide range of degenerative spine pathology, and – not only that – practitioners are more and more comfortable with indications such as discitis or tumors. PSE has similar indications proposed to those for open spine surgery and similar outcomes, as demonstrated by several randomized-controlled trials (RCTs) and meta-analyses [5–9]. Additionally, PSE offers better visualization, decreased damage to musculoskeletal tissues and preservation of spinal stability, a lower risk for reherniation, a lesser incidence for epidural scar tissue, less blood loss, diminished post-operative pain, reduced hospitalization and faster rehabilitation [10, 11]. Minimally invasive spine surgery (MISS) encompasses techniques and innovative devices to reduce approach-related morbidity by sparing normal anatomic spinal structures during spine surgery. Minimally invasive techniques can be performed for treatment of the vast majority of pathologic conditions of the spine and offer a compelling alternative to traditional approaches. MISS is simply res ipsa loquitur (i.e., the thing speaks for itself). PTE is solely based on the thorough 3D understanding of the structure called The Kambin’s triangle (Figure 64.1). This is presented as a 2D plane, which is actually confusing for the interventionist and makes the learning curve steep or even wrong. From a 2D perspective, the boundaries of Kambin’s triangle are the superior end plate of the inferior vertebral body (base of the triangle), the superior articulating facet (the height of the triangle), and the exiting superior nerve root (the hypotenuse of the triangle) [1]. It is used to access critical structures in a variety of lumbar and thoracic spine procedures being a so-called “safety zone” as it is absent of vascular and neural structures of importance. Figure 64.1 Kambin’s safety triangle (shaded area) at L4/L5 [1]. This step is important in order to delineate the degenerated fragment for easy identification and removal during endoscopy. It can be done with a colored solution (indigo carmine/methylene blue) and contrast agent so that the visibility is ensured both endoscopically and fluoroscopically. It is almost always done the same way for all endoscopic techniques. Any kind of herniated discs (Figure 64.2): Figure 64.2 Various types of lumbar disc herniation. Disc herniations can be accompanied by radicular and lumbar pain, neurologic symptoms which are refractory to rehabilitation, physical therapy and pharmacologic treatment [12–14]. Various approaches have been developed whether transforaminal or interlaminar according to the segmental lumbar level and type of pathologic conditions. Table 64.1 Summary of factors affecting the learning curve. *The 1-year clinical success rate and 1-year reherniation rate were assessed in 47 patients with initial success of percutaneous endoscopic lumbar discectomy.[6] The patient must be placed in ventral decubitus. Analgosedation is necessary for both the patient’s comfort and their pain response when the nervous structures are injured. After localizing the vertebral level using C-arm anesthesia is done on the skin, a 5-mm incision is made, through which, a spinal needle is inserted in order to inject the anesthetic throughout the muscle and bony plane (facet or lamina depending on the technique).
64
Complications of Percutaneous Spinal Lumbar Endoscopy (PELD)
2 Pain Centre, Provita, Bucharest, Hungary
3 Saint Pantalion Hospital and Provita Clinic, Bucharest, Romania
Introduction
Rationale for Minimally Invasive Spine Surgery
Goals of PELD
Anatomy
Discography
Indications
Contraindications
Absolute Contraindications
Relative Contraindications
Limitations of PSE
Case No.
Mean age (range), yrs
Male/female
Operating time (range), min
Failure rate, %
Complication rate, %
1-Year clinical success rate, %*
1-Year reherniation rate, %*
Group I
1–17
33.9 (24–52)
10/7
62.1 (30–90)
0
5.9
82.4
17.6
Group II
18–34
35.6 (18–49)
10/7
47.6 (30–105)
17.6
5.9
92.9
7.1
Group III
35–51
39.8 (15–55)
12/5
37.9 (30–60)
5.9
0
93.8
6.3
p Value
0.20
0.72
0.0004
0.31
1.0
0.51
0.60
Recommendations
Technique
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