Endoscopic Spine Surgery: What It Is and What It Isn’t

According to data, there are approximately 1.62 million instrumented spinal procedures performed each year in the United States.1 Minimizing the amount of tissue injury, trauma and post-operative pain are important to optimize any patient’s recovery from back surgery. Over the years, we have seen great strides in spine surgery technology, equipment, instrumentation, and procedures. Endoscopic Spine Surgery (ESS) is currently the foremost example of how far we’ve come in the surgical treatment of our patients with back and neck pain. Let’s examine what ESS is and what it isn’t.
Endoscopic spine surgery being performed with specialized instruments.Endoscopic spine surgery uses a small incision and specialized instruments to surgically treat spinal disorders. Photo Source: Jay Jagannathan, MD, and Hyungjun Jeon, MD.

What Is Endoscopic Spine Surgery?

By definition, ESS is a surgical procedure using micro-sized incisions (less than 1-inch) and small tubular systems in combination with an endoscope to visualize the surgical field. While endoscopic surgical approaches are commonly used to treat other areas of the body (eg, gastrointestinal), advances in optics, visualization of tissues, and spinal imaging make ESS a surgical treatment choice for many patients.
A surgical trocar is slid through the incision between tissues to the operative spinal area. Endoscopic spine surgery uses a small incision and specialized instruments to surgically treat spinal disorders. Photo Source: Jay Jagannathan, MD, and Hyungjun Jeon, MD.Endoscopic spine surgery is an advanced, state-of-the-art form of minimally invasive spine surgery designed to provide the patient a quicker recovery time and less recurring pain than traditional spine surgery methods. ESS also can help preserve normal range of spine mobility post-operatively. In some cases, the ESS procedure can be performed using regional anesthesia instead of general anesthesia, decreasing overall medical risks in patients who are older and/or have co-existing medical disorders that may increase surgical risk.

Let’s not confuse ESS with other types of spine surgery.

Endoscopic spine surgery should not be confused with traditional procedures—such as minimally invasive, micro invasive and/or laser spine surgeries. In the experienced hands of a spine surgeon who regularly performs endoscopic spine surgery using tubular retractors and the endoscope—the surgery is performed in a different way offering patients many potential benefits, including:

  • Tubular retractors reduce the need to cut through soft tissues (eg, skin tissue-to-muscle injury or damage)
  • Less blood loss
  • Less post-operative discomfort or pain
  • Fast recovery and healing

However, ESS may not be appropriate for all spine surgery indications, such as scoliosis, spinal instability, cancer, or trauma. In those types of cases, the surgeon may recommend a traditional open or minimally invasive spine procedure.

ESS Benefits vs Risks

As with any type of spine surgery, including ESS, there always are benefits and risks associated with surgery. That’s why it is important you and your spine surgeon consider and discuss your personal potential benefits and risks related to treatment of your spinal disorder with an endoscopic spine surgery procedure.

Potential Benefits: Small incisions and hyper-targeting of the surgical site means less trauma to skin, muscle, and soft tissues resulting in less blood loss and a faster recovery. Furthermore, most ESS procedures can be completed in about one hour allowing the patient to be back on their feet a few hours following post-operative recovery.

Potential Risks: ESS is a highly specialized surgical skill that is somewhat still in its infancy. As such, relatively few spine surgeons perform ESS techniques with regularity to be proficient. Usually, endoscopic spine surgery is not suitable for revision surgery, cases of clear spinal instability, high-grade spondylolisthesis, and/or cancer.

How is Endoscopic Spine Surgery Performed?

First, the patient is prepped for surgery including administration of a local anesthetic to block pain. A 1-inch or smaller skin incision is made and a tubular trocar (about the width of a pencil) is inserted. Depending on the patient’s specific diagnosis, the endoscopic technique may access the spine using one of two approaches: either an intralaminar (from the back of the spine between two laminae) or transforaminal (from the back/side of the spine into the neuroforamen; a nerve passageway) approach.

Next, a tiny camera is inserted through the trocar to the targeted area of the spine. Throughout ESS, the camera captures and projects real-time images of the operative site onto a monitor in the surgeon’s direct view. The endoscopic camera assists and guides the surgeon during the surgical procedure.
Endoscopic image during spine surgery used to remove a herniated disc.An example of an endoscopic image during spine surgery to remove a herniated disc. Photo Source: Jay Jagannathan, MD, and Hyungjun Jeon, MD.When the operation has concluded, the endoscopic camera and trocar are gently removed and the small incision is closed with a suture and small dressing (eg, Band-Aid).

Are You a Candidate for ESS?

Many patients who are candidates for endoscopic spine surgery have been diagnosed with common types of spinal disorders. Some of these diagnoses include moderate to severe disc herniation, facet arthropathy, sciatica, and spinal stenosis. However, spine surgery is not always the first treatment. It is generally recommended that types of non-surgical treatment (eg, spinal injections, physical therapy) be tried before any type of spine surgery, including ESS.

How Do I Find an ESS Surgeon?

It may seem like a daunting task to locate a specific type of spine specialist in your area. However, your health care providers, often starting with your primary care provider, are good places to start. They know your medical history and probably have provided you non-surgical care before moving forward to considering spine surgery. It is always good to make sure your spine surgeon is board certified and fellowship trained, and regularly performs the surgical procedure recommended to you.

Concluding Thoughts

Advances in technology and technique have developed endoscopic spine surgery—a spine surgical option could be considered revolutionary in nature. In the hands of highly skilled and experienced spine surgeon, the potential benefits of this extreme version of minimally invasive surgery may provide relief to a new generation of patients living with chronic back and neck pain.

Disclosures
Dr. Jagannathan and Dr. Jeon have no financial disclosures.

Updated on: 01/25/19
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Outpatient Spine Surgery: What You Need to Know

Improvements in technology and surgical techniques have allowed for more spine surgeries to be performed outside of the traditional hospital setting and in outpatient spine surgery centers.
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