1. Endoscopic Spinal Surgery Aprajay Golash Consultant Neurosurgeon Royal Preston Hospital, UK

2. In this presentation I am trying to give a flavour of current spinal endoscopic surgery and hopefully raise some interest in this evolving field. I am making no attempt to give details of any techinques but would be very happy to be contacted on aprajay.golash@lthtr.nhs.uk for details. aprajay.golash@lthtr.nhs.uk

3. Let’s see a case! 55yr, Female Spastic paraparesis for 6 months, getting worse

4. Options for access Thoracotomy Thoracoscopic (Video assisted) Mini- thoracotomy Posterior approaches

5. Approach I chose Thoracoscopic Discectomy- because it retains the advantages of thoracotomy for exposure but avoids high morbidity

6. Clinical outcome Good neurological recovery Less post operative pain Early mobilisation Intra operative CSF leak

7. Post Operative scans

9. Endoscopic Spinal Surgery This is a developing and sometimes controversial field. While developing, patient safety must be maintained. Outcome compared with “Gold standard” (there are no agreed gold standards for many conditions!)

10. Why endoscopic surgery? Less damage to normal structure Less blood loss Quick recovery Less post operative pain Easier approach in Obese patients! May be done under local anaesthetic & sedation.

11. Cervical Endoscopic foraminotomy Percuteneous access with serial dialatation Endoscopic magnified (but 2-D !) visualisation. Minimal injury to muscles Same results as open foraminotomy.

12. Cervical Endoscopic foraminotomy Indications- –Ideally for soft disc herniation but can be used for “hard” disc. –Lateral recess or foraminal stenosis Contra indications- –Large central disc or stenosis –Instability or severe kyphosis

13. Cervical Endoscopic foraminotomy Benefits- (over open procedure) –Minimal muscle trauma –Decreased hospital stay Disadvantages- –Steep learning curve –Separate approach required for bilateral procedure

14. Cervical Endoscopic discectomy Anterior percuteneous approach under x- ray control Mainly for soft disc C3-C7 Better approached from contralaterl side May be done as day case Avoids fusion

15. Thoracoscopic spinal surgery Herniated disc (even large calcified!) Spinal fractures Anterior release for scoliosis Biopsy for tumour or infection

16. Endoscopic Lumbar surgery Approaches- –Interlaminar –Posterolateral –Far lateral or extreme –Anterior retroperitoneal –Anterior trans peritoneal

17. Endoscopic Lumbar surgery Indications- –Disc herniation –Degenerative disc disease –Spinal stenosis –Infection –Tumour

18. Endoscopic Lumbar surgery Disadvantages- –Difficult for migrated disc –Long learning curve –Access to L5/S1 may be difficult –Difficult with previous spinal surgery

19. Further Developments Images Guided endoscopic spinal surgery 3-D endoscopes Intra dural endoscopic procedures I was planning to put some video clips in this presentation but I found many good ones in You tube! Though this is not an alternative to visit some experienced surgeons but is good enough to get a flavour.

20. Caution! Patient safety must be maintained while learning curve is achieved. Patient selection is critical. No harm in using traditional approach if in any difficulty.