1. LA VIA ENDOSCOPICA INTRAFORAMINALE
Rome Rehabilitation 2011
XX Congresso Nazionale S.I.C.D.
LA VIA ENDOSCOPICA INTRAFORAMINALE
NEL TRATTAMENTO DELLE ERNIE DISCALI LOMBARI
Relatore: Luigi D’Orazio
Medicina del dolore
A.O. San Camillo-Forlanini

2. The TESSYS-Concept Operation of lumbar disc herniations via
lateral, transforaminal,
endoscopic Approach

3. clinical signs of nerve root compression
The TESSYS-Concept
Indications
Radiologic confirmation of lumbar herniated discs using MRI- or CT with
clinical signs of nerve root compression

4. Foraminal Approach: Lumbar Spine
Adjunct to Traditional Surgery
Preferred for foraminal and extraforaminal HNP
Allow access to these pain generators:
Disc
Exiting nerve
Traversing nerve
Epidural space
Superior facet
Axilla containing the DRG
Foraminal osteophytes
Visualizes the “Hidden Zone” Foraminal of MacNab
Hidden Zone

5. The TESSYS-Concept Transforaminal puncture of
the disc space at the medial pedicular plane
Entry point at the skin about
8 to 18 cm from the midline

6. The TESSYS-Concept
The direction of the trajectory depends on the specific localization of the disc herniation

7. The TESSYS-Concept Discography or chromography and insertion of
the guide wire

8. The TESSYS-Concept Stab incision at the entry point on the skin and
insertion of the guiding rod
(angled or straight) into the
neuroforamen

9. The TESSYS-Concept
If necessary enlargement of the neuroforamen using guiding tubes and crown reamers (5, 6.5, 7.5 mm Ø) to remove parts of the facet joint

10. The TESSYS-Concept Advancement of fenestrated
working tube (outer diameter
7.5 mm) over the red guiding
tube and insertion of the
foraminoscope

11. The TESSYS-Concept Viewing angle 30° Outer diameter: 6,3 mm
Working channel: 3,7 mm
Length: 174 oder 208 mm

12. The TESSYS-Concept Removal of disc material using forceps
Application of the
radiofrequency probe
to arrest bleeding

13. The TESSYS-Concept Anatomic considerations Neuroforamen Pedicle
Facet joints
Spinous process
Spinal canal
Disc space
Thecal sac and nerve roots

14. The TESSYS-Concept
Anatomic considerations

15. The TESSYS-Concept
Radiologic landmarks

16. The TESSYS-Concept Patient positioning In prone or lateral position
in analgo-sedation or general
anesthesia

17. The TESSYS-Concept Requirement in the OR
Radiolucent table and C-arc in ap and lateral view
Optimal arrangement of monitors and instruments

20. Amount of removed disc material

21. Wound closure in subcutaneous fashion

22. herniation at level L5/S1
The TESSYS-Concept
Limitations
Massive deformity
Spondylolisthesis
Dorsal stenosis of the
spinal canal
Steep iliac crest for
herniation at level L5/S1

23. herniation at level L5/S1
The TESSYS-Concept
Limitations
Massive deformity
Spondylolisthesis
Dorsal stenosis of the
spinal canal
Steep iliac crest for
herniation at level L5/S1

24. herniation at level L5/S1
The TESSYS-Concept
Limitations
Massive deformity
Spondylolisthesis
Dorsal stenosis of the
spinal canal
Steep iliac crest for
herniation at level L5/S1

25. herniation at level L5/S1
The TESSYS-Concept
Limitations
Massive deformity
Spondylolisthesis
Dorsal stenosis of the
spinal canal
Steep iliac crest for
herniation at level L5/S1

26. VANTAGGI The TESSYS-Concept 1)Non problemi di sanguinamento
2) Ridotte complicanze( danno nervoso,trombosi,infezioni)
3) Possibile in paz. obesi< BMI 30-40
4) Riabilitazione più rapida
5) Nessuna formazione di aderenze post-operatorie
6) Anestesia locale e sedazione
7) Non crea instabilità
8) Consente di eseguire la foraminotomia
9(Day- Surgery)
10)E' una piattaforma per futuri trattamenti chirurgici discali

27. Incidence of Complications 3
Incidence of Complications 3.5% Yeung AT, Tsou PM :Spine Vol 27 April 2002
Gradual decrease with avoidance experience
Dysesthesias 5%-15% (Most common, usually temporary, not completely avoidable!)
DRG, Circulatory changes, furcal nerves, anomalous nerves
Persistent sensory deficit 1%
Persistent motor weakness 2%
Discitis .03%
Dural tear 1%
Thrombophlebitis .5%
Bowel injury 1/3,000 (.003%)
Vascular injury 0%
Dural tears do not need repair
Due to no Surgical approach
dissection

28. The TESSYS-Concept CASISTICA L4-L5 10 F 7 M 3 L5-S1 5 F 2 M 3
Tot Lateralità Dx Sn
Mediana 1

29. The TESSYS-Concept COMPLICANZE
Disestesie temporanee (regredite con terapia medica)
Irritazione temporanea del nervo 1
Interventi interrotti (per anomalia del nervo
Interventi convertiti con altro approccio ( approccio mediano per via endoscopica L5- S1)

30. The TESSYS-Concept Conclusion Due to:
minimal invasivity
good clinical results
low complication rate
the Tessys-method represents an :
attractive and efficient treatment modality for
median to extraforaminal positioned lumbar disc
herniations even at the level L5/S1 and reduces the indication for „open“ disc surgery

31. GRAZIE