Rajavithi Hospital Bangkok Thailand - Bệnh viện Bạch Maibachmai.edu.vn/FileUpload/Documents/Hoi thao Noi soi Viet Thai/1... · Percutaneous full-endoscopic lumbar discectomy

Pornpavit Sriphirom MD

Rajavithi Hospital

Bangkok Thailand

Standard Open Micro-Scope Endo-Scope

Percutaneous full-endoscopic lumbar discectomy

Interlaminar technique

Transforaminal technique

Posterolateral technique

Percutaneous full-endoscopic thoraco discectomy

Posterolateral technique

Transthoracoscopic technique

Percutaneous full-endoscopic cervical discectomy

Anterior technique

Posterior technique

Thoraco-endoscopic spinal surgery

Vertebectomy and interbody fusion instrumentation

Degeneration occur in the spinal

motion segment Spinal stenosis

Reduced disc hieght

disc tend to bulge into canal

Ligamentum flavum thicken and buckle

Appophyseal joints degenerate and

hypertrophy

Reducing available space

Advanced degenerative

lumbar spinal stenosis Ballooning of the disc

Marked thickening of the

ligamentum flavum

Hypertrophy of the superior

articular processes

“ Trefoil configulation “

HNP

(herniated disc) Spinal Stenosis

Young age

Low back pain

Sciatica

Straight leg raising

test positive

Old age

Caudication

Low back pain

Straight leg raising

test negative

P

Timing Acute : less than 3-6

month

Chronic : > 6 month

Conservative

Intervention

Nucleoplasty

Classical discectomy

Microscopic discectomy

Endoscopic discectomy

Randomized to 3 groups

Group 1 micro-endoscopic discectomy

Group 2 microscopic discectomy Group 3 standard discectomy

Micro-Endo Discectomy

Microscopic Discectomy

Standard Discectomy

Classic Discectomy (CD) versus Microdiscectomy

Amount of bleeding

Classical Discectomy (CD) versus Endoscopic Discectomy

Amount of bleeding

Return to work one year postoperative

Endoscopic Discectomy (ED) versus Microscopic Discectomy

PELD OMLD

Equipment

Instruments

Operative table

C-arm fluoroscope

VDO system

Instruments

VDO System

Water Pumper

RF Bipolar for

stop bleeding

Step by step

Far-lateral Herniation

Foraminal Stenosis

AP view

Ferguson view

Total case 65 case

Retrospective review 53 case

Exclude from review 1 case

(Intra –op nerve root injury

convert to open surgery)

8

41

7

0

5

10

15

20

25

30

35

40

45

L 3-4 L4-5 L5-S1

level 2 levels 13 cases

From June 2009-April 2010

General anesthesia

From June 2010

Tranforaminal technique

Local anesthesia

Interlamina technique General anesthesia

<40 yr 40-60 yr >60 yr

HNP 10 12 0

Stenosis 0 15 15

0

2

4

6

8

10

12

14

16

8

31

8

2

0

5

10

15

20

25

30

35

Excellent Good Fair Poor

Meralgia Paresthica 2 case

resolve

Discitis 1case ;IV antibiotic

resolve

Root injury 2 cases

Recovery 1 case

Foot drop 1 case

Case

CC : ปวดน่องขวา และ กระดกข้อเท้าขวาไม่ขึ้น 2 สัปดาห์ PTA

PI : 6 yr PTA ปวดหลงัร้าวลงขาขวา ชาขาขวา มีอ่อนแรงขาขวา กระดกข้อเท้าขวาและหัวแม่เท้าขวาไม่ขึน้ มารพ. SLRT +ve Rt. (70 ⁰) Motor Rt. Ankle DF gr. 0 , Rt. EHL gr.0 ,other gr.5 ท า MRI LS spine DX : HNP L4-5 Rx : Try conservative treatment * 3เดือน อาการไม่ทุเลา จึงท า OR :Discectomy L4-5 post.op. อาการปวดและชาลดลง อ่อนแรงดีขึ้น เดินได้

TRANSFORAMINAL ENDOSCOPIC DECOMPRESSION IN

FAILED BACK SPINAL SURGERY

Pornpavit Sriphirom MD.

Kiattisak Wongvorachart MD.

Rajavithi Hospital

Bangkok,Thailand

ACMISS 2013

Inuyama Japan

Jan,2011 April,2011 Aug,2011 Feb,2012

Failed Back Surgery Syndrome

1. Failure of decompression

2. Failure of fusion

3. Failure of instrumentation

Failure of Decompression group

it can be sub-classified into 2 subgroups

1. Immediate post operative no improvement of

symptoms these are the results from

2. Wrong pre-operative diagnosis • Tumor

• Infection

• Metabolic disorder

• Discogenic pain

• Decompression was performed too late, more than 6 months for disc

sequestration

• Psychosocial problem

3. Technical Error • Wrong level

• Inadequate decompression

• Failure to recognize spinal stenosis as part of disc herniation

• Conjoined nerve root

A. Early recurrence of symptoms (within weeks)

- Infection

- Meningoceal cyst

B. Intermediate (within weeks to months)

- Recurrent disc prolapse

- Battered root, Perineural scarring

- Arachnoiditis

C. Long term (within months or years)

- Recurrent stenosis from new bone formation or disc collapse

- Adjacent level failure

- Instability from disc excision or lumbar decompression

Endoscopic Decompression in Failed Back Surgery Syndrome in Rajavithi Hospital

From June 2009-May 2012

169 cases

FBSS 22 cases

From June 2009-April 2010 General anesthesia

May2010-June2012

Transforaminal technique Local Anesthesia Interlaminar technique General Anesthesia

Transforaminal endo-discectomy

For failed conventional discectomy

Transforaminal decompression

Extra-foraminal decompression

Procedures

22 FBSS

8 recurrent disc herniation

14 foraminal stenosis from adjacent disease

22 patients presenting FBSS were included.

Average age was 54 years old , from 28 to 80

years old

Sex Ratio was M/F : is 6/16.

Average duration for symptoms was 10

months

Level of involvements were

1 level = 19 patients

2 level = 3 patients

Thai Female

52 year olds

5 mo. 11 mo. 14 mo.

Flexion Extension

Back : no point of tenderness, hyperlordosis

Buttock pain and leg pain Lt side

Neurogenic claudication both sides Lt > Rt

SLRT Positive Lt side

Decrease sensation L4,L5 both

Reflex 2+ all

Endoscopic Extra-Foraminotomy L4-5

Pre-op Post-op

(6mo.)

VAS [ Visual Analog Scale ]

7.6 3.3

ODI [Oswestry Disability

Index]

66% 32%

No wound and neural elements complication.

5 patients were complaint for dysestheis.

2 patients were spontaneous recovery in 2

months.

2 patients ( 9% ) were considered to failure

and agreed to have an additional surgery

within 6 months.

All patients were satisfied to avoid opened

surgery at first.