Dr. Jae Lim, MD performing and endoscopic spine surgery in Reston, VA

Endoscopic Spine Surgery

Endoscopic spine surgery is a minimally invasive procedure that uses micro incisions and specialized tools to address spinal conditions with greater accuracy, more safety and better results.

What is Endoscopic Spine Surgery?

In simple terms, endoscopic spine surgery is a minimally invasive spinal procedure that uses micro incisions as well as specialized visualization and surgical tools to treat a wide variety of spinal conditions.

This cutting-edge technique is used at the affected portion of the spine with minimal muscle and tissue disruption. A small camera, known as an endoscope, allows the surgeon to view what they’re doing without opening up large portions of the back.

Why is Endoscopic Spine Surgery Groundbreaking?

Endoscopic spine surgery is a minimally invasive spine surgery meaning that there is less disruption to the muscles, nerves and soft tissues that surround the spine. Additionally, it boasts greater surgical accuracy which lends itself to a safer operation and speeds up recovery dramatically.

The average incision size for a minimally invasive surgery is around 1 inch. In contrast, open spine surgery generally requires a 6-inch incision--a dramatic difference.

However, one of the primary benefits of minimally invasive spine surgery is also one of its largest drawbacks. In these procedures, surgeons are required to work through a very small opening and have almost no ability to see where they’re working with their naked eyes. In the past, they’ve used fluoroscopes as well as large, bulky microscopes to visualize the spine. While these solutions are suitable for a trained surgeon, they don’t always provide great views of the spine and can, depending on the location of the affected area, force the physician to work in an awkward position.

Enter the endoscope.

An endoscope is a thin, flexible tube with a light and a camera attached to the end. It’s an instrument pretty commonly used in the healthcare industry to give physicians a high-resolution look at internal organs and structures.

The first endoscope was invented in the early 1800s by a man named Philipp Bozzini. However, it wasn’t until the mid-1900s, when fiber optics were first being pioneered, that endoscopes really started to become a practical and powerful tool in the operating room.

Originally, endoscopes were designed for exploring areas of high risk such as the throat, lungs, stomach and intestines. While they’re still used in this way today, they’ve also found a critical place in minimally invasive surgical procedures.

In the field of orthopedics, surgeons have been using endoscopes to treat damage in the knees and shoulders without exposing the entire joint. However, implementation in the field of neurosurgery has been rather slow because working around critical structures of the spine requires an unparalleled degree of accuracy.

Recent advances in visual technology and the creation of specialized tools are now allowing highly-trained neurosurgeons to safely integrate the benefits of endoscopy into the field of minimally invasive spine surgery.

Summary

Endoscopic spine surgery is groundbreaking because it requires a much smaller incision while still giving neurosurgeons the ability to see everything clearly. This increases accuracy and speeds up recovery.

HOW DOES ENDOSCOPIC SPINE SURGERY WORK?

In an endoscopic spine surgery, a surgeon will make a small keyhole incision in the back, often about 7mm, and place a specialized endoscope down to the affected area of the spine.

This endoscope is an instrument specially created for spine surgery, giving enough room for a high definition camera and light source as well as a working channel for the neurosurgeon's instruments and an irrigation channel.

This gives the surgeon everything they need to perform their operation safely and effectively without having to open up a large section of the back.

Unlike open spine surgery, which requires surgeons to scale or cut through muscles and soft tissue when accessing the spine, neurosurgeons simply need to push the soft tissues aside when traveling down to the affected portion of the spine. This gentle approach is safer and causes far less post-operative pain.

Once the endoscope has reached the affected portion of the spine, the neurosurgeon is able to run specialized tools down through the tube and shave, clip or extract the damaged portions of the disc or spine that are pressing up against the nerves.

In terms of visualization, the endoscope is second to none. With the high definition camera and a powerful light source, physicians are able to see exactly where they’re working and what’s occurring in the back at all times.

The endoscopic camera is connected to a monitor that sits in front of the operating surgeon which he watches while performing the procedure. This is, undoubtedly, one of the most technical parts of the operation because the neurosurgeon must work with their hands while watching a screen.

Being able to do this with the level of precision required for spine surgery takes years of specialized training.

Below is a real-life example of what a neurosurgeon sees while performing an endoscopic spine surgery.

Types of Endoscopic Spine Surgery

Endoscopic Discectomy

Endoscopic discectomy is one of the most common forms of endoscopic spine surgery and is a minimally invasive procedure utilized to remove a diseased, damaged or degenerated disc that is causing pain in the lower, mid or upper back.

It is most commonly used to treat a herniated disc that is pressing up against the sensitive nerve roots that exit the spine or a degenerated disc that has collapsed.

During this procedure, the surgeon will enter the back through a small incision and, using x-ray control, will thread what is known as a guide wire down to the affected disc. Using this guide wire, they will then insert a tapered dilator down to the spine. This tool helps gently create space in the back, allowing the endoscope to enter and exit smoothly.

Finally, a portal tube is slid over the tapered dilator and the dilator is removed. There is now a direct opening to the damaged disc and the endoscope is placed through the tube and the neurosurgeon begins the discectomy.

In most instances, the surgeon will use special surgical instruments to grab the pieces of the disc that are herniated or damaged and remove them through the tube; relieving pressure being placed on the nerves. Once this is complete, the surgeon will remove all the instruments and close up the site of the incision with a stitch or two. All in all, this procedure takes about 30 minutes and the patient is able to walk out of the hospital in about 2-3 hours.

Endoscopic Foraminotomy

Endoscopic foraminotomy is a minimally invasive procedure used to combat spinal stenosis and enlarge the space around a nerve root in the lumbar or cervical spine that is being compressed by a bone spur, disc herniation, thickened ligament or scar tissue.

To begin this procedure, a neurosurgeon will make a small, keyhole incision above the damaged area of the spine and insert a guide wire, followed by a tapered dilator and a portal tube. Finally, he will insert the endoscope and, using specialized tools, shave down the bone overgrowth around the affected nerve. During the whole procedure, the nerve is protected by the smooth surface of the portal tube. After opening up enough space for the nerves to move around with compression, the surgeon will remove all instruments and close up the incision using a couple of stitches.

After the procedure, the patient is encouraged to walk around, and is free to go home the same day.

Endoscopic Facet Rhizotomy

Endoscopic facet rhizotomy is a minimally invasive procedure used to treat debilitating back pain caused by facet disease, severe whiplash, failed back surgery syndrome and more by deadening the nerves that are being affected by the condition.

To start the surgery, the neurosurgeon will make a small incision in the back (usually about 7mm) and, using fluoroscopic guidance, send a guide wire near the location of the affected nerves. Then, they will insert a tapered dilator (smaller than the size of a pencil) down to the spine followed by a portal tube. Finally, the surgeon will insert the endoscope and use it to identify the small nerve branches that need to be deadened.

The neurosurgeon will then use a laser or other specialized tool to deaden the nerves, which only provide sensory function, to help relieve pain. After this has been carefully completed, all tools are removed from the back and the site of the incision will be closed with a few stitches.

Once the surgery is completed, the patient is free to leave the hospital the same day.

Endoscopic Lumbar Laminotomy

Endoscopic lumbar laminotomy is a minimally invasive procedure that is used to treat spinal stenosis, bone spurs, herniated discs or facet joint disease that is occuring in the lumbar spine.

In this procedure, the neurosurgeon will make a small 1-2cm incision in the back and, under robotic and fluoroscopic guidance, send a guide wire down to the affected area of the spine. From there, he will insert a tapered dilator and portal tube allowing him to properly identify the affected laminae.

Every lumbar vertebra is made up of four major parts, the vertebral body which contains the disc, the transverse processes which are the bony arms that stick out to the left and right, the spinous process which is the bony arm pointing towards your rear and the laminae. Laminae are the part of the spine that protects the spinal cord from damage. However, over time, this part of the bone can experience degeneration, stenosis, bone spurs and other processes that can impinge the sensitive nerves housed in the spinal column.

During an endoscopic lumbar laminotomy, your neurosurgeon will carefully remove the small area of the lamina bone that is pressing up against the nerves. If the ligaments within the spine are thickened, small sections of this can also be removed, creating space for the nerves.

Once this has been completed, the surgeon will remove the tools from the back and close up the site of the incision with a couple of stitches and the patient is free to go home the same day.

Summary

Endoscopic spine surgery can be used a treat a wide number of spinal conditions using minimally invasive, precise techniques. In many cases patients are able to walk up and leave the hospital the same day.

ROBOTIC ENDOSCOPIC SPINE SURGERY

Within the last several years, incredible advances have been made allowing highly trained neurosurgeons to combine the minimally invasive benefits of endoscopic spine surgery with the accuracy and cutting-edge precision provided by robotic technology.

Is Robotic Spine Surgery is Safe

As we’ve mentioned before, diseased or damaged discs in the spine aren’t always in convenient locations for surgeons. Often, they’ll have to enter the back at an awkward angle in order to avoid hitting nerves or damaging too much soft tissue during the operation. Additionally, they’re often tethered to their high-powered microscope which, while adjustable, is simply not capable of moving everywhere with the surgeon.

This is where robotics combined with endoscopy makes a dramatic impact.

Before putting anyone on the operating table, neurosurgeons are able to create what is a called a pre-operative plan using 3D scans and x-rays of the patient’s spine. This allows them to put together a roadmap of exactly how they want to handle the operation. They’re able to see exactly where the affected portions of the spine are, how they should enter, what should be removed, what implants or screws need to be added, etc. They are then able to program all this information into the Mazor X robotics system and, during the operation, the robot will move based on the commands the surgeons put into its system.

The result is an accuracy rate of over 98%.

It’s important to note that the robot is not operating on the spine at any point. Rather, it’s a guidance system that helps ensure that surgeons are working precisely where they should at all times.

Now, couple the accuracy and safety benefits of robotic spine surgery with the minimally invasive and visualization benefits of endoscopic spine surgery and you have one of the most groundbreaking, safest methods of back surgery on the planet.

Summary

The combination of endoscopic spine surgery and robotics is a truly groundbreaking advancement. Mechanical guidance helps surgeons attain unparalleled accuracy and endoscopy allows them to visualize their workspace clearly.

BENEFITS OF ROBOTIC-GUIDED ENDOSCOPIC SPINE SURGERY

Robotic-guided endoscopic spine surgery is a minimally invasive procedure which means that patients can reap the benefits of a smaller incision, less tissue damage and a smaller amount of blood loss. This, in turn, helps them recover more quickly from their procedure and get back to regular, active life.

SMALLER INCISION

As a powerful subset of minimally invasive spine surgery, one of the main benefits of endoscopic spine surgery is the fact that it requires a very small incision, usually less than one inch.

A common misconception about incisions is that they’re just used to break the skin and open up the interior of the body, kind of like cutting your finger with a knife. This isn’t actually the case. To a surgeon, an incision is the act of cutting through the skin and through the underlying tissue (including muscle) in order to access the affected portion of the body.

Large incisions, which are common in open spine surgery, are problematic because they force surgeons to cut through and pull back more muscle and soft tissue than is actually necessary. It’s typically done so that surgeons can see the spine with their naked eyes and operate carefully around the nerve roots that exit from the spinal column. However modern technology has made this methodology obsolete and completely unnecessary.

Affecting more anatomy than is absolutely required can make recovery more painful and extend it dramatically.

Physicians who specialize in endoscopic spine surgery use what is known as a keyhole, or laparoscopic incision. This means that they create an opening just large enough to allow their surgical instruments to fit into the body; nothing more.

By opening up less of the back, patients are better protected from excessive blood loss, infection, misplaced surgical instruments while still giving surgeons the visualization they need to perform the surgery safely and accurately.

IMPROVED SURGICAL ACCURACY

As mentioned previously, robotic guidance allows surgeons to attain accuracy during surgery that is simply unattainable by the human hand. This, coupled with the fact that they are able to clearly see everything that’s happening where they’re operating and are able to work in a position that’s comfortable to them means that they are able to focus solely on the surgery at hand.

Studies have found that surgeons who use robotic guidance are accurate to a degree of 1.5 millimeters. For scale, that’s slightly smaller than the width of a quarter.

This accuracy is absolutely essential when working in the area of the body because surgeons are often operating around some of the most complex and critical components in the body including nerves and major arteries. There is simply no room for error or lack of accuracy when dealing with such vital systems.

LESS ANAESTHESIA AND INTRAOPERATIVE RADIATION

Because surgeons are able to work through such a small incision in the back, they don’t need to give patients as much general anesthesia and, because they’ve already pre-mapped out their operation they don’t need to take as many intra-operative scans.

This is an incredible benefit for patients because, despite the fact that complications arising from anesthesia or intraoperative radiation are very rare, it simply removes another risk factor from the operation.

QUICKER RECOVERY

For many patients, post-operative recovery can be one of the most difficult parts of their surgery. The truth is that every surgery, regardless of its level of invasiveness, has an impact on the body and will require some time to heal.

However, minimally invasive techniques can help shorten the amount of a time a patient has to stay in the hospital and speed up their recovery time dramatically.

In the past, patients were expected to spend at least 2-3 days recovering in the hospital after their surgery. Now, thanks to better technology and minimally invasive techniques, patients can walk out of the hospital, often pain-free, the day of their surgery.

Additionally, it used to take patients an estimated 3-4 months of rest and recovery to fully heal from their spine surgery. This often meant that they weren’t able to exercise strenuously, couldn’t work a job that required manual labor and were on pain-relieving medication for months after their operation.

With minimally invasive techniques, however, patients can expect to make a full recovery in an average of 6 weeks or less with rehabilitation.

Summary

Robotic-Guided Endoscopic Spine Surgery provides patients with all the benefits of minimally invasive procedures while simultaneously being one of the most accurate and safest procedures in healthcare.

AM I A CANDIDATE FOR ENDOSCOPIC SPINE SURGERY?

If you are suffering from a debilitating or painful spinal condition that has not been corrected through conservative treatments like physical therapy or medication or your spine specialist has recommended that you undergo spine surgery to address your back pain, you might be a candidate for endoscopic spine surgery. Our neurosurgeons can use the combination of endoscopy and robotic-guidance to treat a wide variety of spinal issues including degenerative disc disease, herniated discs, scoliosis and spondylolisthesis. If you’re interested in learning more about robotic spine surgery, please get in touch with our office.

Contact Us

Schedule an initial consultation today to discuss all of your surgical and non-surgical treatment options.

Schedule an appointment
Atlantic Brain and Spine A graduate of both Yale and Stanford, Dr. Jae Lim is a board-certified spine surgeon who specializes in minimally invasive spine surgery and robotic spine surgery, significantly reducing surgical impact and recovery times. (703) 876-4270
8501 Arlington Blvd. Suite 330
Fairfax
Virgina
22031
United States
Jae Y. Lim Ben L. Nguyen