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Transcript of Lecture-Endoscopic Discectomy- -Endoscopic Discectomy-.pdf  Percutaneous Endoscopic Discectomy...

  • 2015-12-28

    1

    Percutaneous Endoscopic DiscectomyTransforaminal / Interlaminar

    Hyeun Sung Kim, MD, PhD,Ji Soo Jang, MD, PhD, Jung Hoon Choi, MD, Sung Kyun Jung MD, Jung Sub Lee, MD

    Department of Neurosurgery, Nanoori Hospital, Suwon City, South Korea

    Medical College of Chosun University , Gwangju, South Korea (1994) / Board of Neurosurgery (1999)

    MEMBERSHIPS & PROFESSIONAL SOCIETIES

    Korean Neurosurgical Society / Korean Spinal Neurosurgery Society / Korean Minimal Invasive Spine Surgery Society / Korean Society of Peripheral

    Nervous System / Korean Spinal Deformity Research Society / Korean Spinal Osteoporosis Research Society / NASS / Eurospine / ISASS / AO Spine /

    AANS / AANS/CNS Section on Disorders of the Spine & Peripheral Nerves / World Spine Society / WCMISST / ACMISST / ISMISS KOREA, TURKEY,

    JAPAN / Korean Society of Thermology / Korean Pain Society / Korean Neuro-Pain Society / The Korean Society of IMS

    Best article award in the Korean Neurosurgical Society / Best Paper Award in the 6h ISMISS TURKEY / Best article award in The Korean IMS Therapy Association

    AWARDS

    Kim HS et al. Balloon kyphoplasty in severe osteoporotic compression fracture: Is it a contraindication? Neurosurgery 2007

    Kim HS et al. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. JKNS 2008

    Kim HS et al. Endoscopic Transforaminal Suprapedicular Approach in High Grade Inferior Migrated Lumbar Disc Herniation. JKNS 2009

    Kim HS et al. Minimally Invasive Multi-Level PLIF Using a Percutaneously Inserted Spinal Fixation System. JKNS 2011

    Kim HS et al. Comparative study between different PEILD techniques. Pain Physician 2013

    PAPERS: MORE THAN 40 PAPERSPAPERS: MORE THAN 40 PAPERS

    Korean Neurosurgical Society: Luncheon Seminar: PELD; Benefits and Limitations / WCMISST 2012, Brazil: Minimally invasive TLIF and PLIF using

    the Apollon system / WFNS 2013, Korea: Structural Preservation PEID

    KNS / WFNS (World Federation of Neurosurgical societies) / NASS / Eurospine / ISAS / World Spine / KOMISS / ACMISST / Asia Spine / WCMISST /

    ISMISS TURKEY / IITS / WENMISS

    LECTURE & PRESENTATION: MORE THAN 100 TIMESLECTURE & PRESENTATION: MORE THAN 100 TIMES

    REFERENCE DOCTORA. Extra-Foraminal Approach

    A. Far lateral Disc

    B. Trans-foraminal Approach

    A. Foraminal Disc

    B. Superior Migration Disc

    C. Inferior Migration Disc

    D. Paracentral Disc

    E. Central Disc

    C. Interlaminar Approach

    Interlaminar Approach

    PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY

  • 2015-12-28

    2

    PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY

    PETLDPERCUTANEOUS ENDOSCOPIC

    TRANSFORAMINAL LUMBAR DISCECTOMY

    ANATOMICAL CONSIDERATION NEURAL ANATOMYNEURAL ANATOMY

    d. Sinuvertebral nerves

    a. Exiting nerve and Ganglia

    b. Traversing nerve

    c. Sympathetic trunk and ganglia

    ANATOMICAL CONSIDERATION VASCULAR ANATOMYVASCULAR ANATOMY

    Segmental Artery

    Aorta

    Radiculomedullary artery

  • 2015-12-28

    3

    MRI Length Measurement MRI Marker Physical Examination

    APPROACH ENTRY POINTENTRY POINT

    10~12 Cm

    8~10 Cm

    6~8 Cm

    4~6 Cm

    APPROACH WORKING CHANNEL INSERTIONWORKING CHANNEL INSERTION

    ANATOMICAL CONSIDERATION APPROACHAPPROACH ANATOMICAL CONSIDERATION APPROACHAPPROACH

    EPIDURAL APPROACHEPIDURAL APPROACH

  • 2015-12-28

    4

    ANATOMICAL CONSIDERATION APPROACHAPPROACH

    EXITING ROOT APPROACHEXITING ROOT APPROACH

    ANATOMICAL CONSIDERATION APPROACHAPPROACH

    TRAVERSING ROOT APPROACHTRAVERSING ROOT APPROACH

    ANATOMICAL CONSIDERATION LIMITATIONSLIMITATIONS

    Anatomical Limitations of PETLD

    Migration

    Canal Compromise

    Iliac crest

    Hard bony foraminal width

    Surgical Limitations of PETLD

    Inside-out / Outside-in approach

    Targetectomy

    Saftey Zone

    Neurological Limitations of PETLD

    Epidural approach

    Exiting root approach

    Traversing root approach

    CURRENT DEBATE OF PETLD ANATOMICAL LIMITATIONSANATOMICAL LIMITATIONS

  • 2015-12-28

    5

    ANATOMICAL CONSIDERATION HIGHTLY INFERIOR MIGRATED L4-5HIGHTLY INFERIOR MIGRATED L4-5

    L4-5

    ANATOMICAL CONSIDERATION HIGHTLY INFERIOR MIGRATED L4-5HIGHTLY INFERIOR MIGRATED L4-5

    Lee SC, Kim SK, Lee SH, et al. Percutaneousendoscopic lumbar discectomy for migrateddisc herniation: classification of discmigration and surgical approaches. EurSpine J 2006

    Lee SC, Kim SK, Lee SH, et al. Percutaneousendoscopic lumbar discectomy for migrateddisc herniation: classification of discmigration and surgical approaches. EurSpine J 2006

    Half-and-Half Technique& Epiduroscopic Approach

    Half-and-Half Technique& Epiduroscopic Approach

    Choi G, Kim JS et al. Percutaneous

    endoscopic approach for highly migrated

    intracanal disc herniations by

    foraminoplastic technique using rigid

    working channel endoscope. Spine. 2008

    Choi G, Kim JS et al. Percutaneous

    endoscopic approach for highly migrated

    intracanal disc herniations by

    foraminoplastic technique using rigid

    working channel endoscope. Spine. 2008

    Foraminoplastic TechniqueForaminoplastic Technique

    Kim HS et al. Endoscopic Transforaminal

    Suprapedicular Approach n High Grade

    Inferior Migrated Lumbar Disc Herniation

    . J Korean Neurosurg Soc, 2009

    Kim HS et al. Endoscopic Transforaminal

    Suprapedicular Approach n High Grade

    Inferior Migrated Lumbar Disc Herniation

    . J Korean Neurosurg Soc, 2009

    SuprapedicularSuprapedicular

    SURGERY RELATED RELAPSERELAPSE

    Segmental Loading Component

    Age

    Disc location

    Herniated disc level

    Disc height

    Healing Component

    Degeneration Scale

    Anti-adhesive agent

    Combined HNP

    SURGERY RELATED RETROPERITONEAL HEMATOMARETROPERITONEAL HEMATOMA

  • 2015-12-28

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    SURGERY RELATED PYOGENICSPONDYLODISCITISPYOGENICSPONDYLODISCITIS CURRENT ISSUES EQUIPMENTEQUIPMENT

    CURRENT ISSUES HIGH CANAL COMPROMISEDHIGH CANAL COMPROMISED CURRENT ISSUES FORAMINAL TO SUPERIOR MIGRATIONFORAMINAL TO SUPERIOR MIGRATION

  • 2015-12-28

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    CURRENT ISSUES FAR LATERALFAR LATERAL CURRENT ISSUES RECURRED HNP AFTER OMDRECURRED HNP AFTER OMD

    CURRENT ISSUES CALCIFIED HNPCALCIFIED HNP CURRENT ISSUES ADJACENT 2 LEVEL HNPADJACENT 2 LEVEL HNP

  • 2015-12-28

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    CURRENT ISSUES CURVED PROBECURVED PROBE

    51 yr / M Highly Inferior Migrated

    CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL

    74 yr / M Highly Inferior Migrated

    CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL

    74 yr / M Highly Inferior Migrated

  • 2015-12-28

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    CURRENT ISSUES FORAMINOPLASTYFORAMINOPLASTY

    67 yr / F Foraminal Stenosis

    PEILDPERCUTANEOUS ENDOSCOPIC

    INTERLAMINAR LUMBAR DISCECTOMY

    ANATOMICAL CONSIDERATION LIMITATION OF PETLDLIMITATION OF PETLD ANATOMICAL CONSIDERATION LIMITATION OF PETLDLIMITATION OF PETLD

  • 2015-12-28

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    Interlaminar

    Trans-Shoulder

    Trans-Axial

    Resection

    Possible

    Wide

    ( + )

    Posterolateral

    ApproachTransforaminal

    Trans-iliac

    Ligamentum Flavum Spare

    Annulus Repair Impossible

    Indication Limited

    Adhesion Weak

    CURRENT DEBATE L5-S1: PETLD VS PEILDL5-S1: PETLD VS PEILD L5-S1: PETLD VS PEILDL5-S1: PETLD VS PEILDCURRENT DEBATE

    L5-S1: Percutaneous Endoscopic Approach

    NEURAL APPROACHNEURAL APPROACHCURRENT DEBATE

    Axilla

    Moderate

    Easy

    Difficult

    Weak

    Easy

    Shoulder

    Learning Curve Short

    Inferior Migration Difficult

    Superior Migration Easy

    Nerve root retraction Hard

    Annulus Sealing Difficult

    LIGAMENTUM FLAVUM SPLITTINGLIGAMENTUM FLAVUM SPLITTINGCURRENT DEBATE

    Classification Technique

    Splitting

    Indirect Choi G

    Direct Kim CH

    Resection

  • 2015-12-28

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    ANNULUS SEALINGANNULUS SEALINGCURRENT DEBATE STRUCTURAL PRESERVATIONSTRUCTURAL PRESERVATIONCURRENT DEBATE

    L5-S1: Structural Preservation

    CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE

  • 2015-12-28

    12

    CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE CURRENT ISSUES HIGHLY INFERIOR MIGRATEDHIGHLY INFERIOR MIGRATED

    38yr/Female38yr/Female

    CURRENT ISSUES HIGHLY SUPERIOR MIGRATEDHIGHLY SUPERIOR MIGRATED

    44yr/Male44yr/Male

    CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD

    53yr/Male53yr/Male

  • 2015-12-28

    13

    CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD

    53yr/Male53yr/Male

    CURRENT ISSUES CONTRALATERAL PEILDCONTRALATERAL PEILD CURRENT ISSUES CONTRALATERAL PEILDCONTRALATERAL PEILD

    43yr/Male43yr/Male

  • 2015-12-28

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    CURRENT ISSUES CALCIFICATION FLOATING TECHNIQUECALCIFICATION FLOATING TECHNIQUE

    Interlaminar: L5-S1: 59/M, Rt.

    CONCLUSION

    Limitation: Anatomical, Surgical, Neurological

    Approach: Epidural, Exiting, Traversing

    In and Out / Out and In

    Highly inferior migrated L4-5

    Advanced surgical science and technology

    Wide PELD indication

    Future of PELD

    CONCLUSION

    Structural preservation technique of

    percutaneous endoscopic interlaminar lumbar

    discectomy

    Ligam