Abstract

Purpose: To Illustrate the foraminal endoscopic approach to the lumbar spine utilizing improvements in endoscope design, instrumentation, and evolving endoscopic surgical techniques to visualize and treat painful patho-anatomy. Materials and Method: A standardized method for endoscopic foraminal surgery is demonstrated: 1. A protocol for optimal instrument placement calculated by lines drawn on the skin from the C-Arm image facilitates needle and cannula placement for endoscopic surgery. 2. Evocative chromo-discography. to confirm discogenic pain. 3. Selective endoscopic discectomy , Thermal discoplasty and annuloplasty guided by vital tissue staining. 4. Endoscopic foraminoplasty 5. Diagnostic and surgical exploration of the epidural space. 6. Probe the hidden zone of MacNab containing the exiting nerve, DRG, and axilla of the traversing and exiting nerve 7. Using the biportal technique for inside-out removal of extruded and sequestered nucleus pulposus. Results: This technique not only allows surgical access to the lumbar spine for treatment of a wide spectrum of painful degenerative conditions of the lumbar spine, but provides motion sparing options to fusion for conditions ranging from discogenic pain to failed back surgery syndrome due to residual/recurrent disc herniation and lateral recess stenosis. Over 3,000 patients have undergone postero-lateral surgical decompression since 1991 Case examples utilizing jpeg and mpeg imaging illustrate the feasibility and reproducibility of this minimally invasive surgical technique for painful degenerative conditions requiring greater surgical morbidity when traditional surgical methods are utilized. Conclusions: The foraminal endoscopic approach requires surgical skills that will be desirable and necessary for the spine surgeon to keep up with innovative new technology in spine care that emphasize preservation of spinal mobility. New horizons focusing on nucleus replacement, annular repair, annular reinforcement, biologics, and even interbody fusion are ideally performed minimally invasively, and the endoscopic will allow for true minimally invasive access to the lumbar spine without affecting and destabilizing the dorsal muscle column.