---
title: 'Transforaminal Endoscopic Lumbar Discectomy, L45, Wide Foramen'
type: 'lecture'
url: 'https://doc.social/lectures/transforaminal-endoscopic-lumbar-discectomy-l45-wide-foramen'
published: '2021-02-10'
author: 'Jin-Sung Kim'
specialty: 'Neurological Surgery'
topics: 'Full-endoscopic Spine Surgery, Transforaminal Endoscopic Lumbar Discectomy, Minimally Invasive Spine Surgery'
transcript: 'yes'
---

# Transforaminal Endoscopic Lumbar Discectomy, L45, Wide Foramen

## Summary

This is the lecture for the spine fellows of the Och Spine Hospital, Columbia University Medical Center, NY, USA on Jan 12 2021.

## Transcript

2,367 words · 23 min · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:03] Hello, everybody. Thank you for having me in this educational series in the the Spine Hospital, the Columbia University Medical Center.
[0:14] It's my great privilege to introduce the basic and complication of endoscic Spine Surgery.
[0:21] Recently, I have been surprised to figure out the thematic adoption of endoscope has been taking place rapidly and also tons of paper are coming out every, every week.
[0:37] I don't know, you have the same pace as me, but after my talks, I'm hoping you guys have sort of motivation for Endoscopic spine surgery more.
[0:49] Just to bring you up to speed about today's residents, let's move on to the contents today.
[0:56] Uh, I have the more specific title like this.
[1:02] This is my disclosure.
[1:04] So I have been involved in the two main endoscopy company, Richard Wolf, uh, the real Spine, and the Eloquence.
[1:16] I'd like to introduce the, the funny pictures.
[1:21] You can see the well-known, the famous renowned Spine surgeon, Doctor Burbon, and also he was trying to catch up some skill set of endosic Spine Surgery from the Doctor Ba. He's the president of the Re Spine Hospital in Korea.
[1:42] He was also the my fellow 2008.
[1:47] So hopefully, I, I don't expect this kind of situation like that, right? So, 2018, Neospine Task For members uh started making the MIS curriculum. We also have the end of the basic three endocri procedures MIS curriculum.
[2:12] This is Espine consensus.
[2:14] So there are a lot of the endoscopy procedures.
[2:19] In the lumbar and thoracic and the cervical Spine, among the kind of the procedures.
[2:28] I briefly introduced the TELD, that is the transforminal endoscopy lumbar discectomy for disccal prolapse, also the one of the common uh procedures transforming endoscopic lumbar foraminotomy.
[2:46] So, I have thought, what's going to be the best ways to learn Endoscopic spine surgery, especially for you guys, Spine surgeons in the United States. The first step is lectures from the experts, and mostly in-person meeting.
[3:04] And in this Pandemic,
[3:07] Uh, situation, we can, you, you guys can be joining the online courses, virtual meeting.
[3:16] Still a lot of the education webinar series, uh, from the industry, the Spine Society meeting, especially in the Asia-Pacific area.
[3:28] They have already posted recorded file of the endospine Surgery in their uh website as well.
[3:38] Also, there are a lot of the videos, you can enjoy the video clips of Endocri spinesor from Bed and YouTube, etc. and also the tons of article and textbooks already available.
[3:57] Right.
[3:58] I also published the uh endoscope procedures on the Spine, right? Also, the NAS and the Global Spine and ASMMIS. They have recently supported the Kaba workshop. I have been uh chair the pre-course of Endoscri Spine, sorry in the NSS and the Global Spine. Since 2018, the Espine double scores.
[4:27] They started the, included the endoscopic Surgery uh module in the Davos Co. Fellowship, uh, ideally, that's gonna be the best uh way to learn the Endoscopic spine surgery.
[4:44] Because the uh Oak Spine Hospital located in the New New York, I have thought the, one of the company eloquence, called Lab in Baldwin, good way. Please mark these main contents today, transform Endoscopic spine surgery for discectomy at the profile level.
[5:02] So the learning objective today is to learn the ideal trajectory of TELE and describe indication and contraindication of transfer endoscope procedures and what's gonna be the basic OR setup, the anesthesia and procedures, step by step, and tips and pitfall, including the case and presentation.
[5:26] So, most recent, uh, evidence about the complication rate, uh, among the various kind of the endoscopic tool from the open and microscope, tubular, and the transferring endoscope, etc. they have highlighted
[5:47] Uh, transform endoscopic Surgery has the lowest, lower risk of all complication and low risk of the complication necessitating the conservative treatment.
[5:58] Right, this meaningful paper from the systematic reviewer.
[6:06] Uh, we can briefly say that the, we have the various, uh, sort of the stage and extent of this coordination.
[6:15] Right? From the simple protrusion bulging and broad-base protrusion and narrow-base protrusion, ri down migrated and protrusion in faster hypertrophy and this kind of severe cannot compromise this explanation. Of course, we have the more complicated cases than this.
[6:37] But uh I would like, I would like to highlight the basic uh ideal cases for the novice surgeons.
[6:47] This is the basic instruments for the procedures. Endoscopic card.
[6:52] Uh, scobile and cannular and grasping forcep and the punch and drill, bipolar coagulator and CM fluoroscope, of course, and the full endoscopic is being done under the continuous cellar irrigation.
[7:12] From the first one to the last one. So I'm gonna explain it briefly, step by step. First one is pre-op planning and OR setup.
[7:24] And your planning should be done, mark the ideal trajectory. Of course, before
[7:32] Decision making for the Endoscopic spine surgery, you, you, you have to check this kind of the checklist.
[7:42] And this is Beijing was setup. Patient positioning, and ideal trajectory.
[7:49] And a little bit kypotic changes position might be ideal because you, you can open up the foramen more.
[7:58] So another key step for ideal trajectory, so what's gonna be the best trajectory for treat this kind of uh disc merging at the profile level and the two-hall level.
[8:12] Because there is the, the exceeding nerve should be avoided.
[8:19] Not to make any kind of the neural complication. Among these three, the full line from the 1 to 4 for treating this kind of hernia. So I think the number 3 and number 4 gonna be ideal trajectory, right?
[8:39] But in some cases, so I cannot compromise discation or the little bit hypertrophic facet joint, we need to resect some per ventral part of the facet joint. That is the name of phangioplasty, right?
[8:59] Red wine is ideal, so additional pliminoplasty is essentially, it, it definitely needed for access the dyscornea.
[9:10] So, next step is needle placing and walking cannula insertion through the ideal trajectory.
[9:19] The phase 3 is insertion of an 18 gauge needle.
[9:25] Along the planned trajectory and the subsequent eile anesthesia and the discography and phase 4 operator insertion and open can insertion and check the location under the fluoroscope should be done always.
[9:42] You can confirm the final uh ideal location of the working killer under the Xian fluoroscope, AP and reintal view.
[9:55] But in some cases foraminal uh stenosis and hypertrophic facet.
[10:01] I, uh, uh, prefer this kind of docking the needle just over the superior notch of the pedicle to avoid the exceeding nerve root irritation or damage.
[10:17] Decision, uh, factors, location and the level. And the phase 4 is a walking cannula insertion smoothly and gently. And if your location
[10:33] Uh, it's perfect.
[10:35] You can see the ruptured hernia directly, right? In the case of the foraminal stenosis and the hypotrophoset, so phanoplasty is essential procedures uh to access the ruptured fragment.
[10:57] So you can use the primal plastic by reamming or the drilling like that.
[11:04] Anyway, you can follow the, any uh option would you like to free that.
[11:12] Actually, the main step of the transplant endoscopy lumbar discectomy. Under the CM, uh, under the endoscope view, you can see the annular tear side as well and the corner of the endop plate.
[11:28] And once you remove the rupture fragment,
[11:33] Well, you can also see the pulsating the epidural space and fat.
[11:39] And traversing nerve root as well. Then you can navigate the endoscopic instruments for accessing the migrated fragments sometimes.
[11:52] And once the discectomy done, so I always recommend peripheral nuloplasty is the additional procedures which may elevate the patient's actual Pain as well from the east side and the central side and the con contractral side as well. By navigating the radiofrequency tip, you can reach out to the, all the way, the ventral side.
[12:20] The annulus like that.
[12:24] The final step is bleeding control and confirmed endpoints of the procedures and finish the procedures of endoscopic discectomy.
[12:36] And let's move on to case illustration from the simple one.
[12:43] The first one is the purging disc for transfer endos lumbar discectomy.
[12:49] Mainly actual Pain and uh repper Pain to the bottom and thigh sometimes. You can also see the gentle disc bulging. This is he made a post-op endoscopic discectomy the day after Surgery.
[13:07] And the 1.5 year, uh, years later, you can see the perfect remodeling of the annulus.
[13:16] The next case is the protrusion with a broad base.
[13:22] See the case?
[13:24] A young female, 37 years old, female patient suffered from the right leg dominant Pain.
[13:35] This is X MRI. You can see the disc protrusion right side dominant.
[13:42] And Priyo City, there's a little bit marginal spur.
[13:46] You, you need to draw the line, ideal trajectory always like that.
[13:52] And then check the foramen always because the enough gaining the enough foramen is essential and isn't going to be mandatory for the ideal.
[14:06] Uh, safe transplant endoscopic Surgery, right?
[14:10] So MRI and CT.
[14:13] Enough foramat for transfer access.
[14:17] Draw the line along the midline and they rattle the AP line. This is walking trajectory.
[14:27] Uh, trajectory should be a little bit cranial caudal angle.
[14:32] And between the two lines, which is gonna be better and safer.
[14:38] To think about the Kempen Triangle.
[14:41] So this is gonna be safer than the left one. And the, once the needle Approach the Camian triangle and recommend the epidural Injection of contrast, so once you inject the contrast, you can figure out the shadow of a traversing nerve and shadow of exceeding.
[15:05] Nerve.
[15:07] Right?
[15:09] So it can advance a little bit more and cause the annulus, a punctured annulus, and then you can inject the discography.
[15:20] In carmine to uh perform the discography, right? We can also draw the imag line defining the lobar dyscornea like that.
[15:33] So you can see the final docking of the CM fluoroscope.
[15:39] The blue stain is the, the nucleus stain in your carmine.
[15:46] Once you remove the main part of the uh ruptured disc, sub-annual portion.
[15:54] You can see this kind of big fragment, right?
[15:58] And then try to lay the tissue with the proper uses of the radio frequency.
[16:07] You can make it shrink it?
[16:09] Uh, more removal of the disc cornea, and sometimes you need to check the CM fluoroscope to check the location.
[16:18] Of your endoscopic armamentary, especially force at the very frequent.
[16:24] On to coagulate the ventral side.
[16:28] So annual portion, this is there's a remained a little bit unmigrated, this cornea like that.
[16:36] Can make it
[16:38] Do.
[16:39] And this, this kind of a right angle hoop, you can explore the ventral path.
[16:47] Right, to check the remnant discord or not.
[16:51] Can
[16:52] Yeah. Cut the PLL fiber.
[16:58] Right
[16:59] And then you can see the ventral pulsating dura and the ventral extra fat here.
[17:07] And angioplasty is done properly.
[17:12] Right.
[17:14] A nicely decompressed discectomy.
[17:19] So this is MRI.
[17:21] He built it the day, one day after Surgery.
[17:26] And this is followup MRI done one year later. It's a perfect remodeling.
[17:34] So, pre-op x-ray, it, patient have the angular, looks like having the angular instability.
[17:42] So, what about the status of the two years follow up? It looks uh stable than pre-op.
[17:52] You can also see the coronal x-ray whole Spine.
[17:57] Well, restoration of the
[18:00] Alignment
[18:03] I'm gonna move to the next case, the protrusion and narrow base.
[18:10] This is the transfer endosin lumbardi skin for focal protuity dyscora.
[18:16] Patient have the right side. It looks like the
[18:22] Burging pop up the dys cornea like the bow tie, right?
[18:27] And patient also have this scholitic, uh, because of Pain. It's a Pain, painful, uh, condition. Patient need to shift her back to the left side.
[18:42] Uh, this is pre-op x-ray, MRI and a cyto. I, I'm gonna always highlight this foramen, the Approach side, right? Foramen is OK.
[18:56] So
[18:58] We have the diagnosis lumbar dyskinesia 45, right side, it's one of the common type. We have the sort of the surgical plan and option.
[19:09] If you like the endoscope Surgery in a laminar on the transforminal, which is gonna be better for you?
[19:17] I, I, I love to transplant endo discectomy.
[19:22] After cutting the postures, some fiber, annulus fiber, we can see the large bolt.
[19:32] Yeah.
[19:33] Disc fragment like the mass.
[19:37] Defining the fragment, main fragment by the.
[19:43] Radio frequent and you can grasp the main fragment and take it out by rotating many verne.
[19:52] OK.
[19:55] Once you cut out the final parallel, this is the uh blood impinged the posterior annulus and PLL.
[20:04] This is an important step for oplasty.
[20:10] This is evident, uh, this is reversing nerve and well pulsating.
[20:15] Patient added Pain is gone already during the Surgery.
[20:19] Yeah. Perfect, pain-free, and perfect MRI done. Next case is the protrusion with down migration disc, one of the common type, and each one.
[20:34] Patient, a young male guy.
[20:38] This kind of half and half docking of the scope is very important to reach out the fragment directly and easily, you can
[20:49] Access the main framework.
[20:52] I'm gonna highlight, you can compare these two MRI post-op embedded and
[21:01] MRI done 4.5 years later, right? There's no obvious changes between the two MRI, I mean the disc signal.
[21:12] This is the real value of the transplantous discectomy Surgery.
[21:17] So
[21:19] Take a message. So I think the
[21:23] Indication, knowing the indication is going to be most important first step, you need to know the Patient Selection.
[21:31] Always see the size of foramen.
[21:35] And the type of the disc hernia, the level of the hernia, I don't recommend the 5% uh for transformational Surgery for beginner, right? In case of formulaing phoplasty prior to discectomy.
[21:51] is needed for safe Surgery.
[21:56] So another the message, transforminal endoscope.
[22:02] Uh, need to ideal trajectory and keep in mind faces.
[22:08] Of step by step and target-oriented Surgery. You can preserve the central disc and the faucet. You can, you don't have to make any scar in the interlaminar space.
[22:24] Right? So it, it, it is definitely looks like a plastic Surgery. Sometimes.
[22:31] I'm gonna be happy to share this kind of concept.
[22:36] If you guys wanna be the plastic Surgery in the Spine area, you need to learn the Endoscopic spine surgery. Thank you very much.