Many of the newest procedures and techniques in spine surgery involve minimally invasive and endoscopic approaches. While surgeons are familiar with these procedures in the lumbar spine, many have not ventured into performing endoscopic surgery in the cervical spine because of its delicate position. Bryan Massoud, MD, a spine surgeon with Spine Centers for America in Fair Lawn, N.J., regularly performs cervical spine surgery using an endoscopic approach and invites qualified spine surgeons to train with him at his practice on the procedure. Dr. Massoud discusses six things to know about the intricacies of cervical endoscopy.
1. Fusion is unnecessary with the endoscopic approach. Spine surgeons typically treat patients with degenerative diseases in the cervical spine through a combination of a cervical discectomy and fusion. However, fusions can cause additional problems for patients. "Once you start talking about fusion procedures and the insertion of hardware, the spine becomes very rigid and patients lose their range of motion," says Dr. Massoud. "Not only do you lose motion with the fusion procedures in the cervical spine, but you fall into the risk of adjacent segment disease because the fusion on one level adds stress to the surrounding levels. The minimally invasive techniques don't require stripping the surrounding tissues off of the spine and the exposure is a lot less. Many times in open cervical discectomy and fusion, you can violate some of the tissues in the area and accelerate degenerative properties at the surrounding level."
Dr. Massoud is using endoscopic cervical foraminotomy to treat patients with cervical degenerative disease, herniated disc and other conditions, which allows him to remove neural pressure without cervical fusion. In endoscopic cervical foraminotomy, which his used for the treatment of bone spurs, scar tissue or herniated disc, the surgeon inserts the endoscope into the cervical spine nerve canal. The surgeon then removes small pieces of enlarge bone/bone spurs, scar tissue and disc with micro instruments (such as burrs) to open the nerve canal. For treatment of degenerative disc disease, once in the target area, the surgeon uses a laser to vaporize targeted disc material, deaden pain nerves inside the disc and hardens the disc to prevent leakage of spinal fluid to the surrounding nerves.
"By entering the disc with a 4-6 millimeter cannula, we are able to perform discectomy and foraminotomy, for example, without the need for fusion because of the small nature of the instruments we use," he says. "We don't need to violate the disc such that would require surgical fusion. In the open procedures, you remove the annulus entirely and need to do the fusion. With the cannula, we can enter and leave the disc without destabilizing it."
2. Procedure is performed in an outpatient setting. The cervical endoscopic surgical procedures can be performed in an outpatient setting under general anesthesia, says Dr. Massoud. "Given the use of the endoscopic approach, patients are able to go home the same day," he says. "We minimize the stripping of tissues and exposure of adjacent levels, which reduces the risk of adjacent level disease and contributes to a more rapid recovery." Additionally, the endoscopic approach requires only a small incision to insert the endoscope and instrumentation, minimizing surgical scarring.
"It's very beneficial to go in and treat these disorders without having to perform a fusion," says Dr. Massoud. "With cervical endoscopy, you can target your working area very specifically and avoid any injury to the surrounding discs and tissues, thereby lowering the chance of adjacent segment degeneration."
3. Surgeons should gain experience first with lumbar and thoracic endoscopy. Since the cervical spine is one of the most sensitive areas of the spine, most spine surgeons don't begin learning cervical spine surgery until after they are familiar with the technique elsewhere on the spine.
"Before a surgeon starts tackling cervical endoscopy, they need to be very familiar with spine surgery and have gained experience in lumbar and thoracic endoscopy," says Dr. Massoud. "The cervical spine is much more sensitive to injury than any of the other structures, so before attempting a cervical endoscopy, the surgeon should be a board certified orthopedic or neurospine surgeon and needs to have significant experience in lumbar endoscopy and have mastery over the endoscope and associated instruments we use."
Significant experience with lumbar endoscopy means successfully performing more than 300 cases before beginning to learn the endoscopic cervical procedure. Using the endoscope presents challenges to even the most experienced spine surgeons because the surgeons must take a three-dimensional approach to performing the surgery. Instead of having the open anatomy in front of them, the surgeon inserts the endoscope over the surgery site and uses the scope's projection of the patient's spine for visual guidance during the procedure.
4. Navigation around the cervical spine is different from the lumbar spine. Performing surgery on the cervical spine has the potential for more severe injury than procedures on other areas of the spine because there is less space and more major structures to navigate through. The cervical spine is located near the trachea, esophagus and carotid artery, which are three major structures the surgeon must avoid when performing surgery on the cervical spine.
"These structures override the anterior portion of the disc where the surgical procedure needs to be done," says Dr. Massoud. "You must be able to successfully move them out of the way and follow the tissue plane to minimize the risk of injury. Once you actually begin the cervical endoscopy, you are dealing with the potential dangers of injury to the spine itself."
Unlike the lumbar spine, where the surgeon has the potential to damage neural structures such as nerve roots and nerve rootlets, surgeons working in the cervical spine are working closely around the nerve roots and spinal cord that is more sensitive to injury. Surgeons must be aware of these differences to successfully avoid damaging the patient.
5. Patients don't need the cervical immobilization collar. Endoscopic cervical spine surgery allows for a quicker recovery and return to normal activity, partially because the patient doesn't need a cervical immobilization collar. Patients who undergo a cervical fusion procedure often wear a cervical collar for 4-6 weeks after the procedure, which keeps them from performing some of their normal activities, such as driving. Most patients who undergo the cervical endoscopy are able to drive one week after surgery. The patients are often able to return to work sooner because the surgeon didn't need to mobilize the cervical spine to allow the fusion to take place. "Patients are very concerned with taking time off work, especially in this economy," says Dr. Massoud.
6. Future is promising for minimally invasive cervical spine surgery. Within 5-10 years, minimally invasive endoscopic approaches could replace open spinal procedures for the treatment of cervical disc herniations and feraminal stenosis, says Dr. Massoud. There are currently techniques under development for minimally invasive cervical fusion surgery, which can be performed with endoscopic assistance. Dr. Massoud is currently involved in advanced training for anterior cervical discectomy and posterior laminectomy procedures.
"It all goes back to really taking an interesting in the emerging field," he says. "It's important for surgeons that are interested in mastering techniques to make a commitment to the training process for these new procedures."
Learn more about Spine Centers of America.
15-01 BROADWAY, STE 20
Fair Lawn NJ 07410
877 722 6008
info@spinecentersofamerica.com
1. Fusion is unnecessary with the endoscopic approach. Spine surgeons typically treat patients with degenerative diseases in the cervical spine through a combination of a cervical discectomy and fusion. However, fusions can cause additional problems for patients. "Once you start talking about fusion procedures and the insertion of hardware, the spine becomes very rigid and patients lose their range of motion," says Dr. Massoud. "Not only do you lose motion with the fusion procedures in the cervical spine, but you fall into the risk of adjacent segment disease because the fusion on one level adds stress to the surrounding levels. The minimally invasive techniques don't require stripping the surrounding tissues off of the spine and the exposure is a lot less. Many times in open cervical discectomy and fusion, you can violate some of the tissues in the area and accelerate degenerative properties at the surrounding level."
Dr. Massoud is using endoscopic cervical foraminotomy to treat patients with cervical degenerative disease, herniated disc and other conditions, which allows him to remove neural pressure without cervical fusion. In endoscopic cervical foraminotomy, which his used for the treatment of bone spurs, scar tissue or herniated disc, the surgeon inserts the endoscope into the cervical spine nerve canal. The surgeon then removes small pieces of enlarge bone/bone spurs, scar tissue and disc with micro instruments (such as burrs) to open the nerve canal. For treatment of degenerative disc disease, once in the target area, the surgeon uses a laser to vaporize targeted disc material, deaden pain nerves inside the disc and hardens the disc to prevent leakage of spinal fluid to the surrounding nerves.
"By entering the disc with a 4-6 millimeter cannula, we are able to perform discectomy and foraminotomy, for example, without the need for fusion because of the small nature of the instruments we use," he says. "We don't need to violate the disc such that would require surgical fusion. In the open procedures, you remove the annulus entirely and need to do the fusion. With the cannula, we can enter and leave the disc without destabilizing it."
2. Procedure is performed in an outpatient setting. The cervical endoscopic surgical procedures can be performed in an outpatient setting under general anesthesia, says Dr. Massoud. "Given the use of the endoscopic approach, patients are able to go home the same day," he says. "We minimize the stripping of tissues and exposure of adjacent levels, which reduces the risk of adjacent level disease and contributes to a more rapid recovery." Additionally, the endoscopic approach requires only a small incision to insert the endoscope and instrumentation, minimizing surgical scarring.
"It's very beneficial to go in and treat these disorders without having to perform a fusion," says Dr. Massoud. "With cervical endoscopy, you can target your working area very specifically and avoid any injury to the surrounding discs and tissues, thereby lowering the chance of adjacent segment degeneration."
3. Surgeons should gain experience first with lumbar and thoracic endoscopy. Since the cervical spine is one of the most sensitive areas of the spine, most spine surgeons don't begin learning cervical spine surgery until after they are familiar with the technique elsewhere on the spine.
"Before a surgeon starts tackling cervical endoscopy, they need to be very familiar with spine surgery and have gained experience in lumbar and thoracic endoscopy," says Dr. Massoud. "The cervical spine is much more sensitive to injury than any of the other structures, so before attempting a cervical endoscopy, the surgeon should be a board certified orthopedic or neurospine surgeon and needs to have significant experience in lumbar endoscopy and have mastery over the endoscope and associated instruments we use."
Significant experience with lumbar endoscopy means successfully performing more than 300 cases before beginning to learn the endoscopic cervical procedure. Using the endoscope presents challenges to even the most experienced spine surgeons because the surgeons must take a three-dimensional approach to performing the surgery. Instead of having the open anatomy in front of them, the surgeon inserts the endoscope over the surgery site and uses the scope's projection of the patient's spine for visual guidance during the procedure.
4. Navigation around the cervical spine is different from the lumbar spine. Performing surgery on the cervical spine has the potential for more severe injury than procedures on other areas of the spine because there is less space and more major structures to navigate through. The cervical spine is located near the trachea, esophagus and carotid artery, which are three major structures the surgeon must avoid when performing surgery on the cervical spine.
"These structures override the anterior portion of the disc where the surgical procedure needs to be done," says Dr. Massoud. "You must be able to successfully move them out of the way and follow the tissue plane to minimize the risk of injury. Once you actually begin the cervical endoscopy, you are dealing with the potential dangers of injury to the spine itself."
Unlike the lumbar spine, where the surgeon has the potential to damage neural structures such as nerve roots and nerve rootlets, surgeons working in the cervical spine are working closely around the nerve roots and spinal cord that is more sensitive to injury. Surgeons must be aware of these differences to successfully avoid damaging the patient.
5. Patients don't need the cervical immobilization collar. Endoscopic cervical spine surgery allows for a quicker recovery and return to normal activity, partially because the patient doesn't need a cervical immobilization collar. Patients who undergo a cervical fusion procedure often wear a cervical collar for 4-6 weeks after the procedure, which keeps them from performing some of their normal activities, such as driving. Most patients who undergo the cervical endoscopy are able to drive one week after surgery. The patients are often able to return to work sooner because the surgeon didn't need to mobilize the cervical spine to allow the fusion to take place. "Patients are very concerned with taking time off work, especially in this economy," says Dr. Massoud.
6. Future is promising for minimally invasive cervical spine surgery. Within 5-10 years, minimally invasive endoscopic approaches could replace open spinal procedures for the treatment of cervical disc herniations and feraminal stenosis, says Dr. Massoud. There are currently techniques under development for minimally invasive cervical fusion surgery, which can be performed with endoscopic assistance. Dr. Massoud is currently involved in advanced training for anterior cervical discectomy and posterior laminectomy procedures.
"It all goes back to really taking an interesting in the emerging field," he says. "It's important for surgeons that are interested in mastering techniques to make a commitment to the training process for these new procedures."
Learn more about Spine Centers of America.
15-01 BROADWAY, STE 20
Fair Lawn NJ 07410
877 722 6008
info@spinecentersofamerica.com