REFERENCE DOCTOR Percutaneous Endoscopic Discectomy Transforaminal / Interlaminar. Hyeun Sung Kim, MD, PhD,

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1 Percutaneous Endoscopic Discectomy Transforaminal / Interlaminar 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 PAPERS: MORE THAN 40 PAPERS 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 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 LECTURE & PRESENTATION: MORE THAN 100 TIMES 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 AWARDS 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 PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY REFERENCE DOCTOR A. 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 Interlaminar Approach C. Interlaminar Approach 1

2 PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY PETLD PERCUTANEOUS ENDOSCOPIC TRANSFORAMINAL LUMBAR DISCECTOMY ANATOMICAL CONSIDERATION NEURAL ANATOMY ANATOMICAL CONSIDERATION VASCULAR ANATOMY Aorta Segmental Artery Radiculomedullary artery a. Exiting nerve and Ganglia b. Traversing nerve c. Sympathetic trunk and ganglia d. Sinuvertebral nerves 2

3 APPROACH ENTRY POINT APPROACH WORKING CHANNEL INSERTION MRI Length Measurement MRI Marker Physical Examination 4~6 Cm 6~8 Cm 8~10 Cm 10~12 Cm ANATOMICAL CONSIDERATION APPROACH ANATOMICAL CONSIDERATION APPROACH EPIDURAL APPROACH 3

4 ANATOMICAL CONSIDERATION APPROACH ANATOMICAL CONSIDERATION APPROACH EXITING ROOT APPROACH TRAVERSING ROOT APPROACH ANATOMICAL CONSIDERATION LIMITATIONS CURRENT DEBATE OF PETLD ANATOMICAL LIMITATIONS 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 4

5 ANATOMICAL CONSIDERATION HIGHTLY INFERIOR MIGRATED L4-5 ANATOMICAL CONSIDERATION HIGHTLY INFERIOR MIGRATED L4-5 Half-and-Half Technique & Epiduroscopic Approach Foraminoplastic Technique Suprapedicular L4-5 Lee SC, Kim SK, Lee SH, et al. Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches. Eur Spine J 2006 Choi G, Kim JS et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine Kim HS et al. Endoscopic Transforaminal Suprapedicular Approach n High Grade Inferior Migrated Lumbar Disc Herniation. J Korean Neurosurg Soc, 2009 SURGERY RELATED RELAPSE SURGERY RELATED RETROPERITONEAL HEMATOMA Segmental Loading Component Age Disc location Herniated disc level Disc height Healing Component Degeneration Scale Anti-adhesive agent Combined HNP 5

6 SURGERY RELATED PYOGENICSPONDYLODISCITIS EQUIPMENT HIGH CANAL COMPROMISED FORAMINAL TO SUPERIOR MIGRATION 6

7 FAR LATERAL RECURRED HNP AFTER OMD CALCIFIED HNP ADJACENT 2 LEVEL HNP 7

8 CURVED PROBE CURVED FORCES AND DRILL 51 yr / M Highly Inferior Migrated 74 yr / M Highly Inferior Migrated CURVED FORCES AND DRILL CURVED FORCES AND DRILL 74 yr / M Highly Inferior Migrated 8

9 FORAMINOPLASTY 67 yr / F Foraminal Stenosis PEILD PERCUTANEOUS ENDOSCOPIC INTERLAMINAR LUMBAR DISCECTOMY ANATOMICAL CONSIDERATION LIMITATION OF PETLD ANATOMICAL CONSIDERATION LIMITATION OF PETLD 9

10 CURRENT DEBATE L5-S1: PETLD VS PEILD CURRENT DEBATE L5-S1: PETLD VS PEILD L5-S1: Percutaneous Endoscopic Approach Approach Ligamentum Flavum Annulus Repair Indication Adhesion Posterolateral Transforaminal Trans-iliac Spare Impossible Limited Weak Interlaminar Trans-Shoulder Trans-Axial Resection Possible Wide ( + ) CURRENT DEBATE NEURAL APPROACH CURRENT DEBATE LIGAMENTUM FLAVUM SPLITTING Learning Curve Shoulder Short Axilla Moderate Classification Technique Inferior Migration Difficult Easy Superior Migration Nerve root retraction Easy Hard Difficult Weak Resection Annulus Sealing Difficult Easy Splitting Indirect Direct Choi G Kim CH 10

11 CURRENT DEBATE ANNULUS SEALING CURRENT DEBATE STRUCTURAL PRESERVATION L5-S1: Structural Preservation HIGH CANAL COMPROMISE HIGH CANAL COMPROMISE 11

12 HIGH CANAL COMPROMISE HIGHLY INFERIOR MIGRATED 38yr/Female HIGHLY SUPERIOR MIGRATED REVISION AFTER OMD 44yr/Male 53yr/Male 12

13 REVISION AFTER OMD REVISION AFTER OMD 53yr/Male CONTRALATERAL PEILD CONTRALATERAL PEILD 43yr/Male 13

14 CALCIFICATION FLOATING TECHNIQUE CONCLUSION Interlaminar: L5-S1: 59/M, Rt. 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 INDICATIONS Structural preservation technique of percutaneous endoscopic interlaminar lumbar discectomy Ligamentum flavum splitting technique Fissure fragmentectomy and sealing technique. Axilla route / Shoulder route Contralateral interlaminar approach Calcification floating technique Paramedian disc herniations with predominant leg pain Subligamentous ruptured or extruded disc migration less than height of disc space Central disc herniation with predominant back pain Annular tears that cause chemical sciatica Formainal disc herniations, synovial cysts of the facet joint Far lateral disc herniation, Superior migrated disc herniation Huge central protruded disc: High canal compromise Recurred Disc Sequestrated disc that had migrated Non-contained Inferior migrated disc Lateral recess stenosis, spinal stenosis Calcified Disc 14

15 INDICATIONS Thank you! 15