Study Design: Review. Objectives: To review the current state of endoscopic spine surgery with regard to discectomy, interbody fusion, and combination with Enhanced Recovery After Surgery programs in order to evaluate its relevance to the future of spine care. Methods: A review of the literature and expert opinion is used to accomplish the objectives. Results: The greatest strength of endoscopic spine surgery lies in its adherence to the basic tenets of minimally invasive surgery and its innate compatibility with Enhanced Recovery After Surgery programs, which aim to improve outcomes and reduce health care costs. The greatest challenge faced is the unique surgical skill set and significant learning curve. Conclusions: Endoscopic spine surgery strives to achieve the core goals of minimally invasive surgery, while reducing cost and enhancing quality. In a healthcare market that is becoming increasingly burdened by cost and regulatory constraints, the utilization of endoscopy may become more widespread in the coming years.
Background: Minimally invasive surgery is heavily dependent on indirect visualization and image guidance, often resulting in non-ergonomic postures. Minimally invasive surgeons are more likely to experience neck pain, shoulder pain, and fatigue compared to open surgeons. Spinal endoscopy is rapidly increasing in popularity among minimally invasive spine surgeons. A primary ergonomic issue is the position of the endoscope display, which is often not in line with the operative field or the surgeon's natural line of sight. Methods: Smart glasses providing a head-up display are used in a case of percutaneous endoscopic lumbar discectomy to bring the surgeon's line of sight into parallel with the operative field. Results: Bringing the surgeon's visual and motor axes into parallel resulted in a more comfortable and ergonomic operating position. Conclusions: Head-up displays may provide an elegant and relatively simple solution to the issue of inadequate ergonomics in minimally invasive surgery.
Minimally invasive spine surgery has the potential to reduce soft tissue destruction, blood loss, postoperative pain, and overall perioperative morbidity while accelerating recovery. Robotic guidance systems are relatively new tools in the minimally invasive surgeon's armamentarium, striving to increase accuracy of instrumentation placement, decrease complications, reduce radiation burden, and enhance surgical ergonomics in order to improve efficiency and maximize patient outcomes. We present the case of a 78-yr-old male with intractable lower back and bilateral lower extremity pain with multilevel degenerative spondylosis. The procedure performed was a L3-5 robotic-assisted endoscopic transforaminal lumbar interbody fusion (TLIF) utilizing the Mazor X robotic guidance system (Medtronic) for both percutaneous pedicle screw placement, as well as trajectory localization for endoscopic discectomy and percutaneous interbody delivery. Previously, clinical and radiographic success has been published regarding the awake, endoscopic TLIF.1 We document the first use of robotic guidance for disc space localization and its combination with endoscopy to achieve interbody fusion, utilizing an expandable, allograft-filled mesh interbody device.2 This video demonstrates appropriate patient positioning, work flow for this unique technique, and the benefits of using robotic guidance to plan and execute percutaneous trajectories through Kambin's triangle. This procedure involves the off-label use of recombinant human bone morphogenetic protein-2 (Infuse™, Medtronic), OptiMesh® graft containment device (Spineology), and liposomal bupivacaine (Exparel®, Pacira).
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