Intraoperative image guidance for endoscopic spine surgery

Abstract

Endoscopic spine surgery is a burgeoning component of the minimally invasive spine surgeon's armamentarium. The goals of minimally invasive, and likewise endoscopic, spine surgery include providing equivalent or better patient outcomes compared to conventional open surgery, while minimizing soft tissue disruption, blood loss, postoperative pain, recovery time, and time to return to normal activities. A multitude of indications for the utilization of endoscopy throughout the spinal axis now exist, with applications for both decompression as well as interbody fusion. That being said, spinal endoscopy requires many spine surgeons to learn a completely new skill set and the associated learning curve may be substantial. Fluoroscopy is most common imaging modality used in endoscopic spine surgery for the localization of spinal pathology and endoscopic access. Recently, the use of navigation has been reported to be effective, with preliminary data supporting decreased operative times and radiation exposure, as well as providing for improvements in the associated learning curve. A further development is the recent interest in combining robotic guidance with spinal endoscopy, particularly with respect to endoscopic-assisted lumbar fusion. While there is currently a paucity of literature evaluating these image modalities, they are gaining traction, and future research and innovation will likely focus on these new technologies.

Clinical efficacy of percutaneous endoscopic posterior lumbar interbody fusion and modified posterior lumbar interbody fusion in the treatment of lumbar degenerative disease

“…The development of endoscopic instruments and the accumulation of endoscopic decompression experience are conducive to the improvement of the learning curve of PE-PLIF technique. PE-PLIF, combined with navigation system and robot-assisted technology, can greatly eliminate the complexity and learning curve of endoscopic technology, improve the safety and accuracy of surgery, shorten the operation time, and reduce radiation exposure (27)(28)(29)(30)(31).…”

Robotic Spine Surgery: Past, Present and Future.

“…88 Robotics may facilitate ESS utilization by standardizing workflow, improving puncture accuracy, and limiting radiation exposure. 85 A match-paired study comparing robotic-assisted to fluoroscopy-assisted transforaminal endoscopic lumbar discectomy found that a single-shot puncture in the robotic group was significantly more precise compared with 4.12 ± 1.71 trials in the fluoroscopy group ( P < 0.001). 86 There was an overall reduction of fluoroscopy time (21.33 ± 3.89 times vs. 33.06 ± 2.92 times, P < 0.001), first puncture to final working channel placement (13.34 ± 3.03 min vs. 15.03 ± 4.5 mins, P = 0.038), and total operative time (57.46 ± 7.49 min vs. 69.40 ± 12.59 min, P < 0.001) using the robot compared with conventional fluoroscopy.…”

“…Robot-guided endoscopic spine surgery (ESS) is in its earliest infancy. 85 While ESS possesses the benefits of minimally invasive spine surgery including reduced perioperative pain, minimal paraspinal structural damage, and less iatrogenic segmental instability, 86 its widespread adoption has met resistance. Current ESS limitations include lack of a preexisting cavity in the spine, two-dimensional visualization impairing depth perception, and increased radiation exposure for creation of working channels.…”

Navigation, mixed reality, and robotics in endoscopic spine surgery

“…Full ESS therefore offers several advantages over other MISS techniques, including tubular approaches [1] . Despite the potential advantages of ESS, concerns exist regarding surgical team radiation exposure, adequacy of decompression, and the associated learning curve [2][3][4][5] .…”