12 Transforaminal Epiduroscopic Laser Annuloplasty for Diskogenic Pain Low back pain can affect up to 85% of the population at some point in life.1 In most cases, low back pain is self-limiting; however, it can become chronic and disabling in 5% of patients.2 The precise anatomical cause can often be difficult to identify. It has been estimated that ~ 40% of chronic low back pain originates from the intervertebral disk.3 Histologic analysis of intervertebral disk revealed significant sensory innervation in the posterolateral aspect of the annulus fibrosus.4 Direct stimulation of the outer annulus fibrosus in vivo demonstrated concordant pain.5 Treatment of chronic diskogenic low back pain has been challenging. Conservative measures often fail to reduce the pain or to improve function. Lumbar arthrodesis for diskogenic pain reported only a 46% satisfactory clinical outcome rate.6 Successful fusion by elimination of a painful motion segment has not demonstrated a significant improvement in pain and functional status.7 In addition, the surgery is associated with its complication risks, morbidity, and prolonged recovery. This has led to the development of minimally invasive intradiskal therapeutic approaches to open surgical procedures, including intradiskal electrothermal therapy (IDET), radiofrequency ablation (RFA), cryotherapy, percutaneous endoscopic laser diskectomy (PELD), and percutaneous endoscopic laser annuloplasty (PELA).8,9 The proposed mechanism of action of intradiskal therapy is a combination of destruction of the annular nociceptors and shrinkage of the intervertebral disk.10,11,12 Given that the pain-generating regions of diskogenic pain are located in the posterolateral aspect of the annulus, an extradiskal epidural approach can also be utilized for assessment and treatment. An extradiskal epidural approach has the added benefit of direct visualization with a flexible endoscope (epiduroscopy) of the epidural space and its structures. In addition, the epidural structure can be assessed to determine whether it is concordant with the patient’s clinical symptoms. Lumbosacral epiduroscopy has been demonstrated to be more accurate in identifying vertebral level pathology than clinical assessment or MRI.13 In addition, epiduroscopic findings were noted to be predictive of treatment outcomes.14 The epiduroscopic approach has been previously reported to treat lumbar stenosis and back-leg pain syndrome.15,16,17,18,19,20,21 However, the traditional approach for epiduroscopy, with its entry site through the sacral hiatus, may be limited by bony stenosis of the hiatus, lumbar stenosis, or epidural scarring from previous surgery.22 In combination with epiduroscopy, the use of a laser can enhance the treatment efficacy for diskogenic pain. Systematic review of the literature for use of laser in lumbar disk decompression demonstrated positive results, with 75% of patients reporting significant pain relief for 12 or more months.23 Laser disk decompression has also been demonstrated to be comparable to diskectomy.24 Various types of lasers have been used in managing spinal disorders.25,26,27 One, the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, has been demonstrated to be effective in managing spine disorders in several clinical studies.28,29,30,31 Fig. 12.1 The standard endoscope (left) has a fixed trajectory to the neural foramen from the skin entry site. A curved endoscope (right) has a similar skin entry site and can navigate into the neural foramen with a less steep trajectory, thus bypassing potential anatomical barriers. This chapter describes an approach for the management of diskogenic pain utilizing a novel curved spinal endoscope and introduction technique in combination with a Nd:YAG laser. The curved endoscope provides transforaminal access where rigid spinal endoscopes or anatomical barriers may limit passage (Fig. 12.1). Transforaminal epiduroscopic laser annuloplasty (TELA) provides a minimally invasive and direct approach to the evaluation and treatment of diskogenic pain. • Internal disk disruption (IDD) • Herniated nucleus pulposus (HNP) with predominately axial back pain • Annular tear • Adhesions secondary to failed back surgery syndrome • Diskal cyst • Mild to moderate neuroforaminal stenosis • Large HNP with radiculopathy • Severe neuroforaminal stenosis • Spinal instability • Modic changes • Patients with high iliac crest and L5–S1 level pathology • The endoscopic system is a disposable semirigid fiberoptic-based micro-endoscope with a single working channel (NeedleView CH; BioVision Technologies, Golden, CO). The endoscope has a 160-mm working length with a 3.4-mm outer diameter. There is a 1.85-mm diameter working channel and a built-in 0.7-mm fiberoptic channel with 17,000-pixel resolution (Fig. 12.2). • The distal third of the endoscope can be bent to a desired angle to facilitate entry into the ventral epidural space from a transforaminal approach (Fig. 12.3). • The NeedleCam HD system (NeedleCam HD; BioVision Technologies) incorporates a light-emitting diode (LED) light source and a high-resolution camera in a single compact unit. • The light source and video images are transmitted through a single cable. The video output is connected to a high- definition display with 1920 × 1080 resolution. Fig. 12.3 The endoscope is bent to the desired entry angle. (a) The endoscope is placed on the molding frame. (b) A curve in the distal end is made to the desired angle. (c) The final configuration of the bent endoscope. Fig. 12.4 (a) Side-firing Nd:YAG laser tip. (b) Insertion of laser fiber through the endoscope. • A pulsed Nd:YAG laser with a wavelength of 1,414 nm is transmitted through 3 m fiber (Accuplasti; Lutronic, Goyang, South Korea). • The laser is delivered through a 550 µm side-firing opening (Fig. 12.4). Fig. 12.5 Instruments required for introduction of the curved endoscope. a, Endoscope bender; b, No. 15 blade for skin incision; c, 18 G spinal needle; d, 18 G Tuohy needle; e, 14 G Tuohy needle; f, 21 G spinal needle; g, guidewire; and h, flexible dilator and sheath. See Fig. 12.5. • 18 G spinal needle • 21 G spinal needle • 14 G × 127-mm Tuohy needle • 18 G × 152-mm Tuohy needle • 12 F cannula and 12 F dilator • 70-cm guidewire • Endoscope bender • No. 15 blade Fig. 12.6 (a) Insertion of spinal needle. (b) Oblique fluoroscopic projection to confirm trajectory to disk space. (c) AP fluoroscopic image to confirm needle position at neural foramen. (d) Lateral image to confirm needle position at the neural foramen.
12.1 Introduction
12.2 Indications for TELA
12.3 Contraindications to TELA
12.4 NeedleView HD Endoscope System
12.5 NeedleCam HD Visualization System
12.6 Laser Device
12.7 Equipment Required for Endoscope Introduction
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Percutaneous Endoscopic Lumbar Diskectomy: Transforaminal Approach
Foramen Magnum Decompression of Chiari Malformation Using Minimally Invasive Tubular Retractors
Percutaneous Endoscopic Interlaminar Lumbar Diskectomy: Structural Preservation Technique for L5-S1 Herniated Nucleus Pulposus
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