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IntroductionENDOSPINE® System FeaturesIndications for the use of the Endospine® systemUse of d’Endospine®Post-operative careComplicationsAdvantages of endoscopyConclusion

1 – Introduction› Top of page

The ENDOSPINE® system consists of an operating tube which is positioned on the laminae after incising the skin and the aponeurosis and detaching the muscles from the spinous process. The ENDOSPINE® working insert has an integrated channel for the telescope. There are two additional channels, one for the suction tube and the other one for the operating instruments.

technique_01-150x150There is an angle of 12° between the working channel ans the channel used by the telescope. This angle always enables the surgeon to see the tips of the instruments and to use a suction tube as second instrument.

technique_01-150x150The ENDOSPINE® system includes a nerve root retractor. This allows the nerve to be medialized thus removing any fragile structure from the operating area.

technique_01-150x150The HOPKINS® 0° telescope offers a wide field of vision of the operating area without distortion and emits the light generated by a cold light source and transmitted to the endoscope via a fiber optic light cable.

The entire procedure is performed under constant video-endoscopic control via the monitor screen. By resecting part of the superior lamina, the articular processes and the yellow ligament, the nerve root, and then the hernia are exposed. The latter is removed and a microdiscectomy can be performed. Once full decompression of the nerve has been confirmed, perfect hemostasis of the muscles can be achieved on withdrawing the ENDOSPINE® operating tube. A special dressing enables the patient to shower or bath on the same day.

2 – ENDOSPINE® System Features› Top of page

  • The ENDOSPINE® system offers four essential advantages during surgery :
    • The ENDOSPINE® operating tube is mobile. This enables the surgeon to illuminate and explore even hidden recesses, and to produce images of them.
    • Perfect quality of vision Provided by a 4 mm HOPKINS® telescope with no shadow or eclipse.
    • Magnification of anatomical structures and a wide field of vision : the eye is practically « inside the spine ».
    • Because of its special design, the surgeon can permanently see the ends of the surgical instruments and the different anatomical structures. This provides better control, increased comfort and, above all, increased safety for the patient.

3 – Indications for the use of the Endospine® system› Top of page

Surgery is necessary in case of a radiculitis well explained by the disc herniation, which resists despite medical treatment or goes along with neurological deficiency signs.

The Endoscopic technique is suitable in all types of disc herniations including recurrences. When its advantages can be discussed for a simple herniated disc in a thin patient, they become obvious in all deep situations like foraminal or extra foraminal disc herniations or for obese patients, situations in which the skin incision keeps the same size.

This technique can also be used in spinal stenosis.

The ENDOSPINE® operating tube is a multiple indication surgical device ; it is designed for all types of disc herniation and particularly for foraminal hernias. For bilateral decompression of lumbar canals stenosis a simple unilateral posterior approach can be used.

4 – Use of d’Endospine®› Top of page

technique_01-150x150The ENDOSPINE® operating tube is inserted and the obturator removed. The working insert and the HOPKINS® telescope are placed in position. The system remains in place without further support. The fiber optic light cable must rest on a table to avoid its slipping along the patient and pulling on the ENDOSPINE®.

technique_01-150x150The position of the ENDOSPINE® operating tube may be readjusted:

  • Using the left hand and the suction tube through its appropriate channel,
  • With the right hand and an operating instrument (here a Kerrison bone punch) through its appropriate channel.
  • It may easily be readjusted using both hands alternately.

When the device is tilted or displaced, the ENDOSPINE® operating tube follows, and the tip of the instrument is permanently in the field of the endoscope.

The working insert may be fixed to the operating tube in different positions:

  • in the superior position, resection of the bone and yellow ligament is facilitated;
  • in the inferior position, the zoom effect facilitates dissection of the nerve root.

technique_10 technique_11

The ENDOSPINE® operating tube is thus in a stable position and does not need to be held or fixed.

5 – Post-operative care› Top of page

The patient is mobilized immediately after recovering from anaesthesia. Physiotherapy is given immediately to mobilize the spine and loosen the muscles. With an impermeable dressing the patient may take a bath or shower straight away. The resumption of former physical activities is encouraged as soon as possible, particularly sports. There is no restriction on the patient after this operation.

6 – Complications› Top of page

Complications are the same as for conventional surgery of herniated discs. The dural tear is normally small and may be treated by Surgicel® packing or by a muscle patch, possibly glued in place, and by close suturing of the fascia. Post-operative care is the same.

Postoperative spondylodiscitis is less frequent with endoscopy than with classic techniques, probably because the instruments which enter the herniated disc never touch the skin.

7 – Advantages of endoscopy› Top of page

The reduced dimension of the access route minimizes muscular trauma and post-operative pain; this considerably facilitates the rapid resumption of physical activities. Patients appreciate the aesthetic outcome of endoscopic-guided operations.

The surgeon’s eye being practically enabled to control the complete operating field means, above all, that anatomical structures can be better identified which largely compensates for the absence of three-dimensional vision. The endoscopic view facilitates haemostasis not only of deeply located structures but also of muscles, thus contributing to improve post-operative comfort.

In addition, the large field of vision and the good depth of focus provided by the HOPKINS® endoscope are the outstanding difference between this technique and other minimally invasive techniques, all the better because the operating field is deep. This is particularly true for foraminal and extraforaminal disc herniations, spinal canal stenosis and when treating obese patients. Finally the reduced rate of infectious complications is a crucial advantage of this technique.

8 – Conclusion› Top of page

Dr. Destandau has been using the Endospine® for over 20 years and it has allowed him to operate on over 7,000 patients, essentially with disc herniations. Even though the contribution of endoscopy may seem to be minimal in common situations, with experience it appears that its use has transformed the problem of foraminal disc herniations and narrow lumbar canals. In fact, the surgical technique is becoming easier, well regulated and the post-operational follow-up is infinitely simpler.

One can imagine that in the future these endoscopic techniques will be developed and will be more and more demanded by patients.