Kern Singh, MD, Professor of Orthopedic Surgery at Rush University Medical Center talks about a new technique for ultra minimally invasive spine surgery.
Could you explain what the endoscopic spine surgery procedure is?
SINGH: Endoscopic spine surgery is basically using a camera instead of opening and making an incision to put either a microscope or a tube or an open retractor, and we put a camera down. It’s basically the same camera, a little bit smaller than what you use inside your knee or inside your shoulder for an arthroscopy. So, I think people can relate to ACL repairs or shoulder repairs. And it’s the same kind of camera that we use for laparoscopic surgeries, gallbladder removals. So, it’s now making its way into spine surgery.
So, it’s a camera in addition to tiny tools. So tiny is the key, right?
SINGH: So, the camera itself is seven millimeters, which is basically one third the size of a penny. And the instruments kind of go through that camera – or through that camera, so you can imagine the instruments are even smaller. But essentially the whole total working portal is about half or three quarters the size of a penny.
And how is this different – and maybe do we want to use the spine model while we answer this question? How different is this from traditional spine surgeries?
SINGH: So, let’s go through the three spine surgeries, which are traditional or conventional, minimally invasive, and then endoscopic. So, the traditional spine surgery, for example, a laminectomy involves making an incision in the middle of your back. So, this is the middle of the back. Cutting through all the muscle, and this is the muscle that surrounds the bone. Cutting through that muscle down to bone and then putting retractors which open up, so separate the muscle. And then you actually cut out the bone and you literally throw it away. That’s a laminectomy. Minimally invasive surgery is making an incision the size of my fingertip, putting a tube, you can imagine kind of a paper towel holder or roll, I should say. And looking through that roll. It’s about 15 millimeters, so half the size of your fingertip. And you come in, take off a little bit of bone, you split the muscle so there’s no muscle cutting, and then you do a Roto-Rooter. You go inside and you clean out the bone. So, you don’t throw out the outside part, everything stays intact, and you pull it out. And then the least invasive is endoscopic, where you actually come in from an incision way off to the side. And you come in the way off the side because you put a camera literally the size of my pen tip, so the camera is this big. And we put a camera in while the patient is awake. And you come into the spinal canal from the side and you’re already inside the canal without cutting any muscle, any bone. And from inside you kind of Roto-Rooter out the bone spurs, the disc bulges, and that way you don’t disrupt any of the muscle, any of the bone, any of the ligaments.
So why is this next generation of spine surgery?
SINGH: Well, it’s the least destructive. So, I think that as we learn more and more, the natural anatomy is very important – that is, the muscle, the soft tissue, the ligaments are very important for people in their recovery. And I think that people are demanding a higher level of functioning following spine surgery, and endoscopic spine surgery in select patients delivers that.
And how did you start performing it? And are you unique in the fact that you do this?
SINGH: So I started doing endoscopic spine surgery as an avenue or a way of doing even less invasive surgery. So, I’ve been doing minimally invasive surgery now for about 13 years. I started dabbling in endoscopic spine surgery about seven or eight years ago, but the instrumentation and the camera wasn’t high definition enough at that point. And now have started incorporating it into my practice as the technology has improved. In a – I would say in 1,000 spine surgeons, 50 may do minimally invasive. And in that 50, maybe one does endoscopic spine surgery. So, it’s a small, select group of people who do it.
So what patients are candidates for this? Anybody?
SINGH: In general, the ideal patient is someone who has stenosis or narrowing, someone who has a lumbar disc herniation, someone who has foraminal stenosis, one or two levels, is highly functioning, wants to get back to whatever activities that they enjoy. In general, is very active. And we generally do these in a surgery center, so a healthier patient.
Are there any disadvantages or side effects?
SINGH: Well, the disadvantage, there’s no real disadvantage except for based upon the expertise of the surgeon, because it can be challenging to get that same disc herniation out, to address that stenosis. So, one of the biggest failures of endoscopic spine surgery is inadequate decompression or inadequate discectomy, so not enough is taken. But if you have someone who does a high volume or skillful, then the downside is very little.
And what’s recovery like? I think that’s one of the advantages of this.
SINGH: So when we do the surgery, the patient is awake. After surgery, a small little Band-Aid’s applied, and the patient leaves the surgical center around 30 minutes to an hour afterwards, up and walking, talking. I tell my patients they can go to work the next morning. Most work from home the same day but return to work the next morning. They literally take off the Band-Aid in a day. There’s absorbable suture. We tell them not to engage in any strenuous exercises for about two weeks. And then, after that, it’s physical therapy and they can go back to full activity.
How long does it take?
SINGH: So the procedure itself depends upon what’s being treated but, in general, it’s about 30 minutes. It’s basically like an injection. You literally put an injection down to numb up the area, then the camera goes in, clean out the bone spur or the disc herniation, and we take some cool video, we give it to the patients. We take some pictures of the disc herniation. They get to see it. I think everyone wants to see what’s going on. And in fact, they’re awake, so I’m talking to them while they’re having surgery.
How long does this procedure take maybe compared to doing a laminectomy the traditional method?
SINGH: Well, those in general took about an hour. But the more challenging part of that is that maybe the procedural time, but you still have to do all the wound closure, the skin closure, the dressings, all that stuff. The patient is intubated, has to be extubated. So, it can be two to three times longer in a conventional, traditional manner.
I don’t think Joe Deacon was – I think – can you tell us if he was asleep?
SINGH: No, he was awake. He fell asleep, but he was awake.
Oh! funny.
SINGH: Because the reason we ask – we have them be awake is because, when we put the camera in, we ask them if their leg hurts because we go right by the nerve. And then when I’m doing the discectomy, I’m opening up the spinal canal. We ask them, is your leg pain better or gone? And when they tell us, then we know we’ve opened it up. So he was awake, he just doesn’t recall it.
That is so funny.
SINGH: The cocktail was good.
Yeah. So the last question, what does this surgery do for somebody’s quality of life, like Joe?
SINGH: Well, it’s a significant improvement. And you don’t leave the operating room until the pain is gone because the patient verbalizes it. So, it’s an immediate improvement in their pain and it’s an immediate return to function as they walk out the door about an hour afterwards.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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