1	Redefining Algorithm in Treatment of Degenerative Spine Disease with Minimally Invasive Spine Surgery in a Digital World John C. Chiu, M.D. Director, Neurospine Surgery California Center for Minimally Invasive Spine Surgery California Spine Institute Thousand Oaks, California
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3	Introduction: Open spinal surgery is associated with significant local morbidity and long-term convalescence, with greater expense Therefore, the search for minimal invasive spine surgery (MISS) began The explosive advances in bio-digital technology and innovative surgical advances have propelled the rapid development of modern minimally invasive surgery in all areas including endoscopic spinal surgery It aims at reducing tissue trauma and preventing iatrogenic problems
4	Introduction: Thorough knowledge of the surgical procedure and the surgical anatomy Specific endoscopic MISS training Hands-on experience in a laboratory Meticulous pre-operative surgical planning Working closely with an experienced endoscopic spine surgeon through its steep surgical learning curve Use of c-arm fluoroscopy
5	Introduction: Traditional spine care leads us to standard open spinal surgery/ fusion with higher complication and morbidity besides longer convalescence with philosophy of “fuse and refuse” Is open surgery/fusion today's gold standard for treatment of degenerative spinal disease? Or is “Less is better – less is more?” We believe in “refuse to fuse” Creative “lateral thinking” (per Dr. Edward deBono) is needed for furthering of spine care
6	Introduction: 41 spine surgeons of MISS from 20 centers around the world with 32,100 operations were gathered and analyzed This multicenter study demonstrates endoscopic spine surgery with 0 mortality and less that 1% morbidity It is an effective, safe, less traumatic procedure, and can be an effective replacement for conventional open spine surgery
7	"Four Generations of MISS:" Four Generations of MISS: 1^st generation: Intradiscal procedure (downstairs technique) I.e. nucleoplasty, disc decompressor, chymopapain injection, laser spinal discectomy, APLD, IDET 2nd generation: in addition to above method, it moves upstairs, with extra discal, transforaminal and epidural technique for discectomy (upstairs technique) with micro instrument, laser, radiofrequency and bipolar probe application 3^rd generation: in addition to above methods, it involves bone work for decompression of spinal stenosis with rongeur, burr, rasp, curette and laser 4^th generation: in addition above methods, it utilizes contemporary biotechnology, biocomputer, image guided surgery, robotic aided instruments, virtual spinal endoscopy, spinal fusion, artificial disc, to further MISS with better precision and accuracy “Less is better, less is more”
8	Material and Methods:
9	Material and Methods: CSI provides one of the most advanced digital endosuite OR Ultramodern high tech surgical environment Ceiling/sky boom system to get rid of clutter Specialized in out patient minimally invasive spinal surgery, pain management and neuro-orthopaedic surgeries
10	Material and Methods: Provides precise diagnosis and treatment with Digital X-ray department Faster, clearer Better quality images Lower x-ray exposure Display on PACS monitor
11	Material and Methods: 3D Medical Planning Laboratory Non invasive total body scan, spine scan, lung scan Virtual colonoscopy, wellness scan and cardiac calcium score scan Early detection of tumors, polyps, etc For disease prevention Osteoporosis bone density scan
12	Material and Methods: 3D Medical Planning Laboratory New state of the art open supercon MRI Open on 4 sides avoiding claustrophobia MRA angiograms 3D Images – virtual patient
13	Material and Methods: Provides unmatched 3D surgical anatomy for surgical planning and approaches Advanced PACS system provides instant storage and connectivity for web based technology, teleradiology and internet conferencing It links with “vital image” (Vitrea) to create 3D “virtual transparent patient”
14	Material and Methods: Surgeons now have x-ray vision through a completely transparent patient
15	Material and Methods: A medical surgical planning laboratory with digital and 3D imaging through PACS, and the virtual imaging system including virtual spinal endoscopy, virtual colonoscopy, virtual coronary arteries etc. Total body scan promotes disease prevention and wellness
16	Material and Methods: Advanced digital electronic system/PACS provides numerous view stations and seamless operation Images can be transmitted instantly to consultation room and operating room for analysis (the future is here)
17	Material and Methods: Continuous intra-operative EMG monitoring prevents undue trauma to the spinal nerve to be decompressed Continuous conscious EEG monitoring with the newest computerized SNAP device (SNAP index) improves anesthesia and reduces drug requirement
18	Material and Methods: Video digital endoscopy tower and anterior cervical endoscopic instruments
19	Material and Methods: Holmium YAG laser equipment for Laser Thermodiskoplasty (LTD)
20	Procedure/Surgical Technique: To facilitate endoscopic spine surgery and avoid potential complications
21	Procedure/Surgical Technique: Patient Positioning and localization Patients are treated in an operating room under local anesthesia and conscious sedation
22	Procedure/Surgical Technique: Surgical technique for anterior medial approach for needle and stylette placement into the disc
23	Procedure/Surgical Technique:
24	AESOP 3000 with Hermes Voice Control
25	Procedure/Surgical Technique:
26	Procedure/Surgical Technique:
27	Procedure/Surgical Technique: With robotic arm
28	New Image Guided MISS: 3D Visualization Endoscopy Advanced image guided endoscopic MISS On April 16, 2002 first case of Image guided lumbar endoscopic MISS was performed at CSI
29	New Image Guided MISS: 3D Visualization Endoscopy With virtual endoscopy and anatomical localization It paves the path for image enhancement and virtual MISS
30	New Image Guided MISS: 3D Visualization Endoscopy It guides MISS with virtual 3D surgical approach With precise localization of the instruments in real time To prevent undue neuro and tissue injury
31	Institutional Information System (IIS) Created for CSI In order to facilitate the MISS process IIS was created at CSI with Complete digital system integration for the ultra advanced MIT medical facility Based on paperless/film less system and digital medical informatics
32	Institutional Information System (IIS) Created for CSI High tech seamless networking in and out of CSI to facilitate the practice and education of MISS
33	Global Multicenter Interactive Web Conference
34	Procedure/Surgical Technique: Endoscopic microdiscectomy – intraoperative video recording
35	Procedure/Surgical Technique: Endoscopic view of laser discectomy for decompression and laser thermodiskoplasty
36	Procedure/Surgical Technique: MISS Approaches for decompressive foraminoplasty MISS decompression of spinal stenosis with various approaches With posterolateral (transforaminal) approach for lateral stenosis - PLLD With paramedium approach for lateral and central stenosis – TSLD With paraspinal approach - PSpLD With cross canal decompression - CCDF
37	Laser Thermodiskoplasty Side firing holmium laser probe (Trimedyne) for disc tissue shrinkage and tightening effect
38	Procedure/Surgical Technique:
39	Procedure/Surgical Technique: Mechanical discectomy decompression Forceps, discectome, trephine under fluoroscopy
40	Procedure/Surgical Technique: Rasp and burr used to remove osteophyte
41	Procedure/Surgical Technique: Posterior lateral approach
42	Procedure/Surgical Technique:
43	Procedure/Surgical Technique: Paramedium approach
44	Procedure/Surgical Technique: L3 stenosis with a large intra spinal synovial cyst Decompression and cystectomy successfully with MEAD (Storz)
45	Procedure/Surgical Technique: Bi-portal MISS spinal decompression
46	Procedure/Surgical Technique:
47	Thousand Oaks Spine & Sports Center Before and after MISS A physical medicine and rehabilitation unit with computerized assistance Motorized pool and hydro therapy equipped with video camera for monitoring and assessment
48	Onto MISS: These new innovations rapidly propel us into this exciting decade of Minimal Invasive Spinal care, and at the start of the a Bio-intelligent age These new technological advances usher us into a newer and higher standard of spinal surgery: “Less is better but less is more”
49	Results: What are the results Overall success rate with our advanced MISS technique: produces good-to-excellent symptomatic relief approximately 94 percent or better for a single disc Significant spinal stenosis is decompressed with digital endoscopic system
50	MISS for Young and Active One month post endoscopic lumbar discectomy Japanese motocross professional
51	MISS for Octogenarian and Beyond 92 year old lady with progressive herniated lumbar discs and spinal stenosis after successful Microdecompressive endoscopic assisted spinal surgery Patient was turned down for conventional spinal surgery/decompression for spinal stenosis and herniated discs
52	MISS for Medically Difficult Patients Morbid Obesity Santa Clause from the North Pole 51 year old male, 425lbs patient one hour after his L2, L3, L4 discectomy Patient was turned down for herniated lumbar disc surgery by a spine surgeon due to his morbid obesity
53	MISS for Naturalist
54	Conclusion I: The evolving endoscopic laser spinal surgery in multicenter studies has proven to be safe, less traumatic, easier, and efficacious with significant economic savings Sufferers with chronic, severe, intractable spinal pain from herniated discs and degenerative spinal disease are treated successfully, with endoscopic laser spinal surgery
55	Conclusion II:
56	Conclusion III: Endoscopic laser spinal surgery is an effective alternative or replacement for conventional open spine surgery in degenerative spine disease Therefore the redefined algorithm for treatment of degenerative spinal disease with endoscopic laser spinal surgery is validated and confirmed
57	Hope you enjoyed this presentation!
58	4th GLOBAL CONGRESS on Minimally Invasive Spinal Surgery & Medicine—2003 November 20-22, 2003 California Spine Institute - Hyatt Westlake Plaza Thousand Oaks, California, USA AAMISMS aamisms.com info@aamisms.com
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