Ask Dr. Zabaleta: In which cases is endoscopic spine surgery recommended?

Endoscopic surgery is the new revolution in minimally invasive procedures for spine surgery. It is especially useful for treatment of herniated discs and lumbar canal stenosis to relieve back pain or symptoms caused by nerve compression. Dr. Zabaleta explains the types of cases in which this type of surgery is recommended. 

This minimally invasive surgery is the surgical technique that causes the least damage to tissues, while allowing effective treatment of herniated discs, lumbar canal stenosis (both canal, recess, and/or foramina) and nerve compressions that cause sciatica, and it offers the patient a quicker recovery. During the endoscopic procedure, the surgeon inserts a very small cannula containing a tiny optical device (scope) which gives the surgeon a larger view of the surgical field on a screen.

This type of surgery is beneficial because it requires only a small incision (approximately 1 cm), causing less damage to the surrounding muscles and soft tissue, thus reducing the risk of bleeding that could occur during the procedure, and the risk of postoperative infection and fibrosis (scarring), in addition to other proven benefits over more traditional microsurgical techniques.

Patients who have endoscopic spine surgery recover very quickly, with little or no postoperative pain (and it usually resolves with simple medications), which allows them to get back to physical activity or work sooner. They usually experience less post-surgical pain and the incision scar will be less noticeable. But endoscopic spine surgery cannot be used for all cases of lumbar pathology.

In this article, Dr. Zabaleta a neurosurgeon who specializes in minimally invasive approaches to the spine and vertebral endoscopy, describes the cases in which endoscopic spine surgery may be the best treatment.


Main Advantages of Endoscopic Spine Surgery

As mentioned above, endoscopic spine surgery is the most minimally invasive technique today. It is an alternative to conventional surgery for both herniated discs and lumbar canal stenosis, which are currently treated by open or tubular microsurgery.

The fact that there is less manipulation and damage to tissues helps reduce post-operative pain, and the patient makes a faster recovery. It doesn’t take very long for the patient to be able to go back to work and go about their normal life. Most patients who undergo this procedure may do not need to stay in the hospital, and can return home the same day as surgery.

The small size of the incision in the skin, less than 1cm, means there is less blood loss and less risk of infection. Tissues will also heal much faster, with less build-up of scar tissue, both in the skin and in the deep tissues (lowering the risk of suffering problems derived from the normal healing process), and the patient will not need as many anti-inflammatory medications and will rarely require narcotics.

There is clear and conclusive scientific evidence that, compared to traditional surgical techniques, this technique results in a lower number of postoperative infections, less bleeding during surgery, fewer chances of cerebrospinal fluid fistula (loss of fluid through wounds), and achieves greater patient satisfaction over time. The scientific evidence published in recent years has been so consistent on these points that many spine specialists think that endoscopic spine surgery is the new "gold-standard" for the treatment of disc pathology and canal stenosis at the lumbar level of the spine.

You can read more about the benefits of endoscopic spine surgery compared to conventional surgical techniques in the following article: 

Advantages of endoscopic spine surgery

In which cases is endoscopic spine performed?

Endoscopic spine surgery can be used to treat a variety of conditions, two of the most common being disc herniation and canal stenosis. The goal of endoscopic spine surgery is to decompress the spinal cord, dural sac, or nerve root that may be compressed, either by creating space within the spine or by removing the material (a bulky hernia or a very thickened ligament, etc.) that compresses and causes the symptoms.

Dr. Zabaleta explains below the cases in which endoscopic spine surgery may be performed:

  • Foraminal lumbar disc herniation. A type of hernia that is inside the hole through which the nerve roots exit. This type of hernia is especially painful, and difficult to treat by traditional surgical methods in which the action of the surgery itself can damage joints of the spine and lead to instability in the operated segment. Unfortunately, when that happens, it can mean that spinal fusion surgery will be needed in the future. Like any other disc herniation, this type is usually caused by the natural degeneration of the intervertebral discs. The most common symptoms are: pain in the lower back, pain radiating to the buttock or leg, muscle weakness, or feeling of tingling or numbness in the area. 
  • Extraforaminal lumbar disc herniation. This is the least common hernia, so uncommon that they sometimes go unnoticed in MRI reports. These hernias occur outside the foramen, and do not cause symptoms unless they are large enough or compress a nerve structure that runs through the area (dorsal root ganglion), which can be particularly painful. The traditional approach to this surgery is very technically demanding, and the surgery itself can cause damage at the muscular level and direct damage to the affected nerve leading to neuropathic pain.  
  • Posterolateral lumbar disc herniation. Posterolateral disc herniation is the most common of all, and usually compresses the lateral area where the nerve roots exit.  This type of hernia is most commonly found in the lower levels of the lumbar spine (L4-L5 or L5-S1), an area of the spine where the anatomical spaces between the vertebrae are sufficient to allow passage of an endoscope, so the surgery can be performed endoscopically rather than by traditional spine surgery.  
  • Foraminal stenosis. This occurs when the hole where the nerves exit becomes too narrow, pressing on the nerve roots and causing pain, which can be exacerbated by standing or hyperextending the spine. The most common symptoms are pain radiating to the buttocks or legs, tingling or numbness, cramping, or muscle weakness in the legs. The main cause is aging and degeneration of the vertebral disc or joints. In this case, the benefit of the endoscopic technique is being able to enlarge this hole without damaging the joints that support the vertebrae, thus avoiding the need to instrument the spine with screws and rods, which would lead to a fusion of the vertebral segment and a change in the dynamics of the movement of the spine.  
  • Central canal stenosis. This condition manifests as difficulty walking (gait claudication) due to progressive pain, weakness, and a feeling of cramping in both legs. It usually occurs in older patients, around 70 years of age. Pain appears mostly when the spine undergoes hyperextension, although there may also be loss of sensation or loss of strength in the legs along with a tendency to walk hunched over. The goal of the surgery is to decompress the dural sac containing the compressed nerves, without damaging the supporting muscle tissue. This type of pathology is where the greatest comparative benefit has been obtained in terms of recovery and relief of symptoms.

This technique is particularly beneficial in patients with obesity, advanced age, or who have other medical conditions that could contraindicate general anesthesia (where the option of surgery with sedation and local anesthesia is considered).

The preoperative studies usually include a lumbar MRI, a lumbosacral CT scan and x-rays (static or moving), in order to determine the best treatment approach for each case.

When a patient’s disc herniation is calcified, or very bulky or migrated (displaced), or when they suffer low back pain as the main symptom, or show signs of spinal instability or spondylolisthesis, endoscopic spine surgery is not advisable.

There are two modes of endoscopic surgery: MONOPORTAL (1 incision), and BIPORTAL (2 incisions). Both techniques offer the comparative benefits that have been described in this article, and which one is used will depend on the specialist's assessment of the particular case. The specialists in endoscopic surgery at Instituto Clavel perform both.

Recovery after endoscopic spine surgery

Recovery following endoscopic spine surgery is different for each patient and depends, in large part, on their habits and daily routine. Because it is a minimally invasive procedure, the recovery time tends to be faster and some patients can walk on the same day after the operation. At Instituto Clavel, patients generally are discharged within 24 hours after the surgery, and can expect a recovery time of between 3 to 6 weeks.

After any spine surgery, it is important to take certain precautions regarding the return to physical activity. Dr. Clavel gives a series of recommendations on recovery time and how you can get back to exercise and sports after the procedure.

Returning to sports after spine surgery

One of the potential benefits of this type of surgery is that it doesn’t require as long a rehabilitation period as other surgeries, because it is minimally invasive and involves minimal manipulation of tissues and bone structures. However, at Instituto Clavel we always recommend following a personalized rehabilitation plan designed specifically for your needs by a team of specialists in the spine.

We have specialists in rehabilitation and physical therapy at IC Rehabilitation, who work hand-in-hand with the team of neurosurgeons at Instituto Clavel to ensure that our patients get the best care. If you have any questions about endoscopic spine surgery or would like to make an appointment, please don’t hesitate to contact us.


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