- Recurrent stenosis from new bone formation or disc collapse - Adjacent level failure. - Instability from disc excision or lumbar decompression.[r]
(1)Pornpavit Sriphirom MD
(2)(3)(4) Percutaneous full-endoscopic lumbar discectomy Interlaminar technique
Transforaminal technique Posterolateral technique
Percutaneous full-endoscopic thoraco discectomy Posterolateral technique
Transthoracoscopic technique
Percutaneous full-endoscopic cervical
discectomy
Anterior technique Posterior technique
Thoraco-endoscopic spinal surgery
(5)(6)(7)(8)Degeneration occur in the spinal motion segment Spinal stenosis
Reduced disc hieght
disc tend to bulge into canal
Ligamentum flavum thicken and buckle Appophyseal joints degenerate and
hypertrophy
(9)Advanced degenerative
lumbar spinal stenosis
Ballooning of the disc
Marked thickening of the
ligamentum flavum
Hypertrophy of the superior
articular processes
(10)(11)(12)(13)HNP
(herniated disc) Spinal Stenosis
Young age
Low back pain Sciatica
Straight leg raising
test positive
Old age
Caudication Low back pain
Straight leg raising
(14)(15)(16) P Timing
Acute : less than 3-6
month
(17) Conservative Intervention Nucleoplasty
Classical discectomy
(18)Randomized to groups
Group micro-endoscopic discectomy Group microscopic discectomy
(19)Micro-Endo
(20)Classic Discectomy (CD) versus Microdiscectomy
(21)Classical Discectomy (CD) versus Endoscopic Discectomy
(22)Return to work one year postoperative
(23)(24)(25)(26)(27)(28)Instruments
Operative table
(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)Far-lateral Herniation
(43)(44)(45)AP view
(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59)Total case 65 case
Retrospective review 53 case
Exclude from review case (Intra –op nerve root injury
(60)8 41 7 0 5 10 15 20 25 30 35 40 45
L 3-4 L4-5 L5-S1
level
(61)(62)From June 2009-April 2010
General anesthesia
From June 2010
Tranforaminal technique Local anesthesia
(63)<40 yr 40-60 yr >60 yr
HNP 10 12 0
Stenosis 0 15 15
(64)8 31 8 2 0 5 10 15 20 25 30 35
(65)(66)Meralgia Paresthica case resolve
Discitis 1case ;IV antibiotic resolve
Root injury cases Recovery case
(67)(68)CC : ปวดน่องขวา และ กระดกข้อเท้าขวาไม่ขึ้น 2 สัปดาห์ PTA PI : 6 yr PTA ปวดหลังร้าวลงขาขวา ชาขาขวา มีอ่อนแรงขา
ขวา กระดกข้อเท้าขวาและหัวแม่เท้าขวาไม่ขึ้น มารพ SLRT +ve
Rt (70 ⁰) Motor Rt Ankle DF gr , Rt EHL gr.0 ,other gr.5 ท า MRI LS spine DX
: HNP L4-5 Rx : Try conservative treatment * 3เดือน อาการไม่ทุเลา จึงท า OR
:Discectomy L4-5 post.op อาการปวดและชา
(69)(70)(71)(72)(73)(74)(75)TRANSFORAMINAL ENDOSCOPIC DECOMPRESSION IN
FAILED BACK SPINAL SURGERY
Pornpavit Sriphirom MD Kiattisak Wongvorachart MD Rajavithi Hospital Bangkok,Thailand
(76)(77)Failed Back Surgery Syndrome
1 Failure of decompression 2 Failure of fusion
(78)Failure of Decompression group
it can be sub-classified into subgroups
1 Immediate post operative no improvement of symptoms these are the results from
2 Wrong pre-operative diagnosis
• Tumor
• Infection
• Metabolic disorder
• Discogenic pain
• Decompression was performed too late, more than months for disc sequestration
• Psychosocial problem
3 Technical Error
• Wrong level
• Inadequate decompression
• Failure to recognize spinal stenosis as part of disc herniation
(79) A Early recurrence of symptoms (within weeks)
- Infection
- Meningoceal cyst
B Intermediate (within weeks to months)
- Recurrent disc prolapse
- Battered root, Perineural scarring - Arachnoiditis
C Long term (within months or years)
- Recurrent stenosis from new bone formation or disc collapse - Adjacent level failure
(80)Endoscopic Decompression in Failed Back Surgery Syndrome in Rajavithi Hospital
From June 2009-May 2012
169 cases
FBSS 22 cases
From June 2009-April 2010
General anesthesia
May2010-June2012
(81)Transforaminal endo-discectomy
For failed conventional discectomy
Transforaminal decompression
Extra-foraminal decompression
(82)22 FBSS
8 recurrent disc herniation 14 foraminal stenosis from
(83) 22 patients presenting FBSS were included Average age was 54 years old , from 28 to 80
years old
Sex Ratio was M/F : is 6/16
Average duration for symptoms was 10
months
Level of involvements were
(84)(85)(86)(87)(88)(89)(90)(91)(92)(93) Back : no point of tenderness,
hyperlordosis
Buttock pain and leg pain Lt side
Neurogenic claudication both sides Lt >
Rt
SLRT Positive Lt side
Decrease sensation L4,L5 both Reflex 2+ all
(94)(95)(96)(97)(98)(99)(100)(101)
Pre-op Post-op (6mo.) VAS
[ Visual Analog Scale ]
7.6 3.3
ODI
[Oswestry Disability Index]
(102) No wound and neural elements complication
5 patients were complaint for dysestheis
2 patients were spontaneous recovery in
months
2 patients ( 9% ) were considered to failure
and agreed to have an additional surgery
within months
All patients were satisfied to avoid opened
(103)(104)