Interventional Pain Surgery

This chapter provides a comprehensive overview and technique guide for endoscopic interlaminar lumbar decompression surgery, a minimally invasive surgical technique for managing herniated discs and spinal stenosis. The authors discuss the relevant surgical anatomy of the lumbar spine, the inclusion and exclusion criteria for the surgery, and explain the surgery’s step-by-step choreography by highlighting the use of advanced imaging and endoscopic technology. The authors review their clinical outcomes and discuss common complications and their management. They highlight the limitations of the procedure. This book chapter is a valuable resource for surgeons and healthcare professionals interested in understanding and implementing endoscopic lumbar interlaminar decompression as an effective and minimally invasive approach for managing sciatica-type low back and leg pain.

Endoscopic transforaminal lumbar discectomy (ETLD) with trephines represents a minimally invasive surgical procedure for treating lumbar disc herniation. This technique best suits the novice surgeon and offers several advantages over traditional open surgery, including reduced tissue trauma, faster recovery, and improved patient outcomes. It simplifies the placement of the endoscopic working cannula by creating an initial working space under fluoroscopic guidance without the need for an initial foraminoplasty. This chapter delves into the technical and procedural aspects of ETLD with trephines, providing a detailed overview of the procedure, its indications, contraindications, surgical steps, and potential complications. Furthermore, we highlight the advantages and limitations of this innovative technique and discuss its established role in spinal surgery

Degenerative lateral lumbar spinal canal stenosis commonly affects the elderly, leading to significant morbidity. This chapter aims to introduce a novel categorization for the lateral compartments of the lumbar spine and to assess the effectiveness of surgical interventions for this condition. A new anatomical classification has been established, partitioning the area into five distinct zones. To ascertain the consistency of this nomenclature, lumbar scans from thirty individuals with single-zone afflictions at our facility were reviewed by a trio of evaluators. Following this, we conducted a prospective study tracking the surgical results in 76 subjects with single-zone lateral lumbar canal narrowing over two years. These individuals were treated using either percutaneous endoscopic transforaminal or interlaminar decompression techniques, chosen based on the newly developed zonal system. Outcomes were evaluated using the Macnab criteria, and changes in leg pain were measured with the visual analog scale (VAS) before and after surgery. During the study employing our categorization, the average observation period was 15.6 months. By the final evaluation, 93.4% of the cases were rated as good or excellent. The average initial VAS score of 5.72 significantly improved to 1.26 within three months after surgery and further to 0.78 by the final assessment. Notably, two individuals experienced dural tears, and one had postoperative bone fragment migration into the vertebral canal. The findings suggest that this innovative lateral lumbar canal classification facilitates precise surgical planning, contributing to the high rate of satisfactory results following endoscopic procedures.

Endoscopic techniques have garnered positive outcomes in treating lumbar spinal stenosis, with percutaneous endoscopic transforaminal decompression showing particular efficacy for addressing stenosis in the intervertebral foramen and lateral recess. However, the use of transforaminal decompression for central lumbar spinal stenosis (CLSS) is often met with skepticism. In this section, the authors share insights from their practice alongside data from a sequential observational study involving 47 CLSS patients treated via a bilateral transforaminal endoscopic approach. Clinical metrics such as the Oswestry Disability Index (ODI), VAS scores for back and leg pain, and the Macnab criteria were employed to measure the outcomes. The radiographic analysis involved comparing the lumbar dural sac's cross-sectional area before and after the procedure. The findings indicate substantial clinical improvement and a notable expansion of the dural sac's cross-sectional area at the final follow-up. There were no reported cases of infection, wound complications, or need for subsequent surgery. Thus, barring principal pathologies located dorsally to the dural sac, the bilateral transforaminal endoscopic approach is advocated as an adequate, reliable, and minimally invasive option for CLSS management.

This chapter provides a comprehensive overview of endoscopic lumbar facet rhizotomy, a minimally invasive surgical technique for managing chronic low back pain originating from the facet joints. The authors discuss the relevant anatomy of the lumbar facet joint complex, the pathophysiology of facet joint-related pain, the inclusion and exclusion criteria for the surgery, and explain the surgery’s step-by-step choreography by highlighting the use of advanced imaging and endoscopic technology for precise targeting and ablation of the medial branch of the dorsal facet nerve. The authors review their clinical outcomes. Furthermore, the authors discuss the current evidence, research advancements, and future directions in the field. This book chapter is a valuable resource for surgeons, pain specialists, and healthcare professionals interested in understanding and implementing endoscopic lumbar facet rhizotomy as an effective and minimally invasive approach for managing facet joint-related low back pain.

Chronic low back pain (CLBP) is highly prevalent and may be caused by arthritic changes in the lumbar facet joints. Percutaneous lumbar facet rhizolysis with radiofrequency (RF) has emerged as a minimally invasive procedure for the management of CLBP originating from the lumbar facet joints by selectively disrupting the medial and lateral branches of the dorsal branch of the sinuvertebral nerves transmitting pain signals from the facet joints to the nervous system. The authors employ a modern RF probe inserted percutaneously near the affected facet joint during the fluoroscopically guided procedure. Once the cannula is positioned correctly, RF energy is delivered, generating localized heat and creating a thermal lesion on the medial branch nerves supplying the facet joint. This selective thermal lesioning disrupts the pain transmission pathway without affecting motor function, thus providing pain relief for an extended period. The RF technology employed by the authors is based on Elliquence low-frequency technology and is known to cause little tissue damage beyond the target area. The authors present the clinical results with their extended clinical cohort. This procedure can be performed outpatient, requiring minimal sedation and quicker recovery than traditional surgical approaches. This chapter aims to illustrate the efficacy of percutaneous lumbar facet rhizolysis with the Elliquence RF Dart probe in the management of CLBP by comparatively analyzing the existing clinical evidence regarding long-lasting pain reduction, improved function, and overall patient satisfaction.

Chronic lower back pain significantly contributes to disability within the musculoskeletal system, affecting a substantial portion of the global population. Among the numerous factors contributing to chronic back pain, degenerative disc disease plays a prominent role, particularly in the aging population. It is hypothesized that the sinuvertebral and basivertebral nerves are the primary mediators of the nociceptive response observed in degenerative disc disease, resulting from the neurotization of these nerves. Extensive research has been conducted to explore the pathoanatomy, pathophysiology, and pain generation pathways involved in degenerative disc disease and chronic back pain. In this book chapter, the authors describe management strategies for sinuvertebral and basivertebral neuropathy and related low back pain symptoms. By examining the current literature, a better understanding of the treatment options and approaches for addressing this condition can be attained.

Posterior cervical foraminotomy stands as a recognized decompressive intervention aimed at alleviating radiating symptoms in the arm, neck, and shoulder stemming from refractory cervical radiculopathy. Although it parallels the anterior cervical discectomy and fusion (ACDF) in application, its endoscopic iteration boasts pronounced merits, especially when juxtaposed with ACDF and conventional open foraminotomy. Such benefits are attributed to reduced tissue insult and diminished postoperative discomfort. In this segment, the authors delineate contemporary advancements made in enhancing the endoscopic posterior cervical foraminotomy procedure. Moreover, they furnish an abundant array of intraoperative endoscopic depictions capturing surgically pertinent landmarks and anatomy, supplemented by their radiographic analogs. 

Posterior endoscopic cervical foraminotomy (FE-PCF) has emerged as an alternative to ACDF or open posterior foraminotomy for treating cervical radiculopathy caused by foraminal stenosis or herniated discs. In this chapter, the authors provide an overview of the surgically applied anatomy relevant to the FE-PCF. The procedure involves using advanced endoscopic visualization and surgical instruments to achieve precise decompression of the affected nerve root. Therefore, the authors summarize the key features of posterior endoscopic cervical foraminotomy, including its advantages over traditional open surgery, such as lower complication rates, reduced tissue disruption, and faster recovery times. They employ illustrative step-by-step instructions that the novice endoscopic spine surgeon can employ to execute the posterior endoscopic cervical foraminotomy safely and effectively.

Cervical endoscopic unilateral laminotomy for bilateral decompression (CEULBD) is a surgical technique that addresses central canal stenosis, often associated with radiculopathy and myelopathy. Previous studies have demonstrated this method's feasibility, safety, and effectiveness, highlighting its advantages over anterior cervical discectomy and fusion (ACDF) in terms of surgical duration, blood loss, and hospital stay. In this chapter, the author focuses on the surgical steps by illustrating the applied surgical anatomy to enable aspiring endoscopic spine surgeons to lean about the key steps this technique and to perform it safely and successfully. This author recommends having an experienced spine surgeon in the operating room for the first several cases before performing posterior endoscopic decompression of the stenotic central cervical spinal canal alone. 

Full-endoscopic cervical medial branch neurotomy (FECMBN) is a minimally invasive procedure for chronic cervical facet joint pain. The procedure involves advanced endoscopic visualization and surgical instruments to achieve precise neurotomy of the medial branch innervating the cervical pain facet joint complex. In this chapter, the authors summarize the key features of the posterior full-endoscopic cervical medial branch neurotomy, including its advantages over traditional nonvisualized radiofrequency-based ablation procedures regarding the treatment effect's safety, efficacy, and durability. They employ illustrative step-by-step instructions that the novice endoscopic spine surgeon can employ to execute the posterior fullendoscopic cervical medial branch neurotomy safely and effectively.

Ossification of the posterior longitudinal ligament (OPLL) can lead to cervical myelopathy, particularly in cases of multilevel involvement that pose challenges for effective management. Minimally invasive endoscopic posterior cervical decompression has emerged as a potential alternative to traditional laminectomy surgery. In this chapter, the authors present their clinical experience and report on an illustrative consecutive observational cohort study of thirteen patients with multilevel OPLL and symptomatic cervical myelopathy. The Japanese Orthopaedic Association (JOA) score and neck disability index (NDI) were assessed preoperatively and at a final follow-up of two years postoperatively. The results demonstrated significant improvements in the JOA score and NDI, indicating enhanced functional outcomes. No infections, wound complications, or reoperations were reported. While the two-year outcomes were promising and comparable to those achieved with traditional laminectomy, further investigations are required to assess potential long-term limitations. 

Unilateral biportal endoscopic lumbar discectomy (UBE) is a minimally invasive surgical procedure for treating lumbar disc herniation that is associated with bony and soft tissue stenosis. This technique best suits surgeons who want to take advantage of their great experience with the translaminar approach. It simplifies the endoscopic learning curve by placing the endoscopic working cannula onto the posterior spinal elements rather than placing it into the neuroforamen. This chapter describes the technical and procedural aspects of UBE by providing a detailed overview of the procedure, its indications, contraindications, surgical steps, and potential complications. Furthermore, we highlight the advantages and limitations of this innovative technique and discuss its established role in spinal surgery. 

Endoscopic Posterior Lumbar Interbody Fusion (PLIF) is a minimally invasive surgical technique to fuse the lumbar vertebrae. This approach combines endoscopy with the established PLIF procedure, reducing tissue damage, improving visualization, and direct neural decompression. The smaller incision size, precise visualization, and specialized endoscopic tools contribute to decreased postoperative pain, faster recovery, and potentially improved patient outcomes. In this chapter, the authors highlight the technical pearls of the endoscopic PLIF by going through the surgery step-by-step with illustrative clinical and intraoperative examples. The authors encourage novice surgeons to obtain specialized training and the necessary equipment to mitigate the potential risks and complications, including damage to neural elements, spinous process fractures, and implant-related problems. While the clinical examples presented herein had excellent functional outcomes and considerable reductions in preoperative pain levels, further research is needed to evaluate the long-term efficacy and outcomes of endoscopic PLIF compared to traditional open procedures.

Adjacent segment degeneration and disease (ASD) following spinal fusion surgery can pose challenges, and various surgical approaches have been developed to address this condition. This chapter presents a comprehensive review of the current literature, including clinical studies, comparing the outcomes of endoscopic and open surgical techniques in patients affected by ASD. The authors' analysis reveals that endoscopic surgery demonstrates comparable effectiveness in pain relief, functional improvement, and patient satisfaction while offering potential advantages such as reduced tissue trauma, shorter hospital stays, and faster recovery times. This chapter also discusses each surgical approach's technical aspects, potential complications, and limitations in comparison to endoscopic decompression surgery for ASD. The evidence suggests that endoscopic surgery is a viable alternative to conventional open surgery for treating adjacent spondylosis. However, further research and long-term follow-up studies are necessary to better establish its long-term efficacy and durability. 

 Thoracic endoscopic discectomy is gaining more popularity. Accessing the thoracic spine through a small skin incision rather than large exposures required for the traditional costotrasversectomy approach, the endoscopic technique alleviates pain and neurological symptoms and improves patient outcomes by targeting the compressive pathology directly. In this chapter, the author reviews the indications for the procedure, the inclusion and exclusion criteria, and its technical caveats by illustrating the application of endoscopic instruments and visualization systems. Preoperative evaluation, including advanced imaging techniques, is crucial for accurate diagnosis and surgical planning. Further, the author demonstrates the procedure's advantages, such as reduced tissue trauma, decreased blood loss, shorter hospital stays, and faster recovery than traditional open surgery. With appropriate patient selection and skilled surgical expertise, thoracic endoscopic discectomy is capable of managing thoracic disc herniation with comparable clinical outcomes compared to open techniques without collateral tissue trauma.