OUTSIDE IN LUMBAR ENDOSCOPIC MICRO

TECHNIQUE DECOMPRESSION

THOMAS HOOGLAND
MUNICH
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MICRO

ENDO
 ALPHA SPINE CENTER
Dr. Hoogland

1990- 2007
 Ruetten et al. Full-Endoscopic Interlaminar and Transforaminal Lumbar Discectomy Versus
Conventional Microsurgical Technique. Prospective Randomized Study
MD Spine Jurnal 20 April 2008 - Volume 33 - Issue 9 - pp 931-939

Literature Hoogland et al, Endoscopic Transforaminal Discectomy for Recurrent Luzmbar Disc Herniation
A Prospective, Cohort Evaluation of 262 Consecutive Cases Spine Journal, Volume No. 33, April 2008

Hoogland T. Transforaminal endoscopic discectomy with foraminoplasty for lumbar

disc herniation. Elsevier SAS (Paris). All rights reserved. Surgical Techniques in Orthopaedics and
Traumatology, 55-120-C-40, 2003, 6p.

Schubert M, Hoogland T. Die transforaminale endoskopische Nukleotomie mit Foraminoplastik

bei lumbalen Bandscheibenvorfällen. Endoscopic Transforaminal Nucleotomy with Foraminoplasty
for Lumbar Disk Herniation.
Urban & Vogel. Oper Orthop Traumatolog 2005/5:641-661.

Hoogland T, Schubert M, Miklitz B, Ramirez A. Transforaminal Posterolateral Endoscopic

Discectomy With or Without the Combination of a Low-Dose Chymopapain: A Prospective
Randomized Study in 280 Consecutive
Cases. Spine 2006;31(24):E890-E897.

Hoogland T, Scheckenbach C. Die endoskopische transforaminale Diskektomie bei lumbalen

Bandscheibenvorfällen. Orthopädische Praxis 1998:34;5,16.

Hoogland T, Scheckenbach C. Endoskopische transforaminale Diskektomie (ETD)- Ergebnisse

nach 2 Jahren.
Orthopädische Praxis 1999/2;35:104-105.

Hoogland T, Scheckenbach C, Dekkers H. Endoskopische transforaminale Diskektomie.

Ambulant operieren 1999/4.

Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation. The surgical
technique, outcome and complications in 307 consecutive cases.
Spine 2002;27(7):722-731.

Knight MTN, Goswami AKD. Endoscopic laser foraminoplasty. In: Savitz MH, Chiu JC, Yeung AT,
eds. The Practice of Minimally Invasive Spinal Technique. 1st ed. Richmond, VA: AAMISMS
Education, LLC, 2000;42:337-340.

Kambin P, Casey K, O´Brien E, Zhou L: Transforaminal arthroscopic decompression of lateral

recess stenosis.
In: J Neurosurg./ March 1996 Volume 84, pp 462-467.

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PRO What is special about maxMorespine?
• maxMorespine
Hoogland 2006 : it does make it posssible to enlarge the
foramen safely in order to place a working cannula through
the foramen into the spinal channel at all levels and is
therefore a direct approach to the herniated fragement

• THESSYS
Hoogland 1998 : sharp reamers + difficulties L5-S1

• YESS & Vertebris

Far lateral approach, no access to spinal channel L5-S1,
inside out technique
GOAL :
PRO
Advantages over Microdiscectomy:
• Local anaesthesia
• Less/no cases of iatrogenic neurological damage
• Smaller risk of infection
• Direct approach to the extruded disc fragement
• Only minimal disturbance of intracanal structure
• Less Scar tissue
• Faster recovery
• Less failed back cases
 Disadvantages?
CONS
• Sequestrated disc?
• L5-S1?

?
• High recurrence rate?
• Less effective?

Hurdles to take
Learning curve 3D view
POSITIONING

Lateral or Prone

First true
lateral or AP
picture
KEY STEP placement and advancement

of the TOMshidi needle

L5-S1
12 cm from midline
(through tip of
facetbone)

L4-5
10 cm from midline
(through tip of
facetbone)

L3-4
8 cm from midline
(directly through
foramen)
advancing

TOM SHIDI
positioning

TOM SHIDI
L5-S1

Model
L5-S1
SAFE

PRECISE

EFFICIENT
DRILLING

4mm

6mm
DRILLING
7mm

8mm
Positioning
working cannula
under C-arm
control
Endoscopic
inspection
of spinal canal
entrance
Endoscopic removal
of the herniated
fragment

endoscopic
inspection of the
spinal nerve

confirmed by free
movement of
previously
compressed nerve
L3-4 CAUDAL
L3-4 LATERAL
L4-5
L5-S1
FORAMINOTOMY
L5-S1
FORAMINOTOMY

... that‘s what WE call a foraminotomy

DOUBLE BARREL
Re-herniation
2001
PRE - POST
 ENDOSCOPIC
TRANSFORAMINAL
NUCLEOTOMY

Results of a prospective clinical

study with a 2 year follow up
N=252

Thomas Hoogland et al.

Results
at 2 years

Satisfaction

(by patients own judgement)

N=252
Results
at 2 years

MACNAB
(by patients own judgement)

N=252
 • There were no infections and no
Results duraleaks
at 2 years
•  No post op headaches
Complications • 2 Patients showed a temporary
(by patients own judgement) increase of leg pain
N=252
• 1 patient reported a permanent increase
of his numbness

• 3 patients were additionally treated with

a nerve block
 • 6 patients showed an early recurrent
herniation within 3 months after pain free
Recurrence interval of 2 – 12 weeks
early (2,4% early recurrent herniation)
At the 2 year follow up all 6 patients had a
good or excellent result after the second
operation
 • 12 patients were treated for recurrent disc
herniation (between 3 months and 2 years)

• Recurrence rate 4,7%

Recurrence • The average interval between 1st and 2nd

late surgery was 184 days

• 8 patients at L5-S1 / 2 patients at L4-5

• after 2 years
9 patients were very satisfied or satisfied
1 unchanged
2 worse
Results
at 2 years Questioned, whether they would undergo
the same surgical procedure again 246 of
252 patients (97,6%) replied yes.
 IT‘S TIME TO CHANGE
TAKE HOME NOTES • Safe instruments - direct approach
• Local anaesthesia
• Less scar tissue and complications
• Safe the dorsal approach
the ligamentum flavum
• No need to retract the nerve

• Learning Curve
CONCLUSION
All herniated discs
now are operated
endoscopically!

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