NEUROLOGY & NEUROSURGERY

Endoscopic Spine Surgery: A Better Option for Disk Disease Treatment?

Sep. 15, 2021 - Todd Ackerman

Houston Methodist has become one of the nation's top providers of endoscopic spine surgery, the minimally invasive procedure that is revolutionizing the treatment of disk disease.

The procedure, which nearly eliminates the trauma and tissue injury often inevitable with open spine surgery, is popular in Europe and Asia but has only recently begun gaining practitioners in the U.S. Probably only about 20 U.S. centers provide the treatment, according to estimates.

"This will play a major role in spinal decompression, possibly mainstream within 5 to 10 years," says Dr. Meng Huang, a spine neurosurgeon at Houston Methodist. "I think you'll see an exponential growth curve of surgeons using this technique in coming years."

Dr. Huang, now routinely performing endoscopic decompression, champions a three-surgeon team in the Houston Methodist Department of Neurosurgery — Drs. Paul Holman and Sean Barber are the other two — that has performed about 100 endoscopic spine surgeries in the past year. The team, already introducing the procedure to neurosurgery residents, will bring on its first endoscopic spine surgery fellow next year.

The benefits of endoscopic spine surgery

Dr. Huang touts the decreased complication profile, speedier recovery time, reduction in postoperative pain, and faster return to work and normal activity associated with the procedure, compared to traditional techniques like microdiscectomy (open surgery using an operative microscope).

Another major potential benefit, although yet to be proven: A decreased risk of further issues at the index treatment level.

The mainstreaming of endoscopic spine surgery in the U.S. would be a major boon to the treatment options for patients requiring surgery for spine problems, given that more than 1.5 million spinal procedures are performed every year in the nation, according to the latest data.

People with herniated disks are the most common candidates for the surgery, but it's also applicable for certain types of central and foraminal stenosis, particular types of spinal infections, and select synovial cysts. It is often not appropriate for spine surgery indications such as scoliosis, spinal instability or trauma.

But for now, endoscopic spine surgery is not yet widely offered in the U.S., largely because of high equipment costs and a steep learning curve necessary to master its technical nuances.

Traditional surgery's collateral damage

As a result, most patients still undergo open traditional decompression, which works well for treating the intended target, but causes collateral soft tissue trauma. Such tissue trauma can be dramatically minimized with the endoscopic technique.

"There's absolutely nothing wrong with microdiscectomy — it's proven to be effective and represents the gold standard technique based on the current available scientific literature in our professional community. But this is the technique I would want for myself if I needed surgery for disk disease," says Dr. Huang.

Dr. Huang, who calls endoscopic spinal surgery "ultra minimally invasive," adds that the procedure can be done anywhere in the spine, from the neck to the lower back. The end goal, he says, is the same as traditional open decompression surgery. "We are achieving the same surgical outcome but are able to minimize disruption to normal supportive muscle, ligament and joint tissue around the spine that are vital to maintaining functional and structural integrity."

Such minimal surgical footprint is achieved thanks to the use of small, 6.5 to 7.5 mm endoscopes with 4K resolution optics, capable of being introduced directly to the site of pathology percutaneously without any surgical dissection of soft tissues. Incisions are roughly a third of an inch, compared to the 2 to 3 inches of typical microdiscectomy surgery.

Another added benefit of the technique: The option to perform the procedure without general anesthesia, which contributes to faster recovery.

One endoscopic discectomy patient's story

One beneficiary of the minimally invasive approach was Bridget Simon-Friedt, a 35-year-old fitness enthusiast who developed pain in her right glute so severe she blacked out when she tried to get out of bed. She began walking with a limp because of accompanying numbness and weakness in her ankle and foot.

Diagnosed with a partial foot drop and sciatica due to acute disk herniation in the setting of preexisting advanced degenerative disk disease at the L4-L5 level, Simon-Friedt underwent an endoscopic discectomy at Houston Methodist. Dr. Huang was afraid that standard discectomy would have destabilized her spine and resulted in the need for a spinal fusion, ideally avoided in highly active younger patients.

The result: Simon-Friedt's pain relief was immediate. A year later, she's running, cycling, taking spin classes and lifting weights again with some modifications. She says she's grateful just to be able to walk and run, given initial fears she'd never again be able to do either.

Early data confirm the procedure's advantages. Studies show endoscopic spine surgery's complication rate is about half that of open spine surgery, and dural tears and infections are almost nonexistent.

What's more, endoscopic spine surgery typically does not take much longer to complete than traditional microdiscectomy and, in select cases, the patient has the option not to require general anesthesia. The surgeries are performed outpatient without the need for an overnight hospital stay, and patients typically return to work and resume normal activity much earlier.

"This is real surgery, just done in a focused, minimally invasive fashion that reduces the risk of future issues arising at the index treatment level, which can result from surgical collateral trauma," says Dr. Huang. "It's just a matter of time, as more and more centers bring on skilled surgeons and more and more trainees are exposed to it, before it takes off."