The activity of our hospital has been focused on minimally invasive spinal surgery (MISS). We are always trying to introduce new technics for MISS. We introduced percutaneous endoscopic lumbar discectomy (PELD) in 2009, and have been gradually expanding the indication of PELD. In last year (2016) we treated approximately 200 patients by using PELD, and we already achieved the treatment of more than 200 patients in this year (until July 2017). Not only patient’s treatment but also academic activities are important to develop new surgical technic. From this point of view, we have been also performing academic activities such as publication on international journals. Our recent studies revealed that PELD has several operative indications except for lumbar disc herniation. Using following pages, we will explain the appropriate operative indication of PELD for better understanding of visitors to this web site.
The Head of Education and Training Center
The head of PELD Center
Iwai Orthopaedic Medical Hospital
At present 8 medical doctors belong to our PELD center. Both neurosurgeons and orthopedic surgeons are working together for the treatment of spinal diseases. Our hospital is certified as training facility for PELD by Neurospinal society Japan (NSSJ) and contributing for education of young surgeons who are interested in the MISS (Site URL). Our hospital is also certified as program of the Advanced Clinical Training of Foreign Medical Practitioners by Japanese government (Site URL), so that our hospital can employ foreign medical doctors for their training. First trainee has been already determined coming from Germany from this December. If you are interested in this training program for foreign medical doctors, please contact to our administration office (email@example.com). We have two different types of medical fellows. One is junior fellow who just joined our PELD team, another is senior fellow who already experienced more than 30 PELD operations. The junior fellow can perform PELD under supervisor, however the senior fellow has an ability to perform PELD independently.
The head of PELD Center
Medical doctor can not perform operation independently. Many medical staffs such as operative nurse, anesthesiologist, medical engineer support to achieve the operation. Not only during the operation, but also before and after operation several medical staffs support the diagnosis and postoperative patient’s care. For such periods, nurse at the outpatient clinic, radiological technician, clinical laboratory technician, physical therapist, and occupational therapist strongly support us. In this context, I would like to mention that many excellent staffs are gathering to our PELD center. Hereafter we will introduce each member on this site.
PELD is minimally invasive spinal surgery using 7mm diameter endoscope.
Percutaneous endoscopic lumbar discectomy (PELD) is one of the most sophisticated operative procedures for the treatment of lumbar disc herniation. However, PELD has an anatomical limitation for endoscope insertion, and there are 3 different operative approaches: interlaminar, transforaminal, and posterolateral. As the minimally invasiveness, short hospital stay (generally 1-2 days) and early rehabilitation in work environment could be achieved.
Exact operative video records.
Case：Lumbar disc herniation (LDH)
Case：Lumbar disc herniation (LDH)
Small skin incision and short hospital stay.
Small skin incision
Compare to conventional microendoscopic discectomy (MED; 18-20 mm skin incision), the skin incision of PLED is extremely small (7 mm).
Early rehabilitation in work environment
The hospital stay of PELD is generally 1-2 days.
The fee of operation is covered with national health insurance.
Using national health insurance, patient’s share of the expenses is approximate ¥200,000 ～ 250,000 (this is a standard for 1-3 days hospital stay).
PELD has lower invasiveness than conventional MED.
Percutaneous endoscopic lumbar discectomy (PELD) was originally established the surgical procedure for the treatment of lumbar disc herniation (LDH), and is the most recent minimally invasive spinal surgery. However, the learning curve is quite gradual because of its technical difficulty and extremely narrow working space (diameter 4.1 mm). Furthermore the narrow working space eliminates the use of surgical instruments, thereby operative time is generally longer than that of conventional operative procedures. Conversely operative indications and the results are depending on the skill of the operator. Therefore, patient has to realize these situations and chose the best treatment possible to receive at the regularly visiting hospital. Otherwise you have to find the appropriate hospital to receive PELD in which there are well‐experienced surgeons and good facilities for full-endoscopic spinal surgery. Using next several pages, we will introduce operative indications of PELD in our PELD center.
Lumbar disc herniation (LDH) is the most suitable indication for PELD. Depending on the location, the size, the vertebral height, and the hardness, surgeons have to select the most suitable operative approach. Although our previous experience of PELD make possible to treat all types of LDH by PELD.Cited from Mini-invasive Surg 2017 Apr 17.
The recurrence rate of LDH has been reported between 4-15 % until five years after operation.cite from B. Braun Melsungen AG
Generally second operation for recurrent LDH is performed through same skin incision. If the first operation was done by conventional open or MED operations, the operative rout is covered with extensive scar tissue. On the other hand, if the first operation was done by PELD, scar tissue formation is limited to a minimum. Therefore the incidence of nerve injury by second operation might be reduced by sequential PELD operation. Alternatively, PELD can avoid such scare tissues, since PELD has 3 differential operative routs (interlaminar, transforaminal, and posterolateral).
Magnetic resonance imaging findings of a patient with recurrent LDH. Preoperative (A, C) and postoperative (B, D) sagittal (A, B) and axial (C, D) T2-weighted magnetic resonance images: orange‐colored arrows indicates the recurrent LDH. Green-colored arrow indicates scar formation by former MED.
Huge LDH is one of the challenging for spinal surgeons. By the conventional posterior approach, larger laminectomy is necessary and traction of dural sac tends to be more powerfully. To overcome these difficulties, several surgeons proposed the solutions. One of such solutions is trans-dural approach. However this approach has a potential risk of postoperative cerebrospinal fluid leakage. Furthermore, bilateral approach has also been reported. Either way the invasiveness of the operative procedures will accrue, thereby these approaches prolong operative time. From our previous experience of transforaminal approach (TFA), we realized huge LDH is a good indication for TFA of PELD.
BMI (body mass index) is one of the indicators for obesity, and BMI > 25 is judged as obesity. Spinal operation for obese patient is more difficult than that with normal figure, because surgeon have to advance through the fatty tissue at the beginning of the operative step. PELD may escape this step, subsequently be performed similar to the operation for the patient with normal figure. We thus recognize TFA of PELD facilitates discectomy in the case of not only recurrence but also obesity.
Magnetic resonance imaging findings of a obese patient with LDH. Preoperative sagittal (A) and axial (B) T2-weighted magnetic resonance images: orange-colored arrows indicate the huge central LDH. Note that wide white area on sagittal (A) MR image indicates subcutaneous fatty tissue.
The arm pain experienced by patients with cervical radiculopathy is commonly caused by either lateral cervical disc herniation or stenosis of the intervertebral foramen due to a bone spur resulting from spondylosis. Surgical treatment of cervical radiculopathy can be divided into two procedures: anterior cervical decompression and fusion (ACDF) and posterior foraminotomy. The latter option involves three types of procedures: open, microscopic and micro-endoscopic surgery.
The posterior endoscopic cervical foraminotomy (PECF) to treat lateral disc herniation was first reported by Ruetten et al. They concluded that PECF is a sufficient and safe supplement and alternative to conventional procedures. Since then, Kim et al. also suggested PECF is an alternative to open surgery. Previously we had been performing micro-endoscopic posterior foraminotomy, however from these evidences we are now performing PECF using PELD endoscopic system.
As in many industrialized countries, low back pain (LBP) is one of the most common health disabilities. In a population-based survey, the lifetime LBP prevalence was reported as 83%.
It has been difficult to identify the cause of LBP. A specific cause of pain can be identified in some cases, but the cause cannot be identified in other cases of LBP. LBP associated with degenerative disc disease (DDD) is one of the identified causes. However, clear diagnosis of this pathological status is still difficult. High intensity zone (HIZ) on magnetic resonance imaging (MRI) provides supportive evidence but not definitive one. The technique of injecting local anesthesia into a disc (discoblock) also provides useful information regarding discogenic LBP, although it is also impossible to provide the definitive diagnosis. Most recently our group established the scoring system as a support tool for diagnosing discogenic LBP consisting of five questions (Site URL). We are now trying to diagnosis discogenic LBP by combination of MRI, discoblock, and original five questions. We perform annuloplasy using PELD endoscopic system against highly suspected discogenic LBP patient.
There are two types of lumbar canal stenosis: central canal stenosis and lateral recess stenosis (LRS). The characteristic symptom of central canal stenosis is cauda equine syndrome, and that of LRS is leg pain due to corresponding nerve root compression. The common etiology of LRS is hypertrophy of the superior articular process and the bone removal by a high-speed drill at this area is the favorite technic for PELD. Posterior decompression of the medial aspect of the facet complex using PELD system is feasible for the treatment of patients with radiculopathy caused by lumbar LRS.
Magnetic resonance imaging findings of a patient right LRS: preoperative (A, B) sagittal (A) and axial (B) T2-weighted magnetic resonance images. Postoperative three-dimensional (C) and axial (D) computer tomographic images of same patient: arrows indicate the removed bone-area for decompression. Note that the removed bone-area is extremely small.
The operative approach for lumbar foraminal stenosis (LFS) is one of the most challenging for spinal surgeons. Excessive removal of the dorsal area of the foramen in a posterior approach can easily lead to iatrogenic spondylolysis, subsequently increasing lumbar instability and spondylolisthesis.cite from Mini-invasive Surg 2017;1:3-5
Recent advances in the PELD technique have made access to the lateral aspect of the lumbar foramen possible without excessive removal of surrounding structures. Despite this advance using a fully endoscopic system, access to the L5/S1 region remains difficult. At L5/S1, the surgeon cannot adequately tilt the endoscope to access the medial portion of the foramen due to the obstacle created by the ipsilateral iliac crest. To access the medial part of the L5 foramen, we improved one of the PELD approach percutaneous endoscopic translaminar approach (PETA), which had been developed for lumbar disc herniation (LDH) with migration into the hidden zone. This improvement uses a primarily posterior approach through an 8-mm skin incision placed just above the corresponding pars interarticularis. The endoscope sheath is placed on the surface, and the dorsal area of the foramen is removed with a high-speed drill.
Representative case of improved PETA. A 70-year-old male complained of left leg pain that worsened with walking. Neurological examination revealed no muscle weakness and a negative SLR sign. Sagittal lumbar MRI revealed left foraminal stenosis at the L5/S1 intervertebral disc level, with marked compression of the left L5 nerve root (A, arrow head). We performed PETA, and his symptom improved (NRS 8→0, JOA 15→22) 2 weeks after PETA. Postoperative MRI revealed decompression of the foramen (B, arrow head). Comparison of preoperative (C, E, G, I) and postoperative (D, F, H, J) CT findings demonstrated the extent of bone removal (arrow heads). (A, B, E, F) sagittal view, (C, D, G, H) axial view, (I, J) 3-dimensional reconstruction. PETA: percutaneous endoscopic translaminar approach; SLR: straight leg rising; NRS: Numeric Rating Scale; JOA: Japanese Orthopedic Association; MRI: magnetic resonance imaging; CT: computed tomography
Far out syndrome was reported by Wiltse et al. in 1984, which is a condition characterized by L5 spinal nerve radiculopathy due to nerve compression outside of the vertebral foramen. There are several variations of soft and hard anatomical structures, such as L5 transverse process, sacral alar, inferior and superior articular processes, and ligaments between surrounding bones. The operative approach to this narrow space is extremely difficult; thereby many spinal surgeons choose more invasive surgery like lumbar interbody fusion of L5/S vertebrae. Technic of PELD is also suitable for the decompression of this kind of narrow space. Thus we have been applying PELD to the far out syndrome and obtaining good surgical outcome.
Lumbar interbody fusion is now a currently accepted treatment for degenerative lumbar spondylolisthesis and scoliosis, but may induce adjacent segment disease (ASD). Approximately 10 % of the patients suffer from symptomatic ASD within 5 years. Previously fusion-extension surgery has been performed for the treatment of symptomatic ASD, but this surgery more invasive than former interbody fusion. Therefore we have been applying PELD to the ASD and obtaining good surgical outcome.
Sagittal computer tomographic (A) and magnetic resonance (B) images of adjacent segmental disease (ASD) after interbody fusion: orange‐colored arrows indicate adjacent vertebral foramen filled with herniated disc fragment. Green‐colored arrows indicate pedicle screws used for former interbody fusion.
|Name||Hospital Iwai Orthopaedic Medical Hospital Iwai Medical Foundation, Medical Corporation|
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|Departments||Orthopaedics / Rheumatology / Rehabilitation / Radiology department / Internal Medicine / Pulmonology / Gastroenterology / Cardiology / Anesthesiology|
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