Daniel Sauer and Christoph Siepe of the Schön Klinik München Harlaching (Munich, Germany) discuss some of the benefits of endoscopic surgery compared with microsurgery and whether or not the former will eventually be seen as the gold standard for treating lumbar disc disease.
Lumbar disc herniation and spinal stenosis are amongst the most common pathologies in the lumbar spine. To date, microsurgical techniques represent a so called ´gold standard´ for the surgical treatment of decompression syndromes such as lumbar disc herniations.
When introduced in the 1980s, microsurgical techniques served to significantly reduce the invasiveness in comparison ´open´ procedures. Substantial benefits included the reduction of access related collateral damage, reduction of postoperative wound pain, earlier mobilisation, shorter hospital stay, reduction of infection/wound healing problems and also substantially improved visualisation of the delicate neurological structures and thus decreased risk of intraoperative complications.
Nevertheless, there have only been small and incremental improvements over the last 20–30 years—an eternity considering the rapid progress that has occurred in the medical field and all around us in the meantime.
Recently, full-endoscopic techniques have been introduced as either an alternative or as a complimentary tool or adjunct to microsurgery in the cervical, thoracic and lumbar spine. The procedure is performed through a single portal under constant irrigation through 25° angled optics and requires only a single stab incision, approximately 6–8mm in size. A variety of endoscopes, surgical tools and approaches are available and which can be chosen in accordance with the underlying pathology.
Endoscopic surgery takes the quality of visualisation of neurological structures to the next level. Flawless images are transmitted through optical fibres from close proximity of the neural structures inside the spinal canal onto large 4K screens, and a wide range of vision is enabled by the 25° angled optics.
Obese patients in particular experience significant benefits from endoscopic techniques, which may be performed through the same, 6–8mm incision, independent of the patient’s weight.
Infections and/or wound healing problems can almost be eliminated, which is a substantial advantage over microsurgical approaches. In this respect, changing from microsurgery to endoscopy could have an enormous impact on infection rates on a global scale.
A vast number of evidence-based data including prospective randomised controlled trials and meta- analyses confirm equal or even superior results of endoscopy over microsurgery. The authors from these studies concluded that endoscopy has the potential to take over from microsurgery as a gold standard for the treatment of lumbar disc herniations over the coming years.1
In summary, and for the same benefits that were seen 40 years ago when going from open surgery to microsurgery, endoscopic techniques are the next logical step for the decompression of lumbar pathologies.
1. Muthu S, Ramakrishnan E, Chellamuthu G. Is Endoscopic Discectomy the Next Gold Standard in the Management of Lumbar Disc Disease? Systematic Review and Superiority Analysis. Global Spine J 2021;11-7:1104-20.