ENDOSCOPIC LUMBAR SPINE
SURGERY SEMINAR & LIVE
SURGERIES IMLAS 2007
1 S T T I M E I N M A L A Y S I A P R I VA T E H E A L T H C A R E
The first Spine Endoscopic Surgery in private hospital Malaysia
was held in Klang. This is the first time program which is organized
by Sri Kota Specialist Medical Centre (SKSMC). The Endoscopic
Lumbar Spine Surgery Seminar & Live Surgeries was successfully
held on 15th & 16th May 2007 at SKSMC.
SKSMC is the dlagship tertiary private medical centre in Klang, ma-
laysia. It is a 9 storey building with 232 beds fully equipped with
modern facilities. With its pool of committed specialist and suppor-
tive medically trained profesionals , SKSMC takes pride in its ac-
claim with the ability to provide the quality yet affordable healthcare
medical services to its patients.
The main organizer for the Seminar & Live Surgeries is International
Musculoskeletal Laser—Society (IMLAS). This is an another CME
SKSMC Chief Executive Officer,
programme in co-operation and supported by Andal Restu Sdn Bhd.
Mr. Eddy Lee Kwee Heng
The first ever program held in Malaysia had been attended
by consultants and surgeons from all over the world. Among those
are Dr. Martin Knight, one of the world top spine surgeon from
United Kingdom, Dr. Satish Gore from India, Dr. Lee Sang Ho, Dr.
Gun Choi, Dr. Shim Shik Chan and Dr. Lee Choon Dae, all are from
Korea. Other than that, SKSMC Consultant Orthopaedic and Spine
Surgeon, Dr. Lim Heng Hing and Dr. Siow Yew Siong, Dr. Mohd
Isa, Consultant Anaesthesiologist and also with Dr. Wong Chung
Chek from Sarawak hospital were among the speakers of the day.
Dr. Martin Knight, one of world top spine surgeon from United Kingdom,
deliver his speech on Endoscopic Lumbar Spine Surgery Seminar 2007.
SRI KOTA SPECIALIST MEDICAL CENTRE is a
232 bedded tertiary care level Medical Centre located in
the heart of Klang town, Malaysia. Our mission is to
provide the residents of Klang and the surrounding areas
with an affordable and yet comprehensive medical care
treatment through the multi-discipline clinical
Our long-term endeavour and commitment in the areas of
medical services is to be a renowned and reputable
Sri Kota Specialist Medical Centre (SKSMC), healthcare provider of choice and to be the preferred
Klang Malaysia Centre for health tourism in the Klang Valley, Malaysia.
THE SICK HUMAN INTERVERTEBRAL DISC
AND ENDOSCOPIC SURGERY
The Intervertebral Discs are anatomically located between The main advantage of the endoscopic spinal surgery is the
two spinal column bones or vertebrae. The structure of the small access which allows the normal anatomy to be
intervertebral discs is unique with multiple layers of collagen preserved. This is an important factor to prevent
coverings arranged in criss crossed manner on the outer subsequent problem like facet joint destabilization and
surface and a gelatinous material contained within the tight spinal musculature injury. There is abundant research
and strong outer envelop. The outer envelop is known as the evidence to shows the physiological role of strong spinal
annulus fibrosus and the inner viscous substance is known as musculature in prevention and treatment o backache. The
nucleus pulposus. The nucleus pulposus is responsible for stronger the back muscle is the better is the spine protected
the turgor or rigidity of the intervertebral disc. The function from future wear and tear processes.
of the viscous substance is to allow the spinal column to
A smaller access and incision often equate to earlier
move as well as to maintain the rigidity of the column so the
ambulation, earlier recovery, shorter hospital stay and
body does not buckle.
earlier return to work. In many spinal surgery centres, this
procedure is done as a daycare procedure or a short
hospital stay procedure.
The second important advantage is that many of the
procedures which traditionally requires general
Viewing anaesthesia can be accomplished under local anaesthesia.
channel This is an attractive option for elderly patients and patients
with poor respiratory function.
The use of local anaesthesia allows cooperation and
feedback from the patients which aids in monitoring the
Operating channel peripheral nerves. An increase in leg pain will alert the
Endoscopy is an invaluable tool for minimally invasive surgeon that the nerve is in danger of injury thus the
surgery of the intervertebral disc. The modern spinal surgeon will have to modify his entry approach. An awake
endoscope has two channels in one tube. One of channels is patient can often tell the operating surgeon when the pain is
for visualization of the anatomy or the pathologies and gone thus indicating surgery has been successfully
another channel is for operating procedures. completed.
The third important advantage is that often the spinal canal The second disadvantage of spine endoscopy is the high
can be avoided while performing the disc excision. equipment cost for the hospital but to the individual patient in
Operating inside the spinal canal often results in fibrosis in Malaysia, the total cost of endoscopic spine surgery and open
the epidural space which in itself can cause pain and spine surgery is approximately the same. In the last few
numbness due to tethering of the dural to the surrounding. decades, the development of better endoscopes, equipment and
In addition, the amount of bleeding from a disc excision is implants, more procedure can be success performed with use
less compared to traditional open surgery because of the of spinal endoscope namely, cervical discectomy, lumbar
pressure of the irrigating fluid. The routine use of laser discectomy, lumbar foraminoplasty, cervical stabilization with
during endoscopic surgery has limited the bleeding and implants, lumbar stabilization with or without fusion,
tissue damage contributing to less fibrosis and nerve endoscopic laser or radiofrequency annuloplasty, endoscopic
adhesion thus improved results. canal decompression and epiduroscopy.
Another advantage of spinal endoscopy especially via the One of the most common procedure perform in our centre is
posterolateral approach is more obvious during surgery for percutaneous endoscopic lumbar discectomy (PELD). This is
recurrent herniated disc. Surgery to remove the recurrent indicated for patient with herniated disc resulting persistent leg
disc is much safer without going through thick scar pain with or without weakness of the limb who has failed
following previous surgery. In larger and obese patients, adequate conservative treatment. An MRI of spine is obtained
spinal endoscopic surgery is more advantageous because to confirm the diagnosis and to locate the position of
the local anaesthesia does not result in postoperative herniation e.g. sequestrated disc or not. Occasionally, a CT
respiratory problems that is associated with general scan to determine if the annulus is ossified or not which will
anaesthesia. Furthermore, there is no need to extend help to know the where only fragment removal is sufficient or
incision as the incision for the operating cannula is the the ossified annulus need to be excised.
same in obese and non-obese patients.
The patient is usually seen by the anaesthetist in the ward who
There are limitations to the type of procedures that can be will administer the sedation, opoids and occasionally propofor.
done by endoscopic methods. There is a high learning The patient will be given preoperative antibiotics. The patient
curve as the field of view is limited, recognition of the was placed in a prone position which the spine slightly flexed.
tissue and lack of tactile appreciation of the tissue are
obstacles to the beginner. That is to imply that the surgeon
can lose his orientation. One of the common problems of The lumbar spine is prepared with povidine and drape as in
surgeon in the early learning curve is deciding when the any open spine operation. The appropriate disc is determined
operation is sufficiently performed. These disadvantages by the use of the fluoroscopy and marked on the skin with skin
can be overcome by adequate training, supervision and marker. The site of the needle entry is anaesthesized with local
familiarizing with normal anatomy of the spine as well as anaesthetics in doses. The size when the needle has entered the
masterful use of fluoroscopy. disc, a blunt-ended guide wire is inserted and needle is
replaced. Then by serial dilatation the working cannula is
inserted and followed by the endoscope.
Endoscopic view of dura and nerve
The prone position of patient
After a thorough visual inspection and fluoroscopic Dr Anthony Yeung from Phoenix, Arizona reported a
confirmation the cannula and endoscope is at the desired success rate of 80%-90% of good and excellent result
position in the disc, discectomy with a combination of depending on what type of herniated disc that is operated
hand instruments, laser and radiofrequency excision of the upon. In orthopedic literature, the incidences of
disc is performed. When the traversing nerve is seen to be complications is lower (5-10%) for PELD compared to open
free or when there is epidural bleeding is seen through the discectomy (10%-30% complication rate).
posterior annulus or the posterior longitudinal ligament
and the patient has symptomatic relief. The procedure is The complications include temporary dysaesthesia and
completed and incision is closed with one or two sutures. backache. However, with future advancement in implant and
The patient is allowed to ambulate on the same day and endoscope technology and surgical concepts, endoscopic
discharge on the same or the next day in our centre. spine surgery may emerge as an important armamentarium
in management disc disorders.
The gold standard for surgical treatment of herniated disc
is microscopic discectomy. PELD has been proven by
numerous expert to be equal in successful result compared
to microscopic discectomy.
The Spine Endoscopy Live Surgery while in