Development of Full-Endoscopic Lumbar Spine Surgery

The goal of utilizing endoscopic techniques in spinal surgery is to access the affected area with precision, minimal harm to surrounding soft tissues, and with the intention of decompressing or fusing the area in question. To attain this goal, three primary elements are crucial:

  • Endoscope that provides a magnified and unobstructed view of the area near the affected site
  • A functional channel for the endoscope, accompanied by specially designed instruments for delivering energy to coagulate, a laser for dissecting soft tissue, and tools for resecting and extracting any loose fragments present in the surgical field.
  • An irrigation system that provides a constant inflow and outflow, which aids in clearing away debris and maintaining a clear view during visualization.

Endoscopic spine surgery utilizes predetermined anatomical pathways for secure equipment passage during precise decompression and/or fusion procedures.

Kambin’s triangle is a specific target working zone that has been successfully decompressed using the transforaminal endoscopic lumbar discectomy (TELD) technique. Endoscopic equipment improvements, such as customized forceps and drills, have expanded the range of medical conditions that can be addressed through endoscopic spine surgery.

Transforaminal Endoscopic Lumbar Discectomy

Endoscopic spine surgery primarily involves TELD, but other techniques have been developed for accessing the secure working area, including inside-out, outside-in with foraminoplasty, and mobile outside-in techniques.

More extensive exploration of the spinal canal can be achieved through techniques such as partial removal of the pedicle and facet complex or resection through the pedicle, particularly in cases of migrated herniated discs.

TELD is an effective treatment for contained or low-level migration of herniated discs in the L1-5 region. It is applicable for disc herniation in central, paracentral, and foraminal regions.

Patients with radicular pain and MRI findings that do not respond to conservative treatment are typically the ones who would benefit from this surgery. The objective of the surgery has evolved over the years from central nucleotomy to discectomy and selective fragmentectomy.

The inside-out method is effective for treating patients with intracanal discs, while foraminoplasty has been developed to improve outcomes for patients with non-contained discs. Foraminoplasty involves expanding the diameter of the foramen at three specific locations to reduce the risk of nerve root damage.

It is effective in relieving foraminal compression and has good long-term outcomes for patients with neurogenic claudication symptoms. The interlaminar approach is preferred for cases involving L5/S1 discs with a high iliac crest.

Advancements in endoscopic spine surgery have expanded its use for more complex discectomy procedures. Modifications to the transforaminal approach have been described, and better equipment has made it possible to use TELD for cases that were previously contraindicated. However, caution should be taken in cases where patients have neurological deficits or cauda equina syndrome.

An endoscopic osteotome has been effective in removing calcified herniations in TELD procedures, and recent studies have shown that TELD can produce good results in treating large prolapsed discs in patients with high canal compromise.

Endoscopic surgery is a better option for patients with recurrent disc herniation due to less scarring and soft tissue trauma. The procedure has been particularly effective for patients under 40 years old, those with symptoms lasting less than 3 months, and those without lateral recess stenosis. Endoscopic surgery has also demonstrated better results compared to open surgery, including shorter operating times, reduced blood loss, fewer complications, better outcomes, and improved pain reduction.

TELD had limitations in treating disc herniations with spinal stenosis due to incomplete symptom resolution. However, TELD can still be used to treat patients with disc herniation and unilateral asymmetrical lateral recess stenosis using an extreme lateral transforaminal approach with foraminoplasty.

Positive clinical outcomes have been reported two years after using this technique. Foraminoplasty directed at the base of the superior articular process can benefit patients with both lateral recess stenosis and disc herniation by reducing neural dysfunction and shortening operative time.

TELD has been used for the removal of facet cysts, discal cysts, and tumors, which are less frequent indications for the procedure. Discal cysts have been treated with TELD and have similar clinical features to herniated intervertebral discs.

TELD has also been employed for treating facet cysts causing lateral recess stenosis, resulting in good clinical outcomes and preserving spinal stability. Tumor debulking has been performed using the transforaminal approach in patients with a low life expectancy, resulting in palliative symptom relief.

The transforaminal approach in endoscopic techniques has advanced and is used for interbody fusion, offering advantages like preserving soft tissue and being performed under local anesthesia.

It’s suitable for patients with spinal instability and significant disc height collapse causing foraminal stenosis, but there are concerns about its limited safety window, and transient neurologic complications and cage subsidence. Literature has shown mixed results with standalone cages in extremely collapsed discs.

Interlaminar Approach

The interlaminar endoscopic approach has gained popularity in treating central and lateral recess stenosis, as well as foraminal stenosis, due to advancements in endoscopic equipment and visualization techniques. It is particularly useful for L5/S1 disc herniation because of the wide interlaminar window.

The approach has three subdivisions, including interlaminar endoscopic lumbar discectomy, interlaminar endoscopic lateral recess decompression, and lumbar endoscopic unilateral laminotomy for bilateral decompression. This technique has become a popular surgical method for discectomy and stenosis decompression.

Doctors at Complete Orthopedics prefer interlaminar endoscopy because they are familiar with interlaminar anatomy from their spine practice. Clinical studies show that interlaminar endoscopic surgery has outcomes similar to traditional open surgery and minimally invasive microscopic tubular surgery but with fewer adverse events and shorter hospital stays. Recent studies suggest that interlaminar endoscopic decompression significantly improves visual analogue scale scores for back and leg pain and the Oswestry Disability Index.

Interlaminar endoscopic techniques can now be used for highly migrated disc herniation, allowing for sequestrectomy to remove migrated disc fragments and prevent subsequent spinal segment instability. The recurrence rate of discectomy is around 1-20%, but annular sealing and reduction of annular defects can decrease the risk of recurrence.

Angled scopes and flexible forceps have enabled removal of sequestrated discs in previously hard-to-access areas, making the surgery viable for less experienced surgeons. However, high canal compromise is a relative contraindication, and gentle handling of neural tissue is necessary during dissection.

Recurrent disc herniation can be challenging to treat with open or endoscopic spine surgery. Revision discectomy and fusion procedures yield similar outcomes. Endoscopic approaches, including transforaminal and interlaminar techniques, result in shorter hospital stays, less blood loss, and a quicker return to work compared to open surgery, while maintaining similar pain and disability scores.

TELD is preferred for revision discectomy due to encountering less scarring than IELD, although IELD can safely explore and perform discectomy even in the presence of significant scar tissue. Endoscopic procedures are less traumatic than open surgery, resulting in less scarring and preservation of soft tissue.

The presence of multiple types of spinal stenosis can lead to severe symptoms in patients, and traditional approaches may have limitations. A new technique called interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) combines paraspinal and interlaminar approaches to safely and effectively decompress all three areas of stenosis using a small working channel and 30° endoscope. This technique allows for no-touch neural decompression and is done in one procedure without the need for multiple approaches.

The uniportal full endoscopic posterolateral TLIF technique is a modified approach to the traditional posterolateral TLIF that safely respects the ipsilateral facet joint with an endoscopic drill.

This technique provides a larger corridor, a safe working region, and a reduced likelihood of exiting nerve root dysesthesia. The technique has been successfully demonstrated in a patient with spondylolisthesis and instability, but further studies are needed to assess its safety and effectiveness.

The paraspinal approach is commonly used for decompression of the nerve root in the foramen and extraforaminal region. It offers the advantage of lower risk of nerve root and cauda equina injury while maintaining facet integrity. However, it has a difficult learning curve and requires careful handling of the dorsal root ganglion and radicular artery.

Injury to the artery can lead to bleeding, hematoma, and may require open surgery. This approach is typically used for treating foraminal and extraforaminal stenosis caused by disc herniation, facet cysts, and foraminal osteophytes.

The paraspinal endoscopic approach can now be used for far-out syndrome, which requires more lateral decompression to access the nerve root existing in the far lateral region. It is particularly beneficial in the L5/S1 region, where the nerve root is compressed between the transverse process of L5, the sacral ala, and/or the bony spur at the extraforaminal region.

The expanding use of endoscopic spine surgery in the lumbar region requires managing complications without open surgery. One such complication is incidental durotomy, which can be addressed through patch-blocking dura repair, using collagen fibrin patches such as Tachosil.

This technique is used in open spine surgery and can also be applied in uniportal and biportal endoscopic surgery. Uniportal endoscopic equipment could eventually allow primary repair, reducing the need for open surgery and enabling surgeons to handle more complex revision cases with greater confidence.

During endoscopic spine surgery, accumulation of fluid in the spinal canal due to improper outflow of irrigation can cause increased cerebrospinal fluid pressure, cerebral edema, seizures, and neurological dysfunction. Epidural suction catheter placement is crucial in open spine surgery to prevent pseudohypoxic brain swelling.

Although less common under local or regional anesthesia due to the presence of neck pain, endoscopic surgeons should pause the procedure if patients report neck pain to allow pressure equilibration. Maintaining good inflow and outflow systems during the procedure with irrigation pressure around 25-30 mmHg is also essential.

The prevention of hematoma formation is essential in endoscopic spine surgery, and careful hemostasis before closing the surgical site is crucial. The surgeon should slowly remove the working channel, visually inspecting the soft tissue and performing hemostasis along the way. A soft suction drain may be used to remove fluids and blood during the first postoperative day if bony drilling and decompression are performed.

Summary of Current and Future Expansions of Indications of Endoscopic Spine Surgery

Endoscopic spine surgery has experienced significant advancements due to the work of pioneers and early adopters, as well as an increase in training courses, fellowships, and peer-reviewed articles. Industry investments are being made to improve equipment and anesthesia techniques. Surgeons must be cautious not to over promise the benefits of endoscopic spine surgery, and be aware of their limitations.

The technique has a steep learning curve, but with practice, up to 90% of uncomplicated lumbar degenerative procedures can be performed. With further refinement and research, endoscopic spine surgery may have wider clinical applications in the future, leading to personalized spine care.

If you are interested in knowing more about development of full-endoscopic lumbar spine surgery conditions you have come to the right place!

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Based on 107 reviews
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.