In recent years, endoscopic spine surgeries have advanced dramatically. Endoscopic spine surgeries are expanding to not only the lumbar spine, but also thoracic and cervical spines. Indications for spinal endoscopic surgery have also been expanded. Central stenosis, lateral recess stenosis, and foraminal stenosis were included in surgical indications of endoscopy. Finally, endoscopic lumbar interbody fusion surgeries have been attempted

Dong Chan Lee

Dong Hwa Heo

Hungtae Chung

Hyeun Sung Kim

Journal of Minimally Invasive Spine Surgery and Technique

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JMISST Journal of Minimally Invasive SpineSurgery and Technique 6(Suppl 1):S81-S83, 2021 eISSN 2508-2043https://doi.org/10.21182/jmisst.2021.00136www.jmisst.orgIntroductionCopyright© 2021 The Korean Minimally Invasive Spine Surgery SocietyThis is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License(http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.Recent Trends and Changes in the Endoscopic Spinal SurgeryDong Hwa Heo1, Dong Chan Lee2, Hyeun Sung Kim3, Hungtae Chung11Departments of Neurosurgery, Endoscopic Spine Surgery Senter, Orthopedics, Seoul Bumin Hospital, Seoul, Republic of Korea2Department of Neurosurgery, Spine Senter, The Leon Wiltse Memorial Hospital, Anyang, Republic of Korea3Department of Neurosurgery, Nanoori Gangnam Hospital, Seoul, Spine Surgery, Seoul, Republic of KoreaCorresponding Author: Dong Hwa Heo, MD, PhDEndoscopic Spine Surgery Center, Neurosurgery, Seoul Bumin Hospital, 389, Gonghang-daero, Gangseo-gu, Seoul, Republic of KoreaTel: +82-31-240-6086E-mail: spineneurosurgeon@gmail.com Received: March 11, 2021Revised: March 12, 2021Accepted: March 14, 2021In recent years, endoscopic spine surgeries have advanced dramatically. Endos- copic spine surgeries are expanding to not only the lumbar spine, but also thoracicand cervical spines. Indications for spinal endoscopic surgery have also been expan-ded. Central stenosis, lateral recess stenosis, and foraminal stenosis were inclu- ded in surgical indications of endoscopy. Finally, endoscopic lumbar interbody fusionsurgeries have been attempted. Key Words: Endoscopy, Spine, Biportal, FusionFigure 1. Recently developed endoscopy systems. Ⓐ: Modified inter-laminar endoscopic system with a large working channel. Ⓑ: Biportalendoscopic systems with two channels (an endoscopic portal and aworking portal).INTRODUCTIONIn recent years, endoscopic spine surgeries have advanced dramatically. In addition to advancements of endoscopic spine approaches, advancements of spinal endoscopy equipment and surgical instruments have also been made. Endoscopic spine surgery was mainly used for lumbar disc herniation surgery and low back pain treatment in the past. It has now advanced to a state where laminectomy, foraminotomy, and spinal fusion are possible2,3,6). Endoscopic spine surgeries are expanding to not only the lumbar spine, but also thoracic and cervical spines. Indications for spinal endoscopic surgery have also been greatly expanded8). Indications for endoscopic spine surgery are almost similar to those for a conventional microscopic surgery.1. New Systems of Endoscopic Spine SurgeryIn the past, uniportal spinal endoscopy mainly used a lumbar transforaminal approach. Spinal endoscopic surgery using a lum- bar transforaminal approach was mainly performed for lumbar disc removal. Recently, interlaminar endoscopes equipped with large diameter working channel have been developed by various companies7). Moreover, various spinal endoscopic surgical instru- ments that can pass through large diameter working channel have been developed (Figure 1A). Various spinal endoscopic dis-sectors, water-proof drills, endoscopic Kerrison punch, and radio frequency probes can be used through the large diameter work-ing channel of modified interlaminar uniportal endoscopic sys-tems (Figure 1A), thus facilitating bone-work such as lamino- tomy, laminectomy, and facetectomy7). Even with a uniportal full endoscopic approach, it is possible to proceed to discectomy, decompression, and fusion through a posterior approach rather than a transforaminal approach.Biportal endoscopic spine surgery (unilateral biportal endos-copy, UBE) introduced in 1996 was first used for lumbar discec- tomy1). Compared to a uniportal endoscopic spine surgery, the surgical method of biportal endoscopy was not widely used. However, in recent years, the biportal endoscopic approach has been re-developed, mainly in South Korea. Biportal endos- copic surgery system, surgical instruments, and radiofrequency notomy, and interbody fusion using biportal endoscopy have been tried3,5). Now they are popularized. With the development of biportal and large working channel uniportal endoscopy sys-Dong Hwa Heo, et al.82   www.jmisst.org1st generation 2nd generation 3rd generation 4th generationEndoscopy systems Uniportal Uniportal Uniportal/Biportal Uniportal/BiportalIndication Disc herniation Disc herniation Disc herniationCentral stenosisForaminal stenosisStenosisInstabilityLesion Lumbar Lumbar LumbarThoracicCervicalLumbar Lumbar interbody fusionApproach Transforaminal interlaminar Posterior InterlaminarTransforaminal Trans-KambinPosterolateral Table 1. Generation and development of endoscopic spine surgeries Figure 2. Generation and paradigm shifting of endoscopic spine surgeries.tems, endoscopic spine surgeries have become more advanced (Figure 1B).2. Paradigm shifting of Endoscopic Spine ApproachesThe development process of spinal endoscopic surgery can be largely divided into four stages (Table 1 and Figure 2). The first generation is the lumbar transforaminal approach, which has been implemented since the early days of spinal endoscopic surgery. Transforaminal endoscopic approach has been in use since its inception. The second generation is an interlaminar approach. A posterior interlaminar approach has been attempted to treat lumbosacral disc herniation, which is difficult to access with a transforaminal approach. With the third generation, surgical indication and site have developed dramatically6). With the first generation and second generation, the indication for spinal endos- copic surgery was mainly lumbar disc herniation (Figure 2 and Table 1). However, with the development of the third generation, central stenosis, lateral recess stenosis, and foraminal stenosis were included in surgical indications of endoscopy. In addition, endoscopic treatment was possible not only in the lumbar spine, but also in the cervical thoracic spine (Figure 2 and Table 1). The biggest change is shown in the fourth generation, with which endoscopic lumbar interbody fusion can be attempted. Using a posterolateral approach and a trans-kambin approach, endoscopic transforaminal lumbar interbody fusion can be perfor- med4).3. Future of Endoscopic Spine SurgeryEndoscopic spine surgeries including biportal and uniportal endoscopic systems are expected to continue to progress. Altho- ugh endoscopic spine surgery will develop on its own, it can be combined with hybrid operation, three-dimensional surgery, navigation, and merged reality in conjunction with various other techniques. Additionally, endoscopic spine surgery might be incor- porated into robotics. Endoscopic spine surgeries are expected to continue to develop with the advancement of optical techno- Recent Trends of Endoscopic Spine Surgery JMISST 6(1) April 2021 83logy and surgical instruments. It is believed that it will replace many parts of the conventional spine surgery.CONFLICT OF INTERESTDr. DH Heo is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. There are no other potential conflicts of interest relevant to this article to declare.REFERENCES 1. De Antoni DJ, Claro ML, Poehling GG, Hughes SS: Translaminar lumbar epidural endoscopy: Anatomy, technique, and indications. Arthroscopy 12:330-334, 1996 2. Heo DH, Eum JH, Jo JY, Chung H: Modified far lateral endos- copic transforaminal lumbar interbody fusion using a biportal endoscopic approach: technical report and preliminary results. Acta Neurochir (Wien), 2021 3. Heo DH, Hong YH, Lee DC, Chung HJ, Park CK: Technique of Biportal Endoscopic Transforaminal Lumbar Interbody Fusion. Neurospine 17:S129-S137, 2020 4. Heo DH, Lee DC, Kim HS, Park CK, Chung H: Clinical Results and Complications of Endoscopic Lumbar Interbody Fusion for Lumbar Degenerative Disease: A Meta-Analysis. World Neuros- urg 145:396-404, 2021 5. Heo DH, Quillo-Olvera J, Park CK: Can Percutaneous Biportal Endoscopic Surgery Achieve Enough Canal Decompression for Degenerative Lumbar Stenosis? Prospective Case-Control Study. World Neurosurg 120:e684-e689, 2018 6. Kim M, Kim HS, Oh SW, Adsul NM, Singh R, Kashlan ON, et al.: Evolution of Spinal Endoscopic Surgery. Neurospine 16: 6-14, 2019 7. Lim KT, Meceda EJA, Park CK: Inside-Out Approach of Lum- bar Endoscopic Unilateral Laminotomy for Bilateral Decompre- ssion: A Detailed Technical Description, Rationale and Outcomes. Neurospine 17:S88-S98, 2020 8. Wu PH, Kim HS, Jang IT: A Narrative Review of Development of Full-Endoscopic Lumbar Spine Surgery. Neurospine 17:S20- S33, 2020

Recent Trends and Changes in the Endoscopic Spinal Surgery

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