Endoscopy in Cervical Spine Surgery

Abstract

The first evidence of spinal surgery was found in Egyptian mummies 2900 BC [1]. In the antiquity, about 2500 years later, Hippocrates who is considered “The father of spine surgery” collected a valuable heritage of knowledge and methodology about the human body. He was the first who described sciatica and low-back pain. He also proposed a traction procedure and invented devices based on his fundamental principle [2]. Concerning the cervical spine, Aulus Celsus was the first who noted death following injury of the cervical spinal cord [3]. Paulus of Aegina performed the first operative repair of injured spinal cord by removing bony fragments which irritated the spinal cord and caused consecutive paralysis in the seventh century [3]. It took spinal surgery about 1900 years until an endoscope was applied. In 1983, the first report of an examination technique for intervertebral disc space after nucleotomy via endoscopy/arthroscopy was described by Frost and Hausmann [4]. Since then new surgical technology and techniques for minimally invasive approaches have revolutionized the work of surgeons of all subspecialties. Procedures such as laparoscopic cholecystectomy and orthopedic arthroscopy have proven to decrease surgically related morbidity, shorten postoperative hospital time and improve clinical outcomes [5–7]. In spinal surgery, morbidity is associated with iatrogenic muscle and soft tissue injury due to approach and exposure of the surgical field. Particularly in lumbar spine surgery, the standard open approach leads to iatrogenic injury of the paraspinal muscles which might result in decreased muscle strength and muscle atrophy after extensive muscle retraction [8, 9]. Biomechanical studies have investigated the function of the posterior column and its importance in maintaining lumbar spinal stability [10, 11]. Serial tube dilators and retractors were designed to split the back muscle gently and thus made to minimize retraction and disruption of the paraspinal muscular integrity. Further, other studies demonstrated that the postoperative recovery of CK and CRP levels occurred within 1 week and that the intensity of low back pain was mild [12, 13]. Mayer et al. studied the postoperative muscle architecture on CT scan and its relevance for failed-back syndrome [8]. They found that the integrity of paraspinal muscles might be of utmost importance for the postoperative result. A tubular retraction system provides direct and focal access to the diseased anatomy via a less invasive approach [14, 15]. Surgery can be done by using either an endoscope or using a microscope for visualization. The microendoscopic technique for interlaminar fenestration is considered safe and effective treatment of degenerative lumbar spine diseases and makes this to be seen as an option along with the traditional technique for every spine surgeon [16].