http://www.drsandeepagrawal.com/spine.php There are many different types of conditions that cause back pain. Like most medical conditions, back pain is treatable through several methodologies. Determining what condition you have is the key to determining the right treatment option for you. Back pain comes in many forms, lower back pain, middle back pain, and upper back pain are just a few of the symptoms associated with spinalconditions. You may also have pain or tingling in your extremities that may be indications of spinal conditions. Feel free to browse through our articles about conditions. Contact your doctor to set up an appointment to start your road to recovery. Every person is different, so symptoms of conditions may present differently for different people. Symptoms also vary depending on the condition, its severity, location, and other factors.

1. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
1
http://www.drsandeepagrawal.com/spine.php
Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
ADVANCES IN SPINE SURGERY
Endoscopic and Minimally
Invasive Spine Surgery

2. 2
Understanding Back Pain Basics of
Spine:
"
"
http://www.slideshare.net/
sandeepcagrawal/understanding-back-
pain-basics-of-spine-drsandeep-c-
agrawal-agrasen-orthopedic-hospital-
gondia-india

3. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
InterVertebral Disc

4. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
4
Herniated disk in the lower back:
"
http://www.slideshare.net/SANDEEPAGRAWALORTHO/
herniated-disk-in-the-lower-back-agrasen-hospital-dr-sandeep-
agrawal-gondia-vidarbha-maharashtra-india-
wwwdrsandeepagrawalcom-wwwagrasenorthocom
"
"
Sciatica low back pain :
"
http://www.slideshare.net/SANDEEPAGRAWALORTHO/
sciatica-low-back-pain-wwwdrsandeepagrawalcom-agrasen-
hospital-dr-sandeep-agrawal-gondia-maharashtra-
wwwagrasenorthocom-60232530
For Details click below links

5. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Degenerative Disc Disease

6. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Provocative Discogram

7. • Provocative discography (+) is the definite diagnosis of DDD
• 90% patients will go on to complete pain relief within 2 to 6
weeks
• NSAID and antispasmolytic medicine are effective in the
management of acute back pain, but is unclear in chronic pain
• Intradiskal electrothermotherapy (IDET) has been proposed as
an option of the treatment
• Lumbar fusion the surgical procedure of choice for the
treatment of discogenic back pain with poor response to
conservative treatment
• Disc excision or decompression procedure are another
recommended procedures in treating DDD
• Successful fusion is obtained in 60% to 90% of patients who
undergo posterior procedure, but clinical outcomes are
satisfactory in only 40% to 70%.

8. • Posterior procedures
– PLIF
– TLIF
• ALIF can remove pain fibers and receptors
from the annulus fibrosus and nucleus pulposus,
eliminate motion across disc, restore disc height
and indirectly decompress neuroforamen, avoid
posterior muscle disruption
– Open
– Laparoscopic ALIF

9. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
IntraDiscal ElectroThermotherapy
( IDET )
For discogenic pain (axial pain)

10. Thermal energy: 65ºC for 17 minutes
•Collagen shrinkage
•Destruction of nociceptive fibers

11. Indications (Saal & Saal)
• Axial pain > 6 months
• Non-operative care at least 3 months
• No psychosocial problems
• SLRT (-)
• Disc height: > 50% preserved
• MRI: no compressive lession
• Provocative discogram (+)

12. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

13. Results of IDET! highly varied
• 70% satisfied result Saal JA. Spine. 2000
• 50% were dissatisfied Davis TT. Spine. 2004
• Not effective Spruit M. Eur Spine J. 2002
• Potentially beneficial in carefully selected patients
Biyani A. Spine. 2003
• Worthwhile in a small proportion of strictly
defined patients Pauza KJ. Spine J. 2004

14. Complications
• Discitis
• Nerve root injury
• Catheter breakage
• Cauda equina syndrome

15. General Concept of IDET
• IDET should be considered as
“Experimental Procedure”
• Maybe useful in highly selected patient

16. ALIF
• Need for an access surgeon (NS)
• Nonunion: 2nd procedure for fixation
• Great vessels and peritoneal injury
• Post-op retrograde ejaculation: 17-25%

17. PLIF
• Advantages
– Single approach
– Prevent ALIF drawback
• Drawbacks
– Wide laminectomy
– Aggressive retraction of thecal sac
– Nerve root injury & dural fibrosis
– Not good for upper lumbar spine

18. TLIF
• Facetectomy and far-lateral approach
• Preserve contralateral side
• Minimize approach-related morbidity
– Aggressive retraction of thecal sac
– Retraction injury of nerve roots

19. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Traditional Surgery

20. Minimal Invasive Surgery
• Less wound size
• Less trauma ( physically and psychologically )
• Less surgical & anesthesia risk
• Same-Day surgery or Less hospitalization
• Early rehab & recovery
• Less cost

21. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Endoscope Assisted TPS
Instrumentation and Fusion

22. Challenges for Posterior Endoscopic
Spinal Surgery
• No physiologic potential space or tissue
plane
• Need to create a working space
• Need to place hardware through small
cannula

23. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

24. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

25. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Muscle-splitting approach:
Interval between multifidus medially and the
longissimus laterally

26. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

27. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

28. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

29. HIVD with Sciatica

30. 1.Exploring sciatica & back pain :
"
http://www.slideshare.net/sandeepcagrawal/exploring-sciatica-back-pain-wwwdrsandeepagrawalcom-
wwwagrasenorthocom-agrasen-hospital-gondia-vidarbha-dr-sandeep-c-agrawal-gondia-maharashtra
"
2.
PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc
"
http://www.slideshare.net/sandeepcagrawal/prolapse-disc-slip-disc-herniation-intervertebral-disc-
agrasen-hospital-gondia-vidarbha-dr-sandeep-c-agrawal-wwwdrsandeepagrawalcom-
wwwagrasenorthocom
"
3.
Discogenic low back pain Treatment:
"
http://www.slideshare.net/sandeepcagrawal/discogenic-low-back-pain-treatment-agrasen-hospital-
gondia-vidarbha-dr-sandeep-c-agrawal-wwwdrsandeepagrawalcom-wwwagrasenorthocom
4.
Radiculopathy(spine) Low back pain :
"
http://www.slideshare.net/SANDEEPAGRAWALORTHO/radiculopathyspine-low-back-pain-
wwwdrsandeepagrawalcom-wwwagrasenorthocom-agrasen-hospital-gondia-vidarbha-dr-sandeep-c-
agrawal-gondia-maharashtra
For Details:
Click below links

31. 31
Back pain and spine injections
http://www.slideshare.net/SANDEEPAGRAWALORTHO/back-
pain-and-spine-injections-wwwdrsandeepagrawalcom-
wwwagrasenorthocom-agrasen-hospital-gondia-vidarbha-dr-
sandeep-c-agrawal-gondia-60235593
For Details click below:

32. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Radiculogram & Nerve Block

33. Indications
• Radicular pain resistant to other
therapeutic means
• Radicular pain for which operation is
contraindicated

34. Contraindications
• Infection
• Disturbed consciousness
• Bleeding tendency
• Emotional instable
• Lack of understanding of the procedure

35. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Needle Position

36. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
L4 Radiculogram

37. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Needle Position

38. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
L4, L5 Radiculogram

39. Results
• 47% improved, 28% unchanged, 16% worse
Tong HC. Spine J. 2003
• 84% success rate
Vad VB. Spine. 2002
• 75.4% had a successful long-term outcome
Lutz GE. Arch Phys Med Rehabil. 1998

40. • Persistent intractable pain> 6 weeks ! surgery
• Disc herniation into stenotic cannal, patients can not
comply with dictates of conservative regimen, numbers
of csiatica episodes are also surgical indications
• Absolute surgical indications are bladder and bowel
involvement and progressive neurologic deficit
• The laminotomy and diskectomy is the gold standard
for surgical treatmentof posterolateral HIVD
• Wiltse paraspinal approach is for extraforaminal
HIVD
• Endoscopic discectomy
– PED
– MED
Surgical Treatment

41. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Percutaneous Endoscope Discectomy

42. Indication
• Radicular pain
• Positive root tension sign
• Positive imaging study
• Persisted symptom at least 6 weeks of
proper conservative treatment

43. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

44. PED Procedures (Marking)

45. PED Procedures (Discography)

46. PED Procedures (Local Anes.)

47. Endoscope-guide Discectomy

48. Endoscope-guide Discectomy

50. PED Procedures (Wound)

51. Results
• Kambin: 88.2% Clin Orthop 1998!
• Hermantin: 97% J Bone Joint Surg [Am] 1999!
• Yeung AT: 81.4% Spine 2002!
• Mayer HM: 3/20 re-op J Neurosurg 1993!
• Kleinpeter G: 5 / 8 < 1 M shift to open !
Surg Neurol 1995

52. PELD Indications for good result
• Soft disc content (CT)
• Contained or not sequestrated (MRI)
• Without spinal stenosis
• Without instability
• Young age (<40 Y/O)
• Shorter S/S duration (3-6Ms)

53. Patient Selection

54. Patient Selection

55. Optimal Position
Poor Good

56. Optimal Instruments
Holmium
Laser
RF

57. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
MED
( MicroEndoscopic Discectomy )

58. MED
(MicroEndoscopic Discectomy)
–1997 , Smith & Foley
•Minimal damage and Direct
visualization by
Muscle-splitting dilators
Endoscope and Video monitor

59. METRx System

60. Introducer Set

61. Instruments & Scope

62. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

63. MED ( METRx System )

64. Scope Images
Disc
Lig. Flavum
Lower edge
of L4

65. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

66. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com
Wound Size ( 2cm)

67. Potential disadvantages
• Learning curve
• Limited visualization
• Inadequate exposure
• Incomplete decompression
• Vessel & nerve damage
• Limited ability to treat lateral recess
and foraminal stenosis

68. Vertebral Compression Fracture
• DETAILED PPT LINK:
Percutaneous Vertebroplasty( SUTURELESS
SURGERY ) and Osteoporotic Spinal
Compression Fracture Treatment:
"
http://www.slideshare.net/sandeepcagrawal/
osteoporotic-compression-fracture-and-
percutaneous-vertrebroplasty-drsandeep-c-
agrawal-agrasen-hospital-gondia-maharashtra-
india

69. Kyphoplasty
SEE OTHER PPT LINK:

70. VATS
• Same indications and goals as open
• Advantages and disadvantages: as
minimally invasive surgery
• 6th intercostal space at midaxillary line
• No need of CO2 insufflation
• Technical demanding & learning curve

71. Applications
• Infection
• Biopsy
• Debridement
• Tumor excision
• Disc excision
• Corpectomy & Fusion
• Deformity correction
• Anterior release
• Hemivertebtal excision
• Internal thoracoplasty
• Anterior fusion and instrumentation

72. Contraindications
• Inability to tolerate one-lung ventilation
• Severe or acute respiratory insufficiency
• High airway pressure with positive pressure
ventilation
• Pleural symphysis
• Bullous lung pathology
• Empyema (relative)
• Previous thoracotomy (relative)
• Previous tube thoracotomy (relative)
• Narrow A-P chest diameter (relative)

73. Complications
• Same as open approach
• Spinal cord injury or ischemia
• Dural laceration
• Intercostal neuralgia (21% patients)
• Incomplete anterior release
• Lung, diaphragm heart, thoracic duct,
azygos vein, esophagus, sympathetic chain,
segmental artery and splanchnic nerves
injury by instruments

74. VATS

75. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

76. DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

77. Other Procedures
• Anterior lumbar scope surgery
– Transperitoneal approach (L4-5, L5-S1)
– Retroperitoneal approach (T12 to S1)
• Anterior thoracolumbar scope surgery

78. 78
Humor And Laughter Are Important!
"
Humor in our daily lives is an essential ingredient!
of happiness. So, learn to look on the funny!
side of things. Even serious situations.
Have you had a good laugh today? !
If you haven't, then please do - don't!
let the day go to waste! Laughter!
melts the distances between people.

79. 79
This presentation is for doctors and students in
general."
. Graphics,Images and jpeg files are taken from Google
and yahoo Image to heighten the specific points in
this presentation. "
• If there is any objection/or copyright violation, please
inform drsandeep123@gmail.com for prompt deletion. "
• It is intended for use only by the doctors of
orthopaedic surgery."
. Views expressed in this presentation are personal.
• .For any confusion please contact the sole author for
clarification. "
• Every body is allowed to copy or download and use
the material best suited to him. "
There is no financial involvement."
• For any correction or suggestion please contact
drsandeep123@gmail.com or www.agrasenortho.com"
or www.drsandeepagrawal.com"