The Role and Future of Endoscopic Spine Surgery: A Narrative Review

Abstract

Many types of surgeries are changing from conventional to minimally invasive techniques. Techniques in spine surgery have also changed, with endoscopic spine surgery (ESS) becoming a major surgical technique. Although ESS has advantages such as less soft tissue dissection and normal structure damage, reduced blood loss, less epidural scarring, reduced hospital stay, and earlier functional recovery, it is not possible to replace all spine surgery techniques with ESS. ESS was first used for discectomy in the lumbar spine, but the range of ESS has expanded to cover the entire spine, including the cervical and thoracic spine. With improvements in ESS instruments (optics, endoscope, endoscopic drill and shaver, irrigation pump, and multiportal endoscopic), limitations of ESS have gradually decreased, and it is possible to apply ESS to more spine pathologies. ESS currently incorporates new technologies, such as navigation, augmented and virtual reality, robotics, and 3-dimentional and ultraresolution visualization, to innovate and improve outcomes. In this article, we review the history and current status of ESS, and discuss future goals and possibilities for ESS through comparisons with conventional surgical techniques.

Keywords: Augmented reality; Endoscopic spine surgery; Minimal invasive surgery; Navigation; Robot-assisted surgery.

Fig. 1.

(A) Standard set-up for tubular retractor. Surgical view during minimally invasive transforaminal lumbar interbody fusion with tubular retractor. Facet joint (B) and interbody cage insertion (C).

Fig. 2.

Overview of unilateral biportal endoscopic spine surgery (A) and operative view (B). Surgical instruments (drills, etc.) could move independently in the endoscope view field.

Fig. 3.

Visualization with tubular retractor (A) and spine endoscope (B). Due to zoom-in effects during endoscopic spine surgery, endoscopic spine surgery showed similar or superior resolution to conventional approaches.

Fig. 4.

Biportal endoscopic transforaminal lumbar interbody fusion (TLIF). (A) Preoperative magnetic resonance images showed degenerative spondylolisthesis L4 on L5 with right foraminal stenosis (arrow). The patient underwent biportal endoscopic TLIF. (B) Preoperative and postoperative lateral x-rays showed spondylolisthesis was reduced well with interbody cage and percutaneous pedicle screw fixation. (C) Endoscopic images show complete discectomy and endplate preparation and inserted titanium cage (arrow).

Fig. 5.

A cervical ossification of the posterior longitudinal ligament patient underwent full endoscopic cervical discectomy and fusion. Preoperative (A) and postoperative magnetic resonance images (B). C-arm lateral image (C) during foraminotomy and operative view after cage insertion (D). (E) Final wound was about 2 cm. All images were provided by Dr. Kangtaek Lim.

Fig. 6.

Thoracic disc herniation with myelopathy in T10–11 underwent thoracic discectomy and postero-lateral fusion by unilateral biportal endoscopic surgery. Preoperative (A) and postoperative magnetic resonance images (B). Postoperative x-ray (C) showed screw fixation. All images were provided by Dr. Mankyu Park.

Fig. 7.

Biportal endoscopic surgery with navigation. The use of fluoroscope during endoscopic spine surgery could be replaced by navigation-assisted endoscopic surgery. An O-arm (A) is needed to apply navigation-assisted endoscopic surgery. Operation field with optical tracer (B), navigation and endoscope monitor (C).

Fig. 8.

Real-time tracking of surgical instruments during navigation- assisted biportal endoscopic spine surgery. Navigation image (A) and endoscopic image (B). Instrument tip is located inside the disc.

Fig. 9.

Excellent visualization provided by a 4K ultraresolution endoscope. In particular, since it is possible to zoom-in closer to the lesion with ultraresolution, a more detailed view can be seen compared to conventional surgery. Left S1 root (asterisk) is well recognized with surrounding blood vessels and epidural fat (A), and tiny structures like foraminal ligaments are visible (arrow) (B).