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Percutaneous Endoscopic DiscectomyTransforaminal / Interlaminar
Hyeun Sung Kim, MD, PhD,Ji Soo Jang, MD, PhD, Jung Hoon Choi, MD, Sung Kyun Jung MD, Jung Sub Lee, MD
Department of Neurosurgery, Nanoori Hospital, Suwon City, South Korea
Medical College of Chosun University , Gwangju, South Korea (1994) / Board of Neurosurgery (1999)
MEMBERSHIPS & PROFESSIONAL SOCIETIES
Korean Neurosurgical Society / Korean Spinal Neurosurgery Society / Korean Minimal Invasive Spine Surgery Society / Korean Society of Peripheral
Nervous System / Korean Spinal Deformity Research Society / Korean Spinal Osteoporosis Research Society / NASS / Eurospine / ISASS / AO Spine /
AANS / AANS/CNS Section on Disorders of the Spine & Peripheral Nerves / World Spine Society / WCMISST / ACMISST / ISMISS KOREA, TURKEY,
JAPAN / Korean Society of Thermology / Korean Pain Society / Korean Neuro-Pain Society / The Korean Society of IMS
Best article award in the Korean Neurosurgical Society / Best Paper Award in the 6h ISMISS TURKEY / Best article award in The Korean IMS Therapy Association
AWARDS
Kim HS et al. Balloon kyphoplasty in severe osteoporotic compression fracture: Is it a contraindication? Neurosurgery 2007
Kim HS et al. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. JKNS 2008
Kim HS et al. Endoscopic Transforaminal Suprapedicular Approach in High Grade Inferior Migrated Lumbar Disc Herniation. JKNS 2009
Kim HS et al. Minimally Invasive Multi-Level PLIF Using a Percutaneously Inserted Spinal Fixation System. JKNS 2011
Kim HS et al. Comparative study between different PEILD techniques. Pain Physician 2013
PAPERS: MORE THAN 40 PAPERSPAPERS: MORE THAN 40 PAPERS
Korean Neurosurgical Society: Luncheon Seminar: PELD; Benefits and Limitations / WCMISST 2012, Brazil: Minimally invasive TLIF and PLIF using
the Apollon system / WFNS 2013, Korea: Structural Preservation PEID
KNS / WFNS (World Federation of Neurosurgical societies) / NASS / Eurospine / ISAS / World Spine / KOMISS / ACMISST / Asia Spine / WCMISST /
ISMISS TURKEY / IITS / WENMISS
LECTURE & PRESENTATION: MORE THAN 100 TIMESLECTURE & PRESENTATION: MORE THAN 100 TIMES
REFERENCE DOCTORA. Extra-Foraminal Approach
A. Far lateral Disc
B. Trans-foraminal Approach
A. Foraminal Disc
B. Superior Migration Disc
C. Inferior Migration Disc
D. Paracentral Disc
E. Central Disc
C. Interlaminar Approach
Interlaminar Approach
PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY
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PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY
PETLDPERCUTANEOUS ENDOSCOPIC
TRANSFORAMINAL LUMBAR DISCECTOMY
ANATOMICAL CONSIDERATION NEURAL ANATOMYNEURAL ANATOMY
d. Sinuvertebral nerves
a. Exiting nerve and Ganglia
b. Traversing nerve
c. Sympathetic trunk and ganglia
ANATOMICAL CONSIDERATION VASCULAR ANATOMYVASCULAR ANATOMY
Segmental Artery
Aorta
Radiculomedullary artery
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MRI Length Measurement MRI Marker Physical Examination
APPROACH ENTRY POINTENTRY POINT
10~12 Cm
8~10 Cm
6~8 Cm
4~6 Cm
APPROACH WORKING CHANNEL INSERTIONWORKING CHANNEL INSERTION
ANATOMICAL CONSIDERATION APPROACHAPPROACH ANATOMICAL CONSIDERATION APPROACHAPPROACH
EPIDURAL APPROACHEPIDURAL APPROACH
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ANATOMICAL CONSIDERATION APPROACHAPPROACH
EXITING ROOT APPROACHEXITING ROOT APPROACH
ANATOMICAL CONSIDERATION APPROACHAPPROACH
TRAVERSING ROOT APPROACHTRAVERSING ROOT APPROACH
ANATOMICAL CONSIDERATION LIMITATIONSLIMITATIONS
Anatomical Limitations of PETLD
Migration
Canal Compromise
Iliac crest
Hard bony foraminal width
Surgical Limitations of PETLD
Inside-out / Outside-in approach
Targetectomy
Saftey Zone
Neurological Limitations of PETLD
Epidural approach
Exiting root approach
Traversing root approach
CURRENT DEBATE OF PETLD ANATOMICAL LIMITATIONSANATOMICAL LIMITATIONS
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ANATOMICAL CONSIDERATION HIGHTLY INFERIOR MIGRATED L4-5HIGHTLY INFERIOR MIGRATED L4-5
L4-5
ANATOMICAL CONSIDERATION HIGHTLY INFERIOR MIGRATED L4-5HIGHTLY INFERIOR MIGRATED L4-5
Lee SC, Kim SK, Lee SH, et al. Percutaneousendoscopic lumbar discectomy for migrateddisc herniation: classification of discmigration and surgical approaches. EurSpine J 2006
Lee SC, Kim SK, Lee SH, et al. Percutaneousendoscopic lumbar discectomy for migrateddisc herniation: classification of discmigration and surgical approaches. EurSpine J 2006
Half-and-Half Technique
& Epiduroscopic Approach
Half-and-Half Technique
& Epiduroscopic Approach
Choi G, Kim JS et al. Percutaneous
endoscopic approach for highly migrated
intracanal disc herniations by
foraminoplastic technique using rigid
working channel endoscope. Spine. 2008
Choi G, Kim JS et al. Percutaneous
endoscopic approach for highly migrated
intracanal disc herniations by
foraminoplastic technique using rigid
working channel endoscope. Spine. 2008
Foraminoplastic TechniqueForaminoplastic Technique
Kim HS et al. Endoscopic Transforaminal
Suprapedicular Approach n High Grade
Inferior Migrated Lumbar Disc Herniation
. J Korean Neurosurg Soc, 2009
Kim HS et al. Endoscopic Transforaminal
Suprapedicular Approach n High Grade
Inferior Migrated Lumbar Disc Herniation
. J Korean Neurosurg Soc, 2009
SuprapedicularSuprapedicular
SURGERY RELATED RELAPSERELAPSE
Segmental Loading Component
Age
Disc location
Herniated disc level
Disc height
Healing Component
Degeneration Scale
Anti-adhesive agent
Combined HNP
SURGERY RELATED RETROPERITONEAL HEMATOMARETROPERITONEAL HEMATOMA
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SURGERY RELATED PYOGENICSPONDYLODISCITISPYOGENICSPONDYLODISCITIS CURRENT ISSUES EQUIPMENTEQUIPMENT
CURRENT ISSUES HIGH CANAL COMPROMISEDHIGH CANAL COMPROMISED CURRENT ISSUES FORAMINAL TO SUPERIOR MIGRATIONFORAMINAL TO SUPERIOR MIGRATION
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CURRENT ISSUES FAR LATERALFAR LATERAL CURRENT ISSUES RECURRED HNP AFTER OMDRECURRED HNP AFTER OMD
CURRENT ISSUES CALCIFIED HNPCALCIFIED HNP CURRENT ISSUES ADJACENT 2 LEVEL HNPADJACENT 2 LEVEL HNP
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CURRENT ISSUES CURVED PROBECURVED PROBE
51 yr / M Highly Inferior Migrated
CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL
74 yr / M Highly Inferior Migrated
CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL
74 yr / M Highly Inferior Migrated
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CURRENT ISSUES FORAMINOPLASTYFORAMINOPLASTY
67 yr / F Foraminal Stenosis
PEILDPERCUTANEOUS ENDOSCOPIC
INTERLAMINAR LUMBAR DISCECTOMY
ANATOMICAL CONSIDERATION LIMITATION OF PETLDLIMITATION OF PETLD ANATOMICAL CONSIDERATION LIMITATION OF PETLDLIMITATION OF PETLD
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Interlaminar
Trans-Shoulder
Trans-Axial
Resection
Possible
Wide
( + )
Posterolateral
ApproachTransforaminal
Trans-iliac
Ligamentum Flavum Spare
Annulus Repair Impossible
Indication Limited
Adhesion Weak
CURRENT DEBATE L5-S1: PETLD VS PEILDL5-S1: PETLD VS PEILD L5-S1: PETLD VS PEILDL5-S1: PETLD VS PEILDCURRENT DEBATE
L5-S1: Percutaneous Endoscopic Approach
NEURAL APPROACHNEURAL APPROACHCURRENT DEBATE
Axilla
Moderate
Easy
Difficult
Weak
Easy
Shoulder
Learning Curve Short
Inferior Migration Difficult
Superior Migration Easy
Nerve root retraction Hard
Annulus Sealing Difficult
LIGAMENTUM FLAVUM SPLITTINGLIGAMENTUM FLAVUM SPLITTINGCURRENT DEBATE
Classification Technique
Splitting
Indirect Choi G
Direct Kim CH
Resection
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ANNULUS SEALINGANNULUS SEALINGCURRENT DEBATE STRUCTURAL PRESERVATIONSTRUCTURAL PRESERVATIONCURRENT DEBATE
L5-S1: Structural Preservation
CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE
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CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE CURRENT ISSUES HIGHLY INFERIOR MIGRATEDHIGHLY INFERIOR MIGRATED
38yr/Female38yr/Female
CURRENT ISSUES HIGHLY SUPERIOR MIGRATEDHIGHLY SUPERIOR MIGRATED
44yr/Male44yr/Male
CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD
53yr/Male53yr/Male
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CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD
53yr/Male53yr/Male
CURRENT ISSUES CONTRALATERAL PEILDCONTRALATERAL PEILD CURRENT ISSUES CONTRALATERAL PEILDCONTRALATERAL PEILD
43yr/Male43yr/Male
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CURRENT ISSUES CALCIFICATION FLOATING TECHNIQUECALCIFICATION FLOATING TECHNIQUE
Interlaminar: L5-S1: 59/M, Rt.
CONCLUSION
Limitation: Anatomical, Surgical, Neurological
Approach: Epidural, Exiting, Traversing
In and Out / Out and In
Highly inferior migrated L4-5
Advanced surgical science and technology
Wide PELD indication
Future of PELD
CONCLUSION
Structural preservation technique of
percutaneous endoscopic interlaminar lumbar
discectomy
Ligamentum flavum splitting technique
Fissure fragmentectomy and sealing technique.
Axilla route / Shoulder route
Contralateral interlaminar approach
Calcification floating technique
INDICATIONS
Paramedian disc herniations with predominant leg pain
Subligamentous ruptured or extruded disc
migration less than height of disc space
Central disc herniation with predominant back pain
Annular tears that cause chemical sciatica
Formainal disc herniations, synovial cysts of the facet joint
Far lateral disc herniation, Superior migrated disc herniation
Huge central protruded disc: High canal compromise
Recurred Disc
Sequestrated disc that had migrated
Non-contained Inferior migrated disc
Lateral recess stenosis, spinal stenosis
Calcified Disc
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INDICATIONS
Thank you !