Current limits and feasible future modifications of lumbar endoscopy

Abstract

After inception of modern percutaneous endoscopic lumbar discectomy (PELD) in 1997 with the development of YESS endoscope a lot of advancement has taken place and is evolving day by day. Problems related to percutaneous endoscopic spinal surgery are being solved gradually. But till now microscopic lumbar discectomy (MLD) is considered as a gold standard treatment for disc herniation though there is tremendous development in the understanding of endoscopic discectomy in terms of knowledge, techniques, evolution of instruments, and other accessories. It is because there is still lack of strong evidences. We are still lacking good classifications that guide management, prognosis, and outcome evaluation. Equipment are evolving day by day but we do not still know how many and what types are required for successful removal of all kinds of disc herniation endoscopically. We are using different bone cutting/shaving devices to enlarge foramen (foraminoplasty) but still do not know which one is safer and cost effective. To overcome steep learning curve of endoscopic procedures there is a need of well-formulated training course and well-organized spinal endoscopic society. We need more detailed study to identify a cause of the recurrence and then we need material that decreases the recurrence or material that helps to regenerate degenerated disc or implant or procedures that prevent the recurrence. We are practicing decompression and discectomy but still lack knowledge on biological treatment of disc diseases. Approval of the endoscopic procedure from governing body is another challenge that is to be solved in future. It is very difficult to predict absolute future modification of lumbar endoscopic discectomy unless we have sound evidences. Time will determine its future and direction. Nevertheless, percutaneous endoscopic spinal surgery will be gold standard treatment for spine problems in the years to come and will replace all open surgeries. Development of endoscopic surgery in future will be in the direction of routine use in other areas of spine such as cervical and thoracic spine, development of high-resolution camera with the ability of 3-dimensional pictures, flexible instrument to reach hook and crooks of spine, better coagulation system which has less thermal effect on cord or nerve, better drilling system, and also delivery tools for disc regeneration. In this chapter we discuss about current evidences, recurrence, learning curve, foraminoplasty, endoscopic equipment and approaches, proposed endoscopic difficulty grade classification of lumbar disc herniation, proposed classification of surgical success grade, legal aspects, and indications other than discectomy including regenerative aspect of disc degeneration and also discuss about the future of the endoscopic spinal surgery.