Maximal Benefit Zone of Endoscopic Spine Surgery in the Cervical and Thoracic Spine: Rationale of Endoscopic Spine Surgery in the Cervical-thoracic Region

Hyeun Sung Kim; Pang Hung Wu; Il-Tae Jang

doi:10.21182/jmisst.2023.00703

Abstract

Complex anatomy, difficult access, and low tolerance of cord manipulation in the cervical and thoracic spine are some of the most challenging aspects of spine surgery. Open cervical and thoracic spinal surgery incurs substantial morbidity, with significant postoperative pain, blood loss, and risk of infection in open cervical and thoracic wounds. With the evolution of endoscopic surgical techniques and increasing familiarity with how to handle endoscopic equipment, the indications of endoscopic spine surgery have expanded to include cervical and thoracic spinal decompression in the surgical armamentarium for treating cervical and thoracic spinal pathologies to provide the maximal benefit zone of endoscopic spine surgery.

Key Words: Minimally Invasive Spine Surgery, Endoscopic Spine Surgery, Cervical Vertebrae, Thoracic Vertebrae, Cervical spine.

INTRODUCTION

Endoscopic Spine Surgery (ESS) has undergone rapid development in the last 20 years and has now broadened its spinal surgical indications which traditionally can only be performed with open surgeries [1]. Endoscopic spine surgery provides maximal benefit in cervical-thoracic region as this region is particularly vulnerable to postoperative morbidities [2]. The early postoperative positive effect of endoscopic spine surgery is it minimizes pain, hence patient can have optimal postoperative ventilation; it avoids the use of chest tube and reduces the usage of intensive care unit and high dependency; its potential benefit of motion preservation and its plausible future as an ambulatory cervical-thoracic procedure should be evaluated. In this editorial we discuss the rationale of minimally invasive spinal procedure for cervical-thoracic region and its potential benefits to the patients (Figure 1).

MINIMIZE PERIOPERATIVE PAIN IN POSTERIOR SPINAL APPROACH

One of limitation in posterior cervical-thoracic spinal surgery is significant postoperative neck and upper back pain due to stripping of paraspinal muscle in posterior approach [3]. Several articles had demonstrated good postoperative pain score and neck disability index after cervical-thoracic endoscopic spine surgery [4-6]. This is important to patients as postoperative neck pain is a significant limiting factor to early return to work.

AVOIDANCE OF MORBIDITY OF ANTERIOR CERVICAL-THORACIC APPROACH

In lower cervical and thoracic spine, anterior approach to the thoracic spine through the chest cavity can lead to significant postoperative pain and ventilation issues [7]. ESS application in thoracic region may decrease such complications [8]. The risk of catastrophic vascular injury in anterior thoracic approach and the risk of pleura and lung injury in thoracic anterior approaches limits access to anterior spinal column in thoracic spine. Rib is often harvested to gain access to the anterior thoracic spine which leads to postoperative chest pain and potential ventilation issues. A posterolateral and transforaminal endoscopic thoracic discectomy surgeries which approach the thoracic anterior column from the posterolateral aspect of spine allows access to anterior spinal column without such morbidities. Transforaminal endoscopic thoracic discectomy procedures can be performed with local anesthesia [9], this decreases the need for respiratory support equipment used for endotracheal intubation for general anesthesia.

PLAUSIBLE CONCEPT OF AMBULATORY CERVICAL AND THORACIC SPINAL PROCEDURE

A single 1 cm incision in approach and avoidance of pleura related complication. A successful completion of transforaminal endoscopic thoracic discectomy under local anesthesia has the potential of being an ambulatory procedure [2].

MOTION PRESERVATION IN CERVICAL AND THORACIC ENDOSCOPIC SPINE SURGERY

We had highlighted cervical-thoracic endoscopic surgery in treatment of degenerative pathologies in cervical and thoracic spine decreases in perioperative morbidities of these high risk surgeries [8,10,11]. The long term benefit of motion preservation in ESS in cervical-thoracic region is arguably the key factor for the pursuance of such procedures among spine surgeons. Anterior Endoscopic Cervical Discectomy [12] and Posterior Endoscopic Cervical Discectomy [13,14] can avoid anterior cervical discectomy and fusion or disc replacement. The patients who underwent ESS treatment can have motion preservation without implants. This is an attractive preposition to many patients.

LONG TERM EVALUATION OF EFFECT OF CERVICAL-THORACIC ENDOSCOPIC SPINAL DECOMPRESSION REQUIRES MORE ACADEMIC STUDIES

As an academic community, we work together to evaluate the long term outcomes of these new endoscopic expansion of indications to assess benefits of this branch of sub specialization of spine surgery [15,16]. The learning curve in cervical-thoracic endoscopic spine surgery is steep and is a demanding procedure, we suggest surgeons who embark on these surgeries to be proficient in lumbar spinal surgeries first [2,17].

MAXIMAL BENEFIT ZONE OF ENDOSCOPIC SPINE SURGERY IN CERVICAL-THORACIC REGION

The benefit zone of minimally invasive surgery is wider in more complex anatomical region and challenging surgical procedures [18]. Although traditional open surgeries in cervical-thoracic region has good clinical outcomes, these surgeries have inherent postoperative morbidity and risks. Endoscopic spine surgery can potentially address these gaps by being direct to its target pathology and minimizing the soft tissue trauma, bypassing the difficult anatomy and providing an alternative route to cervical-thoracic region [15].

CONCLUSION

The steep learning curve of cervical-thoracic endoscopic spine surgery is worth the challenge in view of significant perioperative and long term benefit of these procedures compared to traditional open procedures. There is potential for cervical-thoracic spinal endoscopy to be the minimally invasive procedure of choice in providing the maximal benefit zone to patients who require surgery in this complex surgical anatomical region.

NOTES

Ethical statements

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the Nanoori Hospital’s Ethics Committee and the National Research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent from patients: All patients had given their informed consent for photographs, videos and images for publication.

Informed consent: Informed consent was obtained from all individual participants included in the study.

Conflicts of interest

Hyeun Sung Kim and Pang Hung Wu are the Editor-in-Chief and Editorial Board of the Journal of Minimally Invasive Spine Surgery and Technique and were not involved in the review process of this article. All authors have no other potential conflicts of interest to declare relevant to this article.

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

ACKNOWLEDGEMENTS

We would like to acknowledge scientific team members Ms. Jae Eun Park, Mr. Kyeong-rae Kim, Ms. Elin Lee, and Mr. Sang Hyuck Yoon for providing assistance in acquiring full text articles and managing digital works.

Fig. 1.

Editorial team for Journal of Minimally Invasive Spine Surgery and Technique: A Minimally Invasive Approach to the Cervical-Thoracic Spine.

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