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ESS: A Minimally Invasive Method

Spinal disorders, such as disc herniation, spinal stenosis, spondylolisthesis, or spinal tumors, can cause debilitating pain, numbness, weakness, and disability for many patients. Before spine surgery, we had almost no methods available to reduce spinal pain and suffering. After the initial development of spinal surgery, for many years, these conditions were treated with “open” spine surgery, which involves making large incisions in the back and manipulating the spinal structures with surgical instruments. The later introduction of some minimally invasive techniques resulted in smaller incisions.

However, both these techniques may have some drawbacks, such as tissue damage, blood loss, infection, scarring, and prolonged recovery time. Moreover, some patients may not be suitable candidates for these procedures (particularly the most invasive techniques) due to their age, health status, or spinal anatomy.

Endoscopic spine surgery (ESS) is a newer technique that offers a minimally invasive alternative to conventional spine surgery. ESS uses a small incision (less than 1 inch) and a tubular system to access the spine through a natural occurring opening. For example, the spine can be accessed through the intervertebral foramen or the interlaminar space.

An endoscope is a thin, flexible tube with a camera and a light source. The endoscope is inserted through the tubular system and provides a magnified, high-definition view of the spinal structures on a monitor. The surgeon can then use specialized instruments that pass through the endoscope to perform the surgery. The method can be useful in removing disc material, bone spurs, or tumors, or placing screws and rods for spinal fusion.

Endoscopic spine surgery may have several advantages over traditional spine surgery:

  • Reduced tissue trauma: ESS causes minimal disruption of the muscles, ligaments, and bones that support the spine, as it uses a natural opening and a small working channel to reach the spinal pathology. This can reduce the risk of postoperative pain, inflammation, and stiffness, and preserve spinal stability and mobility.
  • Reduced blood loss: ESS requires a smaller incision and less tissue manipulation than traditional spine surgery. This can lead to less bleeding and less need for blood transfusion.
  • Reduced infection risk: Because ESS uses a smaller incision and is effectively a “closed” system. There can be a lower risk of wound infection and spinal infection than in more traditional spine surgery.
  • Reduced scarring: The smaller incision normally leaves a smaller and less visible scar than traditional spine surgery. This has cosmetic benefits, and more reduces the risk of scar tissue adhesion.
  • Reduced recovery time: As a result of reduced tissue damage during the approach, ESS allows for a faster recovery and return to normal activities than traditional spine surgery. This means shorter hospital stays and quicker rehabilitation.

As with any medical procedure, there are also disadvantages and limitation:

  • Endoscopic Spine Surgery is a relatively new and expensive technique, which requires specialized equipment, training, and expertise. The cost of this type of this type of procedure may vary depending on the type and complexity of the surgical intervention, the hospital, and the insurance coverage. It can prove to be more expensive than traditional spine surgery.
  • Limited availability: Dr. Goldstein performs Endoscopic Spine Surgery, but the technique is not available in many locations. Naturally the procedure requires skilled and experienced surgeons and staff who can perform the procedure safely and effectively, but more significantly not all hospitals have the endoscopic systems or the qualified personnel to perform ESS. Therefore, patients may have limited access to this technique and may have to travel long distances to find a suitable surgeon.
  • Technical issues: ESS is dependent on the proper functioning of endoscopic systems and the imaging modalities that are used to observe and guide the surgery. Any technical malfunction or equipment failure may compromise the safety and success of the surgery. In the event of such an event, the surgeon and the surgical team may need to switch to a conventional technique or abort the surgery.
  • Potential complications: ESS involves risks, some of which may be similar to conventional spine surgery, such as nerve injury, spinal cord injury, hardware failure, or nonunion. These complications may require additional surgery or medical treatment, and may affect the patient’s quality of life.

Endoscopic spine surgery is indicated for patients who have symptomatic spinal disorders that affect one or two levels of the spine, and who have failed conservative management and/or require surgical intervention. Currently, ESS is most commonly used for lumbar disc herniation, especially when it is located in the foraminal or extraforaminal region, where the nerve roots exit the spinal canal.

ESS is contraindicated for patients who have any of the following conditions that may compromise the success or safety of the procedure:

  • Advanced degenerative disease of the facet joints or the disc space with associated instability or deformity
  • Ossification of the posterior longitudinal ligament or the ligamentum flavum
  • Severe spinal canal stenosis or spinal cord compression
  • Systemic bone illness (osteoporosis, osteopenia, or metabolic bone disease)
  • Known allergy to the implant’s materials (polyether ether ketone [PEEK], titanium, or cobalt-chromium)
  • Infection or inflammation in the spine or adjacent tissues
  • Morbid obesity or poor general health

ESS is a technique that offers many potential benefits for both surgeons and patients. It has found a place in Dr. Goldstein’s armamentarium* of treatment and technique.

If you are suffering from a spinal condition that affects your function and quality of life, you may be a candidate for ESS. However, not everyone is eligible for this surgery, and there are some risks and complications involved. Dr. Goldstein will discuss the option and others with you.

Dr. Goldstein serves as Director of Education, Division of Spine Surgery and Director of the Spine Surgery Fellowship at NYU Langone Orthopedics, as well as the Director of Spine Fellowship NYU Langone Orthopedics. He is a Clinical Professor of Orthopedic Surgery and Neurosurgery at NYU Grossman School of Medicine. There is no one better qualified to assist you in determining the optimum treatment for your spinal condition. Please contact the office to learn more.