elow are some question and answers about Aware State Endoscopic Laser Surgery to the Spine:
Q: In what position will I be on the operating table?
A:
During surgery you will be positioned on a curved table, so that you are face downwards as if on a hump backed “bridge”, in order to expose the spine as much as possible for easier access by the surgeon.
Q: What level of awareness will I feel?
A:
You will be sedated. This is not like a general anaesthetic where you are totally unaware of all around you. It is similar to being in a dream-like/half aware state.
Q: Will I be awake during surgery and will I be able to feel pain?
A:
You will be aware of other people around you and of the surgeon asking you questions. This awareness is not the same as being fully awake. It is more like a dulling of the senses and being half asleep. You will not be able to feel the probe or any other instruments in your body. You will be able to answer questions put to you about where the stimulus is felt in your body. This is not a sharp pain, but an awareness of discomfort.
Q: How long will the operation take?
A:
This depends very much on the type of surgery you are having and you should ask your surgeon about this. Your awareness will be of going into the operating theatre and waking up sometime later. The events whilst in the operating theatre feel like a dream. Whilst sedated you will have very little concept of time.
Q: Is the benefit of the surgery felt immediately? Is the pain relief total? Will there be residual pain?
A:
The effects of the surgery are immediately noticeable. When you wake up the sensations of pain and numbness previously felt will be noticeably different and may well have disappeared altogether.
Q: How active will I be after the operation? How long is the recovery period?
A:
You will be encouraged to walk about as soon as you wake up and to undertake a guided exercise programme to improve your mobility. The length of time to full recovery will depend on you. You will be able to help yourself by taking care of your diet and building up your stamina. It is important to keep moving as much as possible. Keep things in perspective. If you have been inactive for a long period of time prior to the operation you will need to build up your programme of exercise steadily so that your muscles do not fatigue.
Q: Why should we use the seal on the endoscope?
A:
This keeps the water pressure up in the working zone and allows bleeding to be controlled, pinpointed and then sealed by radiofrequency or Laser energy.
Q: Should we always work within the sheath?
A:
Initially yes, but as experience is gained then once the position of the nerve has been identified and protected by the working sheath, then you can advance beyond the working sheath with endoscope. This allows you to utilise the benefits of the elliptical shape of the endoscope for entry through small foramina and in to settled discs.
Q: What tricks do you use to control bleeding?
A:
Raise the water pressure in the working zone. Rotate the sheath until the shoulders press on the bleeding point and keep the pressure on this point. When bleeding has been controlled for over 30 seconds, gently rotate the tube backwards to display the vessel and then seal it formally.
Q: What is Foraminoplasty?
A:
Foraminoplasty is the clearance of abnormalities in and around the nerve in the foramen by clearance of perineural scarring, removal of impacting indenting ligaments or bone, correction of the pathway of the nerve, mobilisation of the nerve from adjacent bone and disc, removal of disc protrusions and (shoulder, vertebral and facet joint) osteophytes and undercutting (decompression) of the foramen to increase its volume.
Q: How should I begin Foraminoplasty?
A:
After completing spinal probing and discography to ensure that the causal level is being addressed, the dilator is railroaded to the foramen and not forced in to the disc.
Direct entry in to the disc is acceptable where the problem is simply a disc protrusion without nerve tethering or pathway displacement. These features are however normally present in more advanced Degenerative Disc Disease.
The initial view of the foramen is obscured by scarring and ligaments. The operator should identify the bone margin and clear tissues along this border and progressively define the superior foraminal ligament, the nerve and lower ganglion and the inferior pedicle and then the Safe Working Zone. In this process, shoulder, vertebral and facet joint osteophytes will be displayed and resected. The essential step in the procedure is that of mobilising the nerve from the surrounding bone and from the disc.
Undercutting (decompression) is achieved by manual reamers, powered reamers and laser resection to restore foraminal volume and achieve access to the epidural space where clearance of sequestra, extrusions and peridural and perineural scarring and facet joint cysts can be treated.
Q: Why is there a difference between the technique of Dr Yeung & Dr Knight?
A:
Dr Yeung’s technique is that of Endoscopic Intradiscal Discectomy whilst that of Dr Knight is that of Endoscopic Laser Foraminoplasty.
Endoscopic Intradiscal Discectomy is confined to treating disc protrusions and some wide based extrusions. Access is gained fluoroscopically by inserting the dilator in to the disc and then clearing the degenerate material from within the disc.
Dr Knight’s technique of Endoscopic Laser Foraminoplasty not only allows Endoscopic Intradiscal Discectomy to be performed but the contents of the foramen may be restored and corrected and the epidural space explored and corrected. This procedure commences with the clearance and treatment of the foramen and after the nerve pathway has been corrected, then the disc may be entered under vision with the nerve protected.
Q: What sort of patients can I treat with these techniques?
A:
Those needing Discectomy or Foraminoplasty and Epidural Clearance.
Initially in the learning curve, the easiest to treat will be disc protrusions which requires intradiscal clearance with manual instruments, laser or radiofrequency devices.
Entry directly in to the disc can be performed and clearance can be performed by manual instruments, RF and Laser resection. The annulus can be shrunk by laser or RF heating of the collagen (Annuloplasty).
More advanced Degenerative Disc Disease produces many combinations of pathology which can be treated by Endoscopic Laser Foraminoplasty (Decompression) such as Chronic Lumber Spondylosis, Failed Back Surgery, Spondylolitic Spondylolisthesis, perineural scarring, non-compressive radiculopathy, compressive radiculopathy, unresponsive, enduring back pain of elusive origin treated by Chronic Pain Management, “Instability”or lateral recess stenosis.
Q: What sort of clinical outcomes can be achieved with these techniques?
A:
The clinical outcomes than can be achieved from these techniques are sumarised in the tables in the following document (Adobe PDF document).
These questions and answers have been compiled with the help of Catherine Casolani who has had aware state endoscopic laser surgery to her spine. September 2000 and supplemented by the Spinal Foundation regarding technique and clinical outcomes.
