Percutaneous Endoscopic Lumbar Disc Surgery: The Pionneering Years 1979-1991
A Schreiber. Percutaneous Endoscopic Lumbar Disc Surgery: The Pionneering Years 1979-1991. The Internet Journal of Minimally Invasive Spinal Technology. 2006 Volume 1 Number 1.
As early as in the the early seventies, in the United States KAMBIN applied a modified CRAIG'instrumentarium for minimum possible fenestration of the annulus fibrosus. This still in combination with the dorsolateral open hemilaminotomy. In the same period, for the first time, HIJIKATA introduced in Japan smaller instruments then the Craig'cannulas for now purely closed percutaneous removal of disc tissue by dorsolateral intervertebral punction. The aim was the same as for KAMBIN : decrease of intradiscal pressure for indirect reduction of the posterior bulge in protrusions. His original publication of 1975 remains the classic keystone for the later considerable evolution of purely percutaneous disc surgery.
In Zürich, having learnt about the experiences of HIJIKATA in occasion of the SICOT Kyoto meeting in 1978, we adopted this operative technique in 1979, starting with Hijikata's original instruments. After a first series, this instrument, conceived for the rather small asiatic statures, could not completely satisfy the needs for the taller european statures. So we had to redesign and adapt the tools in 1980. The result was a pluricannular instrument for bilateral percutaneous approach (Howmedica™), which after several further modifications in design and material still is basically in use for the actual percutaneous techniques. Experiments on cadaver specimens demonstrated in 1981, that the former experimental technique of arthroscopy (Storz™)) could be adapted also for intradiscal control in combination to the bilateral percutaneous approach. So in 1982, with a modified arthroscopic device, together with my late cooperator SUEZAWA, we performed successfully for the first time "in vivo" this percutaneous discoscopy. This keystone for further evolution of endoscopic spinal surgery was presented at the Spine Symposium in Erlangen in March 1983 and published for the first time in the western world in the Textbook "Neuroorthopädie", edited by D. Hohmann with Springer Publisher. This helpful routine procedure has been recognized and adopted in its fundamental value later also also by other authors.
Our experience with percutaneous interbody bone grafting goes back to 1986/7. In 1988 external fixation following the technique of MAGERL (Synthes™) was in use for elective probatory lumbar spine fixation. In cases with positve response, togehter with my collaborator LEU, we started to perform then additional percutaneous interbody fusion in 1988. In our concept, the external pedicular fixation device is most valuable for identification of proper indication for fusion and, when necessary to evaluate the clinical impact of eventually necessary segmental realignment, distraction and/or correction of lordosis. For the adequate elaboration of the endplates, in 1988 also a special excentrically abrasive milling cutter was developed by LEU and has since become a standard tool (Aesculap™) for this decisive step of the procedure. In 1993 KAMBIN, in order to avoid external fixation, introduced his technique of subcutaneous bolt connectors (Smith & Nephew™).
With the clinical introduction of laser application under discoscopy, worldwide for the first time in Zürich in January 1989 by LEU, again an important step towards further minimized and selective subligamentary discharge of disc herniations became available. After preliminary experiences with the Excimer-UV-Laser and the Neodymium:YAG since 1991 the Holmium:YAG has been found the optimal available for disc surgery under endoscopic control. This for decompression and also for adequate evacuation of disc tissue in percutaneous endoscopic interbody fusion. Nevertheless, the mid term results of laser disc decompression reamained below their promising early results so that since 1997 in our concept laser is no more in routine use.
Resuming the european evolution since 1979, the minimal invasive approach to the intervertebral space has outgrown to a complete therapeutic concept of percutaneous endoscopic spine surgery. So a tendence in the whole field of surgical procedures towards minimization of invasivity, conserving efficiency by endoscopic control has finally made its way also in the field of spinal surgery.