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2015-12-28 1 Percutaneous Endoscopic Discectomy Transforaminal / Interlaminar Hyeun Sung Kim, MD, PhD, Ji Soo Jang, MD, PhD, Jung Hoon Choi, MD, Sung Kyun Jung MD, Jung Sub Lee, MD Department of Neurosurgery, Nanoori Hospital, Suwon City, South Korea Medical College of Chosun University , Gwangju, South Korea (1994) / Board of Neurosurgery (1999) MEMBERSHIPS & PROFESSIONAL SOCIETIES Korean Neurosurgical Society / Korean Spinal Neurosurgery Society / Korean Minimal Invasive Spine Surgery Society / Korean Society of Peripheral Nervous System / Korean Spinal Deformity Research Society / Korean Spinal Osteoporosis Research Society / NASS / Eurospine / ISASS / AO Spine / AANS / AANS/CNS Section on Disorders of the Spine & Peripheral Nerves / World Spine Society / WCMISST / ACMISST / ISMISS KOREA, TURKEY, JAPAN / Korean Society of Thermology / Korean Pain Society / Korean Neuro-Pain Society / The Korean Society of IMS Best article award in the Korean Neurosurgical Society / Best Paper Award in the 6h ISMISS TURKEY / Best article award in The Korean IMS Therapy Association AWARDS Kim HS et al. Balloon kyphoplasty in severe osteoporotic compression fracture: Is it a contraindication? Neurosurgery 2007 Kim HS et al. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. JKNS 2008 Kim HS et al. Endoscopic Transforaminal Suprapedicular Approach in High Grade Inferior Migrated Lumbar Disc Herniation. JKNS 2009 Kim HS et al. Minimally Invasive Multi-Level PLIF Using a Percutaneously Inserted Spinal Fixation System. JKNS 2011 Kim HS et al. Comparative study between different PEILD techniques. Pain Physician 2013 PAPERS: MORE THAN 40 PAPERS PAPERS: MORE THAN 40 PAPERS Korean Neurosurgical Society: Luncheon Seminar: PELD; Benefits and Limitations / WCMISST 2012, Brazil: Minimally invasive TLIF and PLIF using the Apollon system / WFNS 2013, Korea: Structural Preservation PEID KNS / WFNS (World Federation of Neurosurgical societies) / NASS / Eurospine / ISAS / World Spine / KOMISS / ACMISST / Asia Spine / WCMISST / ISMISS TURKEY / IITS / WENMISS LECTURE & PRESENTATION: MORE THAN 100 TIMES LECTURE & PRESENTATION: MORE THAN 100 TIMES REFERENCE DOCTOR A. Extra-Foraminal Approach A. Far lateral Disc B. Trans-foraminal Approach A. Foraminal Disc B. Superior Migration Disc C. Inferior Migration Disc D. Paracentral Disc E. Central Disc C. Interlaminar Approach Interlaminar Approach PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY

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2015-12-28

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Percutaneous Endoscopic DiscectomyTransforaminal / Interlaminar

Hyeun Sung Kim, MD, PhD,Ji Soo Jang, MD, PhD, Jung Hoon Choi, MD, Sung Kyun Jung MD, Jung Sub Lee, MD

Department of Neurosurgery, Nanoori Hospital, Suwon City, South Korea

Medical College of Chosun University , Gwangju, South Korea (1994) / Board of Neurosurgery (1999)

MEMBERSHIPS & PROFESSIONAL SOCIETIES

Korean Neurosurgical Society / Korean Spinal Neurosurgery Society / Korean Minimal Invasive Spine Surgery Society / Korean Society of Peripheral

Nervous System / Korean Spinal Deformity Research Society / Korean Spinal Osteoporosis Research Society / NASS / Eurospine / ISASS / AO Spine /

AANS / AANS/CNS Section on Disorders of the Spine & Peripheral Nerves / World Spine Society / WCMISST / ACMISST / ISMISS KOREA, TURKEY,

JAPAN / Korean Society of Thermology / Korean Pain Society / Korean Neuro-Pain Society / The Korean Society of IMS

Best article award in the Korean Neurosurgical Society / Best Paper Award in the 6h ISMISS TURKEY / Best article award in The Korean IMS Therapy Association

AWARDS

Kim HS et al. Balloon kyphoplasty in severe osteoporotic compression fracture: Is it a contraindication? Neurosurgery 2007

Kim HS et al. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. JKNS 2008

Kim HS et al. Endoscopic Transforaminal Suprapedicular Approach in High Grade Inferior Migrated Lumbar Disc Herniation. JKNS 2009

Kim HS et al. Minimally Invasive Multi-Level PLIF Using a Percutaneously Inserted Spinal Fixation System. JKNS 2011

Kim HS et al. Comparative study between different PEILD techniques. Pain Physician 2013

PAPERS: MORE THAN 40 PAPERSPAPERS: MORE THAN 40 PAPERS

Korean Neurosurgical Society: Luncheon Seminar: PELD; Benefits and Limitations / WCMISST 2012, Brazil: Minimally invasive TLIF and PLIF using

the Apollon system / WFNS 2013, Korea: Structural Preservation PEID

KNS / WFNS (World Federation of Neurosurgical societies) / NASS / Eurospine / ISAS / World Spine / KOMISS / ACMISST / Asia Spine / WCMISST /

ISMISS TURKEY / IITS / WENMISS

LECTURE & PRESENTATION: MORE THAN 100 TIMESLECTURE & PRESENTATION: MORE THAN 100 TIMES

REFERENCE DOCTORA. Extra-Foraminal Approach

A. Far lateral Disc

B. Trans-foraminal Approach

A. Foraminal Disc

B. Superior Migration Disc

C. Inferior Migration Disc

D. Paracentral Disc

E. Central Disc

C. Interlaminar Approach

Interlaminar Approach

PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY

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PERCUTANEOUS ENDOSCOPIC LUMBAR DISCECTOMY

PETLDPERCUTANEOUS ENDOSCOPIC

TRANSFORAMINAL LUMBAR DISCECTOMY

ANATOMICAL CONSIDERATION NEURAL ANATOMYNEURAL ANATOMY

d. Sinuvertebral nerves

a. Exiting nerve and Ganglia

b. Traversing nerve

c. Sympathetic trunk and ganglia

ANATOMICAL CONSIDERATION VASCULAR ANATOMYVASCULAR ANATOMY

Segmental Artery

Aorta

Radiculomedullary artery

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MRI Length Measurement MRI Marker Physical Examination

APPROACH ENTRY POINTENTRY POINT

10~12 Cm

8~10 Cm

6~8 Cm

4~6 Cm

APPROACH WORKING CHANNEL INSERTIONWORKING CHANNEL INSERTION

ANATOMICAL CONSIDERATION APPROACHAPPROACH ANATOMICAL CONSIDERATION APPROACHAPPROACH

EPIDURAL APPROACHEPIDURAL APPROACH

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ANATOMICAL CONSIDERATION APPROACHAPPROACH

EXITING ROOT APPROACHEXITING ROOT APPROACH

ANATOMICAL CONSIDERATION APPROACHAPPROACH

TRAVERSING ROOT APPROACHTRAVERSING ROOT APPROACH

ANATOMICAL CONSIDERATION LIMITATIONSLIMITATIONS

Anatomical Limitations of PETLD

Migration

Canal Compromise

Iliac crest

Hard bony foraminal width

Surgical Limitations of PETLD

Inside-out / Outside-in approach

Targetectomy

Saftey Zone

Neurological Limitations of PETLD

Epidural approach

Exiting root approach

Traversing root approach

CURRENT DEBATE OF PETLD ANATOMICAL LIMITATIONSANATOMICAL LIMITATIONS

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ANATOMICAL CONSIDERATION HIGHTLY INFERIOR MIGRATED L4-5HIGHTLY INFERIOR MIGRATED L4-5

L4-5

ANATOMICAL CONSIDERATION HIGHTLY INFERIOR MIGRATED L4-5HIGHTLY INFERIOR MIGRATED L4-5

Lee SC, Kim SK, Lee SH, et al. Percutaneousendoscopic lumbar discectomy for migrateddisc herniation: classification of discmigration and surgical approaches. EurSpine J 2006

Lee SC, Kim SK, Lee SH, et al. Percutaneousendoscopic lumbar discectomy for migrateddisc herniation: classification of discmigration and surgical approaches. EurSpine J 2006

Half-and-Half Technique

& Epiduroscopic Approach

Half-and-Half Technique

& Epiduroscopic Approach

Choi G, Kim JS et al. Percutaneous

endoscopic approach for highly migrated

intracanal disc herniations by

foraminoplastic technique using rigid

working channel endoscope. Spine. 2008

Choi G, Kim JS et al. Percutaneous

endoscopic approach for highly migrated

intracanal disc herniations by

foraminoplastic technique using rigid

working channel endoscope. Spine. 2008

Foraminoplastic TechniqueForaminoplastic Technique

Kim HS et al. Endoscopic Transforaminal

Suprapedicular Approach n High Grade

Inferior Migrated Lumbar Disc Herniation

. J Korean Neurosurg Soc, 2009

Kim HS et al. Endoscopic Transforaminal

Suprapedicular Approach n High Grade

Inferior Migrated Lumbar Disc Herniation

. J Korean Neurosurg Soc, 2009

SuprapedicularSuprapedicular

SURGERY RELATED RELAPSERELAPSE

Segmental Loading Component

Age

Disc location

Herniated disc level

Disc height

Healing Component

Degeneration Scale

Anti-adhesive agent

Combined HNP

SURGERY RELATED RETROPERITONEAL HEMATOMARETROPERITONEAL HEMATOMA

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SURGERY RELATED PYOGENICSPONDYLODISCITISPYOGENICSPONDYLODISCITIS CURRENT ISSUES EQUIPMENTEQUIPMENT

CURRENT ISSUES HIGH CANAL COMPROMISEDHIGH CANAL COMPROMISED CURRENT ISSUES FORAMINAL TO SUPERIOR MIGRATIONFORAMINAL TO SUPERIOR MIGRATION

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CURRENT ISSUES FAR LATERALFAR LATERAL CURRENT ISSUES RECURRED HNP AFTER OMDRECURRED HNP AFTER OMD

CURRENT ISSUES CALCIFIED HNPCALCIFIED HNP CURRENT ISSUES ADJACENT 2 LEVEL HNPADJACENT 2 LEVEL HNP

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CURRENT ISSUES CURVED PROBECURVED PROBE

51 yr / M Highly Inferior Migrated

CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL

74 yr / M Highly Inferior Migrated

CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL CURRENT ISSUES CURVED FORCES AND DRILLCURVED FORCES AND DRILL

74 yr / M Highly Inferior Migrated

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CURRENT ISSUES FORAMINOPLASTYFORAMINOPLASTY

67 yr / F Foraminal Stenosis

PEILDPERCUTANEOUS ENDOSCOPIC

INTERLAMINAR LUMBAR DISCECTOMY

ANATOMICAL CONSIDERATION LIMITATION OF PETLDLIMITATION OF PETLD ANATOMICAL CONSIDERATION LIMITATION OF PETLDLIMITATION OF PETLD

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Interlaminar

Trans-Shoulder

Trans-Axial

Resection

Possible

Wide

( + )

Posterolateral

ApproachTransforaminal

Trans-iliac

Ligamentum Flavum Spare

Annulus Repair Impossible

Indication Limited

Adhesion Weak

CURRENT DEBATE L5-S1: PETLD VS PEILDL5-S1: PETLD VS PEILD L5-S1: PETLD VS PEILDL5-S1: PETLD VS PEILDCURRENT DEBATE

L5-S1: Percutaneous Endoscopic Approach

NEURAL APPROACHNEURAL APPROACHCURRENT DEBATE

Axilla

Moderate

Easy

Difficult

Weak

Easy

Shoulder

Learning Curve Short

Inferior Migration Difficult

Superior Migration Easy

Nerve root retraction Hard

Annulus Sealing Difficult

LIGAMENTUM FLAVUM SPLITTINGLIGAMENTUM FLAVUM SPLITTINGCURRENT DEBATE

Classification Technique

Splitting

Indirect Choi G

Direct Kim CH

Resection

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ANNULUS SEALINGANNULUS SEALINGCURRENT DEBATE STRUCTURAL PRESERVATIONSTRUCTURAL PRESERVATIONCURRENT DEBATE

L5-S1: Structural Preservation

CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE

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CURRENT ISSUES HIGH CANAL COMPROMISEHIGH CANAL COMPROMISE CURRENT ISSUES HIGHLY INFERIOR MIGRATEDHIGHLY INFERIOR MIGRATED

38yr/Female38yr/Female

CURRENT ISSUES HIGHLY SUPERIOR MIGRATEDHIGHLY SUPERIOR MIGRATED

44yr/Male44yr/Male

CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD

53yr/Male53yr/Male

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CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD CURRENT ISSUES REVISION AFTER OMDREVISION AFTER OMD

53yr/Male53yr/Male

CURRENT ISSUES CONTRALATERAL PEILDCONTRALATERAL PEILD CURRENT ISSUES CONTRALATERAL PEILDCONTRALATERAL PEILD

43yr/Male43yr/Male

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CURRENT ISSUES CALCIFICATION FLOATING TECHNIQUECALCIFICATION FLOATING TECHNIQUE

Interlaminar: L5-S1: 59/M, Rt.

CONCLUSION

Limitation: Anatomical, Surgical, Neurological

Approach: Epidural, Exiting, Traversing

In and Out / Out and In

Highly inferior migrated L4-5

Advanced surgical science and technology

Wide PELD indication

Future of PELD

CONCLUSION

Structural preservation technique of

percutaneous endoscopic interlaminar lumbar

discectomy

Ligamentum flavum splitting technique

Fissure fragmentectomy and sealing technique.

Axilla route / Shoulder route

Contralateral interlaminar approach

Calcification floating technique

INDICATIONS

Paramedian disc herniations with predominant leg pain

Subligamentous ruptured or extruded disc

migration less than height of disc space

Central disc herniation with predominant back pain

Annular tears that cause chemical sciatica

Formainal disc herniations, synovial cysts of the facet joint

Far lateral disc herniation, Superior migrated disc herniation

Huge central protruded disc: High canal compromise

Recurred Disc

Sequestrated disc that had migrated

Non-contained Inferior migrated disc

Lateral recess stenosis, spinal stenosis

Calcified Disc

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INDICATIONS

Thank you !