Live Surgery

Relevant Surgical Anatomy

Many minimally invasive procedures including various endoscopic procedures have been introduced to maintain the overall spinal structures. The multifidus muscle is very important in its function as a stabilizer of spine and locomotor action. Even minimally invasive surgeries including various endoscopic procedures might damage the medial multifidus, which is innervated by the medial branch of the dorsal ramus with no segmental nerve supply as in the other paraspinal muscles. This approach through spatium intermusculare with biportal endoscope and small cannula can prevent the erecta spinae from the injury by overdistracting procedures (Fig.1). Furthermore, variable access angles permit wider and further view of the contralateral side. The paraspinal extraforaminal approach with this technique gives a wider view of the foraminal lesion avoiding injury of the exiting nerve and radicular artery (Fig. 2). With the proper biportal endoscopic surgical technique, the injuries to these structures can be avoided. By this procedure, we could treat all kinds of spinal stenosis including central, lateral recesses, and foraminal stenosis.

References : How I do it? Biportal endoscopic spinal surgery (BESS) for treatment of lumbar spinal stenosis
Chang Myong Choi, Je Tea Chung, Sang Jin Lee, Dae Jung Choi : Acta Neurochir (Wien). 2016; 158 : 459–463.
Published online 2016 Jan 18. doi : 10.1007/s00701-015-2670-7

Fig.1
Multifidus muscle and spatium intermusculare
with corresponding intraoperative endoscopic view

Fig. 2
Schematic representation of the arteries around intervertebral foramen artist’s drawing :
diagrammatic representation of the entry points for the portal sites and direction of the scope and instruments

Paraspinal Approach

For working /Skin line for hole
For scope
midline
Initial target point : outlet of lateral recess

Flow of irrigating saline

Multifidus triangle

Potential space between multifidus fascicles and spinous process

Flow of irrigating saline

1. Minimally invasive, effective endoscopic decompression for lumbar stenosis.

2. Excellent surgical view
(better than microscopic view)

3. Procedures are the same as open spine surgery

Surgical Technique / Presurgical Preparation

· Patient Positioning
(ie. bed set-up, O.R. set-up etc..)
· Instrumentation
· Surgical Considerations
· Preop. Planning
(targeting and skin incision, X-rays)

· Skin marking
· X-ray
· Skin Incisions
· Access and Targeting (scope docking,
working channel access using dilators,
docking of universal retractor etc..)
· Decompression (disc prep, NR release)