Disc herniations are the main indication for the use of the VERTEBRIS system.
The concept was developed for all disc herniations that cannot be treated using conservative therapies. The following objectives should always be a top priority:
- Direct decompression of neural structures: "target approached" access to reach and remove the disk herniation directly.
- Least invasive access trauma: choosing the approach with minimally traumatization of surrounding soft tissue and bone structures which don´t belong to the pathology.
- Reducing the risk of recurrences: partial and selective diskectomy to reduce the risk of recurrences.
Standardized surgical approaches have been developed in order to meet the requirement for minimal invasiveness.
Transforaminal approach is used for pathologies starting at L4/5 and higher segments.
In order to meet the concept's demand for direct decompression and least invasive access trauma, different access directions are selected for the transforaminal approach:
Lateral transforaminal approach
- Access direction approx. 20° to horizontal
- For intraspinal (mediolateral) and intraforaminal (lateral) localized pathologies
- Access to the ventral epidural space and the dorsal intervertebral disk
Posterolateral transforaminal approach
- Access direction approx. 45° to horizontal
- For intradiscally localized pathologies
- Access to the central disk
In narrow intervertebral foramina, parts of the ascending facet and pedicle can be removed with manual and motorized burrs to achieve free access.
Extraforaminal approach is selected for extraforaminal disc herniations and foraminal stenosis for all segments of the lumbar and thoracic spine.
Prefered lateral to posterolateral access direction with 20° to 30° to horizontal. In order to prevent injuries to the exciting nerve root, the puncture cannula is anchored in the caudal pedicle. From there, the VERTEBRIS diskoscope with working sleeve and instruments is moved cranially under full-endoscopic view to identify and remove the herniated disc.
Preferred indications for interlaminar access are intraspinal localized pathologies in L5/S1, where the use of burrs for lateral extension of the interlaminar window is not required.
However, this is necessary if the interlaminar full endoscopic approach is used in higher segments of the spine or if spinal stenoses have to be surgically expanded for decompression. The interlaminar access direction is posterior.
The main indications for cervical endoscopic operations are "soft" herniated discs with radicular symptoms. Standardized surgical techniques for the anterior and posterior approaches were developed for the VERTEBRIS cervical full-endoscopic concept.
Due to the different anatomical structures need to be passed, the access and endoscope systems for these approaches also differ fundamentally.
Anterior transdiskal surgical technique
Indications for the endoscopic anterior approach are mainly medially to mediolaterally localized herniated discs, which cannot be reached with the posterior full-endoscopic approach.
After manual palpation and passage of the ventral anatomical structures (esophagus, arteries), a thin dilator is inserted directly into the disk under X-ray control. A special oval dilation system is pushed under X-ray view up to the dorsal edge of the cervical disk. After opening the dorsal anulus of the intervertebral discs, the herniated disc is removed transdiskally through the access sleeve under endoscopic view.
Posterior surgical technique
Indications for the full-endoscopic posterior approach are mainly mediolaterally to laterally localized herniated disks.
This access with 7mm diameter allows the atraumatic passage of the soft tissue until the laminae and the facet joint are reached. Using high-resolution endoscopic visualization, parts of the laminae and the facet joint can be removed with mechanical burrs to locate and remove the nerve root and the herniated disk.
Endoscopic imaging has also been playing an important role in spine surgery for many years, because high-resolution intraoperative imaging facilitates minimalized access ports to the operating site.
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