Evolution of Endoscopic Spine Surgery
A comprehensive look at the evolution of percutaneous endoscopic methods, from chemonucleolysis to the current state-of-the-art NANO technique.
2 Book Chapters
40+ Peer-Reviewed Papers
All abstracts reviewed and accepted by major organizations
Commended by AANS
"The surgery of the future" — AANS official, 1996
From Open Surgery to NANO
The history of open surgical treatment of herniated lumbar discs started over sixty years ago. Williams described Microlumbar Discectomy in 1978 — a small incision technique using an external overhead microscope. This small open operation requires a posterior midline skin incision of at least one inch, incision of paravertebral fascia, detachment of muscle, removal of a portion of the ligamentum flavum, usually bone removal, retraction of the root and dural sac, and opening of the disc inside the spinal canal.
Minimally invasive endoscopic methods, performed by passing the scope from the skin surface, should be differentiated from open surgery. These are puncture opening (percutaneous) procedures, with skin openings just large enough to admit the scope, for internal viewing through scope placement directly at the tissue — as compared to working from an external view (with or without a microscope) through an open incision.
Key Milestones
Lyman Smith first used Chymopapain to treat a lumbar disc disorder.
Day described the posterolateral extradural route to the lumbar disc.
Hijikata developed percutaneous nucleotomy.
Kambin described arthroscopic techniques for posterolateral herniated disc removal.
Onik developed the nucleotome for automated percutaneous lumbar discectomy.
Mayer and Brock reported 95% of endoscopic patients returning to previous occupations.
The small, guided endoscopic transforaminal technique was presented at the AANS meeting and commended as 'the surgery of the future.'
The NANO procedure at Back Institute represents the culmination of decades of advancement — the world's smallest scope with the least traumatic access.
Understanding Spinal Anatomy
The spinal nerve in the "neural foramen" — a canal or doorway for the nerve to leave the spinal canal and go out into the body. Disc herniations, bone spurs from the vertebral body and bone spurs from the facet joints can press on the nerve in the neural foramen.
Normal discs in the lower back have a central part with a significant amount of water, behaving like an expensive gel-filled seat cushion. This inner part (the nucleus) is surrounded by the outer part (the annulus) — a tough, fibrous layer that keeps the softer nucleus in place.
Aging and injury cause a disc to lose water, weakening the disc and decreasing its shock absorber capabilities. In cases of herniation, a fragment of the central part of the disc can slip backwards to narrow the spinal canal or press on nerves.
During our non-traumatic procedure, a small endoscope with fiber optics is directed from the skin directly to the disc — without cutting through muscle or removing bone.
Our Major Publications
All articles have been peer reviewed. Abstracts were reviewed by the indicated organization and accepted for publication.
Removal of Lumbar Foraminal Free Fragments with a New "Nano" Endoscope, Long Term Follow-up
EANS 2024 Annual Congress, Sofia, Bulgaria
Escaping Lumbar Fusion with a Small Outpatient Procedure (Long Term Follow-up)
13th Annual EANS Young Neurosurgeons' Meeting, Hamburg, Germany
Avoiding Lumbar Fusion with a Small Endoscopic Partial Discectomy: Long Term Follow-up
WFNS, Cape Town, South Africa
Precision Posterior Intradiscal Placement For Lumbar Endoscopic Partial Discectomy Procedures
ASRA, New Orleans, LA
Paramedian lumbar endoscopic spinal canal fragmentectomies without bone removal – long term follow-up
EANS, Dublin, Ireland
Endoscopic Discectomy and Reconfiguration at L5-S1 – Long Term Follow-up
ISASS 19th Annual Conference, Anaheim, CA
Nano Endoscopic Approach for Central Lumbar Disc Herniations
ISASS, Boca Raton, FL
Removal of Disc Fragments from the Lumbar Spinal Canal Without Normal Anatomy Disruption
Spine Summit 2016, Orlando, FL
Paramedian, Zero Trauma Approach Through the Ligamentum Flavum for Extruded Disc Herniations
Congress of Neurological Surgeons, New Orleans, LA
Endoscopic Anterior Cervical Discectomy Without Fusion Through a Two Millimeter Opening
ISASS Annual Meeting, Orlando, FL
Non-Traumatic Approach Through the Ligamentum Flavum for Extruded Disc Herniations in the Lumbar Spine
AANS/CNS Section Meeting, Orlando, FL
Decision Making in Spinal Care – Chapter 61 (Book Chapter)
Thieme Publishers
Multifactorial Lumbar Stenosis Treated Successfully with Primary Factor Treatment Only
AANS/CNS Section Meeting, Orlando, FL
Successful Unifactorial Treatment of Multifactorial Spinal Stenosis
SMISS Annual Meeting, Miami, FL
"Lumbar Fusion Candidates" Avoid Fusion: Long Term Follow-up
Congress of Neurological Surgeons Annual Meeting
Non-Traumatic, Trans-Ligamentum Flavum Approach for L5/S1 Extruded Disc Herniations
AANS/CNS Section on Disorders of the Spine
Treatment of central and paracentral lumbar disc herniations with a transforaminal double access non-traumatic discectomy
WCMISST
Decision Making in Spinal Care – Chapter 63 (Book Chapter)
Thieme Publishers
"Lumbar Fusion Candidates" Avoid Fusion (Long Term Follow-up)
Minimally Invasive Surgery of the Spine, San Diego
7 cases with previous surgeries and free fragments: 100% success
IITS, France
Non-traumatic Transforaminal Endoscopic Approach to the Lumbar Spinal Canal for Removal of Migrated Free Fragments
IITS, Phoenix
Enhanced Discography (Pre-Operative Mapping) A Prelude to Small Guided Non Traumatic Discectomy
IITS, San Diego
Outpatient Small Non Traumatic Discectomy In L4/5 Lateral Recess Lumbar Disc Herniations
Peer Reviewed Publication
Double Approach Small Non Traumatic Discectomy in L4/L5 and L5/S1 True Central Disc Herniations
CNS, San Francisco
Paramedian Small Endoscopic L5-S1 Discectomy
CNS, Philadelphia
Preparative Analysis for Precision Lumbar Endoscopic Disc Surgery
CNS, San Diego, CA
Endoscopic Lumbar Discectomy: Small, Soft Scope Technique
Spine & Peripheral Nerves Section
Contrast Disc Analysis and Mapping as a Prelude to Endoscopic Lumbar Discectomy
IITS Annual Meeting, Phoenix, AZ
IDET and PED: Benefits of Combination Treatment
Spine & Peripheral Nerves Section
Endoscopic Transforaminal Lumbar Discectomy and Reconfiguration: A Postero-lateral Approach into the Spinal Canal
Surgical Neurology, Volume 49, Number 6, pp.588-598
Paramedian Percutaneous Non Traumatic Discectomy: New Surgical Technique and Initial Clinical Results
CNS, Seattle, WA
The Development of Percutaneous Lumbar Endoscopic Microdiscectomy (This Author's Twelve Year Experience)
The Eleventh Annual International Intradiscal Therapy Society Meeting, San Antonio, TX
Endoscopic Transforaminal Percutaneous Discectomy for Recurrent Lumbar Disc Herniation
IITS Meeting, Naples, FL
True Transforaminal Endoscopic Percutaneous Lumbar Discectomy
IITS Meeting, Naples, FL
Endoscopic Transforaminal Disc Removal and Reconfiguration (Selected as best paper for publication)
Joint Section AANS/CNS, Lake Buena Vista, FL
Non Traumatic Discectomy (Faculty)
International Intradiscal Therapy Society, Amsterdam
Endoscopic Spinal Surgery (Invited Faculty — commended as 'surgery of the future')
AANS, Minneapolis, MN
Percutaneous Transforaminal Non Traumatic Discectomy
North American Spine Society, Washington, D.C.
A New Superior Technique for Removal of Herniated Lumbar Discs
Canadian Journal of Neurological Science, Vol 22, No 2
Comprehensive Percutaneous Endoscopic Spinal Surgery
AANS, Orlando, FL
A New and Superior Technique for Removal of Herniated Disc: Endoscope and Nucleotome Combination
Joint Section AANS/CNS, Phoenix, AZ
Percutaneous Discectomy Over Age Sixty (Nucleotome With Laser Enhancement)
Joint Section AANS/CNS, Ft. Lauderdale, FL
A Safer, Effective Alternative to Laminectomy
International College of Surgeons, San Diego, CA
A New Technique for Intra and Extra Discal Percutaneous Endoscopic Lumbar Surgery
Symposium: Techniques in Spinal Surgery, NYC
New Comprehensive Percutaneous Discectomy Using a Working Channel Scope and Nucleotome
Seventh Annual Intradiscal Therapy Society Meeting, Aberdeen, Scotland
Percutaneous Discectomy in the Older Patient
Second Annual Symposium, NYC
Percutaneous Discectomy — Lasers and Fiberoptics
National Scientific Conference (Westside Hospital), Hawaii
Percutaneous Discectomy — Recent Advances
National Scientific Conference (Westside Hospital), Hawaii
Back Pain and Alternatives to Back Surgery: Percutaneous Discectomy
Lecture Series, Beverly Hills Medical Center
Arachnoiditis
Congress of Neurological Surgeons' Annual Meeting, Houston, TX
Subdural Hematoma, Chronic
National Critical Care Institute Journal, Vol 5, No 9
Benign Brain Tumor
National Critical Care Institute Journal, Vol 5, No 11
This list represents a selection of major publications. Additional abstracts and presentations are available upon request.
See Our Procedures in Action
Watch news segments and educational videos about our non-traumatic spine procedures, featuring real patients and their results.
Breakthrough Procedure Uses Tiny Scope
Four out of five Americans suffer low back pain at some point in their lives. When therapy and medicine fail, a new procedure may be the simplest surgical solution yet.
Easing That Pain in Your Back Without Undergoing a Major Operation
About 400,000 Americans may be getting highly invasive back surgery unnecessarily. A local doctor says he's found great success with an outpatient procedure to remove herniated disc material.
Back Institute Overview
Physicians, surgeons, professors and other professionals come to the Back Institute for their personal care. Hear why medical professionals trust us with their own spine.