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■ Cervical
+ Percutaneous Endoscopic Cervical Discectomy (PECD)

The Percutaneous Endoscopic Cervical Discectomy (PECD) is applied to patients with symptoms of neuralgia by the compression of the shoulder and arm due to the herniation of the disc nucleus from a ruptured annular fiber. Unlike conventional surgery which requires skin incisions and the removal of the whole disc, the procedure preserves most of the disc tissue to minimize complications. It is the most advanced therapy that can be performed on the elderly or patients with diabetes without concern.

Surgical Technique
Percutaneous Endoscopic Cervical Discectomy(PECD) is a less invasive surgery with inserting the thin canal under local anesthesia. With endoscopic view, the surgeon can insert the 0.4cm canal into the disc through the skin and shrinks the herniated disc with a laser.

The soft cervical disc herniation that has showed no improvement by the physical therapy or exercise would be a main indication. However, it is desirable to treat the patient before the cord compression which might cause severe condition. It is necessary that open surgery should be performed on the patient if the patient cannot run or walk as fast as they normally could, because of a compressed spinal cord.

What is the Soft Cervical Disc Herniation?
The Soft Cervical Disc Herniation is defined as when the disc between the vertebral bodies is torn and the nucleus pulposus is herniated so that it could compress the nerve root and spinal cord.
The upper limb neuralgia, which causes pain in the arm, is a common symptom since the nucleus pulposus is usually exited posterolaterally. Also it often causes some pain around the scapula.
Unless the patient is cured, the muscles of the arms and hands could be weakened and the tendon reflex could worsen as well as the sensory neuron could be deteriorated. In a severe case, the patient could have difficulty of walking and could suffer from loss of consciousness or even a stroke.

• Epidural hemorrhage of nerves or fiber attachments around nerves is not created.
• Since disc portions are retranslocated, the need of metallic discs or bone fusion is not necessary.
• Spine instability is almost eliminated.
• The recurrence of disc nucleus inside the nerve cavity can be prevented since the surgery makes a small channel at the front of the cervical disc.
• Recuperation is fast due to the short operation and hospitalization period.

   The disc height after surgery is almost same with preoperation state.

Success Rate
The success rate of Percutaneous Endoscopic Cervical Discectomy (PECD) for the soft cervical herniation is 88%. The rest of them, 7% of the patients showed a relatively fair condition and 5% of the patients required open surgery.
  Open surgery Percutaneous Endoscopic Cervical Discectomy (PECD)
Indication All kinds of cervical diseases Soft cervical disc disease or elderly patients
Characteristic Open surgery with knife Minimally invasive spinal surgery with endoscope and laser
Advantage Broad view
Accurate treatment
Characteristic Open surgery with endoscope and laser
Disadvantage - No cosmetic effects
- The operation time is long and it is performed under the general anesthesia.
- Demands artificial disc or bone graft Fusion.
- Requires the experienced surgeons due to narrow views.
- Needs advanced medical equipment such as endoscope and laser.
- Hard cervical disc herniation should be avoided.
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+ Anterior cervical foraminotomy

This surgical technique was studied and practiced on cadavers before it was applied in living patients. The goal was to achieve direct and effective anatomical decompression of the spinal cord with maintenance of spinal stability, thus eliminating the need for bone fusion and immobilization. The surgical technique of microsurgical anterior foraminotomy has been reported elsewhere.[4] The operation is performed after general endotracheal anesthesia has been attained in the patient. Somatosensory evoked potentials (SSEPs) are obtained by stimulating the upper and lower extremities immediately after induction of general anesthesia. Once the baseline SSEPs are obtained, SSEP monitoring is used continuously until the end of the operation. Positioning of the patient is similar to that for the conventional anterior approach to the cervical spine. With the patient supine, a bolster is placed behind both shoulders to maintain gentle extension of the cervical spine. When the patient is properly positioned, the baseline spinal cord function is reconfirmed with SSEP monitoring. The head is positioned with the midline upright. Both shoulders are gently pulled and fixed caudally with tape to facilitate a lateral view of the cervical spine on intraoperative roentgenogram. A cervical traction device is not used. The entire anterior neck is prepared with antiseptic solution and draped. A 3- to 6-cm long transverse incision is made at the anterior neck along a skin crease that is similar to the incision made for an anterior approach to the cervical spine. The skin incision is made ipsilaterally to the radiculopathy or to the narrower side of the spinal canal. The first two-thirds of this incision is made medially to the sternocleidomastoid muscle and the remaining one-third is kept lateral to the medial border of the sternocleidomastoid muscle. The subcutaneous tissue and the platysma muscle are incised along the line of the skin incision. The loose connective tissue layer under the platysma muscle is cleanly undermined to provide space to operate. A combination of sharp and blunt dissection is used to access the anterior column of the cervical spine to keep the carotid artery and the sternocleidomastoid muscle lateral and the strap muscle, trachea, and esophagus medial. The prevertebral fascia is opened, and the anterior column of the cervical spine is exposed. The correct level is then confirmed with a radiographic lateral view of the cervical spine. Up to this point, the procedure is similar to that for an anterior approach to the cervical spine. An anterior cervical discectomy retractor system is then applied; only smooth-tipped retractor blades are used. Retraction naturally exposes the ipsilateral longus colli muscle rather than the midline anterior disc surface. An operating microscope is used at this stage. The medial portion of the longus colli muscle is excised to expose the medial parts of the transverse processes of the upper and lower vertebrae. The vertebral artery (VA) is located anterior to the C-7 transverse process and beneath the longus colli. Therefore, when operating at the C67 level, care must be taken not to injure the VA while removing the medial portion of the longus colli. Because the VA occasionally enters the transverse foramen at another level, the longus colli is incised carefully under the operating microscope. For operations above the C67 level, the VA is not exposed purposefully at this point. Once the medial portions of the transverse processes of the upper and lower vertebrae have been identified, the ipsilateral uncovertebral joint between them can be seen; however, advanced spondylosis may obscure the anatomical landmark of the uncovertebral joint and transverse processes. Anterior spondylotic spurs at the intervertebral disc can act as a guide, leading to the uncovertebral joint superolaterally. Although the interface of the uncovertebral joint will be angled approximately 30° cephalad from the horizontal line of the intervertebral disc in the normal cervical spine, advanced spondylotic changes may obscure the normal anatomy. The uncovertebral joint is drilled between the transverse processes using a high-speed microsurgical drill attached to an angled hand piece (Fig. 1). To prevent injury to the VA, a thin layer of cortical bone is left attached to the ligamentous tissue covering the medial portion of this artery. Drilling continues down to the posterior longitudinal ligament. As drilling advances posteriorly, the direction of the drill is gently inclined medially. When the posterior longitudinal ligament is exposed, a piece of thin cortical bone is left attached laterally to the periosteal and ligamentous tissue covering the VA. This lateral remnant of the uncinate process is dissected from the ligamentous tissue and fractured at the base of the uncinate process. It is further dissected from the surrounding soft tissue and removed, which enables identification of the VA by its pulsation between the transverse processes of the vertebrae. It is necessary to proceed cautiously with drilling at the base of the uncinate process because the nerve root lies just adjacent to it. After the uncinate process becomes loosened at its base, it is safer to remove the thin layer of remaining bone of the uncinate process by fracturing it rather than by continued drilling. When the remaining piece of the uncinate process is removed, the posterior osteophytes are drilled by crossing the midline diagonally toward the opposite margin of the spinal cord dura mater. The size of the hole made by the drilling at the uncovertebral joint is usually approximately 5 to 6 mm wide transversely and 7 to 8 mm vertically. The posterior longitudinal ligament is incised and resected to achieve decompression of the ipsilateral nerve root and spinal cord. The beginning of the contralateral nerve root is identified for adequate decompression of the spinal canal in the transverse axis (Fig. 2). Multiple anterior foraminotomies are performed as needed. Using the holes of anterior foraminotomies, the spinal cord canal is enlarged in the longitudinal axis by removing the posterior portion of the vertebral bodies with Kerrison rongeurs and a long-armed up-biting curet. The bone bleeding is controlled with the application of bone wax. Epidural bleeding from the posterior longitudinal ligament can be controlled with bipolar coagulation. Hemostatic agents are not used in the epidural space. Finally, the platysma is closed with interrupted No. 3-0 absorbable stitches, and the skin is approximated with subcuticular sutures. To minimize postoperative incisional pain, a local anesthetic (a few milliliters) is injected subcutaneously. A cervical collar is not used. Although microsurgical anterior foraminotomy for cervical radiculopathy has been performed as outpatient surgery, this group of patients with myelopathy stayed in the hospital overnight to observe their spinal cord function clinically; they were discharged home the next morning. The surgery was performed with patients supine, and a prevertebral surgical exposure of the affected cervical disc level was accomplished on the affected side as described by Cloward.1 Figures 1 and 2 (A to E) illustrate the site of surgical decompression and summarize the steps of the procedure. The anterior cervical retractor naturally tends to maintain exposure centered over the medial border of the longus colli muscle. A long segment of the colli muscle was mobilized laterally to expose the transverse processes above and below the affected disc space without removal of the muscle (Figure 2A). Dissection around the circumference of the vertebral body between the transverse processes and lateral to the uncus with a curet or Freer type instrument was accomplished. Fluoroscopic imaging (Figure 3) was helpful to guide the placement of a 1 to 4-in. or 3 to 8-in. malleable blade retractor inserted between the vertebral body and vertebral artery that maintained retraction of the colli muscle and protected the artery. The malleable retractor was attached to a table-mounted (Greenburg type) retractor to maintain the exposure (Figure 2B). The lateral view fluoroscopic image showed correct placement of the retractor inserted to the midvertebral body to avoid compression of the nerve root posteriorly. The remainder of the procedure was then completed with microscopic magnification. The lateral portion of the uncovertebral joint was drilled (Figures 1 and 2C) until a thin posterior cortical rim was left posteriorly that was removed with curettage and Kerrison rongeurs to expose the lateral posterior longitudinal ligament overlying the exiting nerve root. Further exploration for removal of any compressive ligament, herniated disc, and osteophytes on the adjacent endplates allowed removal (Figure 2D). The small remaining portion of the uncus was then removed to complete the anterior foraminal decompression (Figure 2E).
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+ Cervical corpectomy and fusion

Displaced bony disk material will be removed from your neck. This displaced material is causing a problem by pressing on nerves. It will be replaced with bone taken from your hip or the fibula bone in your lower leg. During the operation, an incision (cut) will be made on your neck (see the diagram below). The size of this incision will depend on the extent of your problem. A second incision will be made on the front of your hip or leg (see the diagram). Bone will be removed from your hip or leg and will be placed in your neck. This transfer is called a bone graft. The surgery may take about four hours. If you have one or two vertebras repaired (a single-level corpectomy), you will probably be sent directly to a general patient unit after surgery. Your hospital stay will be two to three days. If you have two or more bones removed (a multiple-level corpectomy), you will probably be sent to the intensive care unit (ICU). During surgery a plastic breathing tube will be inserted down your throat, to keep your airway open. This is necessary because of swelling in your neck. You will remain in the ICU while you have a breathing tube. Most patients stay in the ICU one to two days. Then you will be sent to a general patient unit for two to five days. Incisions are usually closed with stitches and may be secured with Steri-strip tapes; paper like strips that stick to your skin and help keep the sides of the incision from shifting. The stitches will dissolve completely. The Steri-strips will fall off by themselves, usually within two weeks of surgery. All patients underwent preoperative MR imaging and CT studies. The position of the manubrium and the great vessels relative to the level of the pathological entity was assessed in each patient. In two patients, both of whom underwent a C-7 corpectomy, a standard horizontal cervical incision was used. The other six patients underwent surgery via an extended cervical approach, which required that an incision be made along the medial border of the sternocleidomastoid muscle, ending at the manubrium. In two patients, the incision was continued caudally in the midline to allow for resection of the rostral third of the manubrium. A left-sided incision was used in seven patients; the anatomical position of one tumor necessitated the use of a right-sided incision in a single case. A left-sided incision was preferred because of the course of the RLN. A standard cervical dissection along the medial border of the sternocleidomastoid muscle, medial to the carotid sheath, was performed to expose the anterior surface of the lower cervical spine. The dissection was extended caudally, angling beneath the manubrium or accompanied by a partial resection of the manubrium. When required, up to 3 cm of the manubrium was resected using a Leksell rongeur. Although resection of the head of the clavicle was not necessary in this series, it has been described and may increase exposure as well.[13,14] A table-mounted self-retaining retractor system, used in all cases, proved to be very helpful in retracting mediastinal contents. The thoracic duct may be ligated and divided if it cannot be retracted out of the field. A narrow, malleable blade was used for caudal retraction. The use of corpectomy, in contrast to discectomy, allowed for visualization of the thecal sac following bone removal. A nearly "end on" view of the caudal VB may be obtained. Following decompression of the spinal cord and nerve roots, a fibular allograft was used as a load-bearing strut. In all cases an anterior cervical plate was implanted to provide immediate rigidity to the construct. The use of variable-angle screws was helpful for the placement of the plates caudally. The angle required for screw placement often required contouring of the plate in addition to the use of variable-angle screws. Four of the eight patients also underwent posterior stabilization procedures for the treatment of gross instability. Postoperative immobilization therapy consisted of a rigid cervical collar in six patients and a Minerva brace in two. The duration of immobilization therapy was 6 weeks in all patients.
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+ Anterior Cervical Discectomy and Fusion (ACDF)

Surgery for anterior cervical fusion is performed with the patient lying on his or her back. A small incision is made in the front of the neck, to one side. After a retractor is used to pull aside fat and muscle, the disc is exposed between the vertebrae. Part of it is removed with a forceps. Then a surgical drill is used to enlarge the disc space, making it easier for the surgeon to empty the intervertebral space fully and remove any bone spurs. Afterwards, only a single ligament separates the surgical instruments from the spinal cord and nerve roots. A small section of bone is obtained from the patient's iliac crest (i.e. hip), through a separate incision and used as a bone graft. The bone graft is placed in the disc space, where it will begin to fuse the vertebrae it lies between. Placing a bone graft between the two vertebral bodies is done in order to create a fusion between these bones. The fusion is a direct result of the bone graft, but small, specialized metal plates are also placed on the front of the cervical spine in order to increase the stability of the spine immediately after the operation. Surgeons use cervical hardware to decrease the amount of time that you will have to wear a collar after surgery, and also to increase your chances of getting a solid fusion between the two vertebral bodies. The operation is completed when the neck incision is closed in several layers. Unless dissolving suture material is used, the skin sutures (stitches) or staples will have to be removed after the incision has healed. Anterior cervical fusion is an operation performed on the upper spine to relieve pressure on one or more nerve roots, or on the spinal cord. The term is derived from the words anterior (front), cervical (neck), and fusion (joining the vertebrae with a bone graft). When an intervertebral disc ruptures in the cervical spine, it puts pressure on one or more nerve roots (often called nerve root compression) or on the spinal cord, causing pain and other symptoms in the neck, arms, and even legs. In this operation, the surgeon reaches the cervical spine through a small incision in the front of the neck. After the muscles of the spine are spread, the intervertebral disc is removed and a bone graft is placed between the two vertebral bodies. Over time, this bone graft will create a fusion between the vertebrae it lies between.

Cervical Laminoplasty
Its popularity in Japan arises from the formidable challenges of anterior decompression for ossification of the posterior longitudinal ligament. These anterior multilevel surgeries would be frequently complicated by dural tears as the dura is usually intimately associated with the ossified ligament. There was also a significant risk of instrumentation or graft failure. It has been reported that the rate of these complications including cerebrospinal fluid leakage and dislodgment or pseudarthrosis of the strut grafted bone was 24% and the rate of the salvage operation required was 12.5%. In the past, laminectomy has been the most common method to achieve posterior decompression of the cervical spine in these patients. However, the procedure has been complicated by postoperative instability resulting in deformity, particularly kyphosis, which may exacerbate neurological symptoms. Kyphosis and instability may leave the spine more vulnerable to cervical spine trauma, especially flexion injuries. In addition, postlaminectomy membranes have been implicated in arachnoiditis and restenosis after simple laminectomy. To avoid the disadvantages of laminectomy, several authors have described the technique of cervical laminoplasty whereby decompression is achieved without removal of the posterior spinal elements, maintaining the biomechanical integrity of the cervical spine and the spinal cord-protective features of the posterior elements. This is a more physiological solution. Expansive open-door laminoplasty was first described by Hirabayashi et al as a development of the air drill laminectomy technique of Kirita and has since been modified by Hirabayashi et al. and many others.

TDR for cervical spine
Initial surgical positioning was similar to that for a standard anterior cervical decompression and fusion. A roll was placed behind the shoulders and the head placed on a foam donut. The neck was extended slightly to facilitate exposure and an image intensifier was draped into the field. A transverse cervical incision was made in the neck over the C5-6 disc space and a standard extensile exposure of the C5-6 disc space was performed. Similarly routine discectomy was performed. The Bryan Cervical Disc System was utilized. The size of the implant (14 mm) and angle of the disc space was calculated precisely prior to placement of the implant. Using custom drill bits, and a milling wheel, a reciprocal concavity was cut into the endplates of C5 and C6. This is shown in Figures 4 and 5. After the endplates were precisely drilled and the decompression effected, the correct size prosthesis was placed into the defect (see Figure 6-9). At the completion of this stage closure was affected over a suction drain. The patient was transferred to the intensive care unit and extubated uneventfully.
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■ Thoracic
+ Percutaneous Endoscopic Thoracic Discectomy (PETD)

PETD with laser is a minimally invasive surgical treatment for symptomatic thoracic disc herniation (TDH). It may also be known as: posterolateral thoracic discectomy; endoscopic laser thoracic discectomy; or endoscopic microdecompressive thoracic discectomy with laser thermodiscoplasty. Symptomatic TDH is rare accounting for between 0.25% and 0.57% of all disc herniations reported in the literature. Symptoms include back pain, radicular pain, nondermatomal leg pain, bladder dysfunction, and lower extremity weakness. If left untreated serious neurological sequelae may occur. The procedure is similar to percutaneous laser discectomy for the lumbar and cervical spine, and aims to decompress the disc using a percutaneous needle and laser ablation. Percutaneous endoscopic laser thoracic discectomy is purported to reduce morbidity and promote earlier return to work, and result in less scarring than other techniques. Other likely advantages are that it does not interfere with the bones or joints of the spine or require manipulation of nerves or the spinal cord. The steep learning curve for endoscopic techniques, the high cost of specialized instrumentation and the relatively low incidence of suitable surgical candidates are all factors contributing the to the very small number of surgeons who appear to be using this technique at present.

Open Thoracic Microdiscectomy
Thoracic corpectomy and fusion
Thorascopic discectomy
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■ Lumber
+ Percutaneous Endoscopic Lumbar Discectomy (PELD)

Percutaneous Endoscopic Lumbar Discectomy (PELD) is not the Conventional excision but a treatment which in between the conservative and open surgery. Therefore, it does not disrupt the normal soft tissue or the vertebral structures. After inserting a thin wire into the skin, the surgeons treat the herniated disc with laser and radio-frequency thermal effect under endoscopic guidance.

- It preserves vertebrae and normal nucleus pulposus and removes only the lesional site so that there is no risk of evoking the neural adhesion. Bloodless surgery, no transfusion is required.
- Under the local anesthesia, the elderly patients or even the diabetes patients could tolerable the procedure.
- Cosmetic effects since it is minimally invasive spinal surgery.
- It saves the time and the costs. 75% of the patients discharged on the same.
- Due to rapid recovery, comparing to open surgeries, it is recommendable for the workers or students with the desire of early return-to-work.

Surgical Techniques
- Patient is in prone position under the local anesthesia so as to communicate with the surgeons and nurses. The surgeon inserts the thin wire into the disc. With the 0.6cm (diameter) of endoscope, the surgeon could observe the inside with safety. With the better view under endoscope, minute forceps, radio-frequency, and Holmium-YAG laser, the surgeon could make the disc shrink so as to diminish the pain. This treatment, regarded as the third generation, is more advancing that the previous first, second generation laser therapy with following additional effectiveness.
- Minimized excision effect (with laser, as fine as hair, which could approach into the small and narrow spinal canal)
- Prevent lumbar pain effect (pain nerve that distributed to posterior annulus fibrosis)
- Disc diminishing effect (diminish the extruded disc)
- Disc intensifying effect (remodeling the collagen component of disc material)
- Hemostasis effect (coagulation)
Laser technique under
the endoscopic view
Radio-frequency technique
under the endoscopic view

This surgical technique is in between the conservative therapy and open surgery. Therefore, either lumber disc herniation or extraforaminal stenosis is an indication, which shows no improvement after conservative therapy.

Successful rate is 93% and 7% showed the recurrence. The 7% recurrence was due to combined spinal canal stenosis.

MRI image of preoperation
A ruptured disc that is dehydrated as black color
between 4th and 5th lumbar vertebra is compressing
the nerve root.
MRI image 3years after the surgery
The corresponding disc level I is maintaining its
original height while the ruptured portion is

Caring for a patient after surgery
    Post operative 1 week
  • Please take a rest at least three days. It is OK to sit, stand and walk with proper position shortly.
  • Please avoid from twistingor bending your back, lifting heavy materials or sitting longer than one hour.
  • You had better have meals on standing posture.
  • Please keep your back straighten up or extended when you stand.
  • It is OK to walk for 30 minutes with right position. Back exercise is not allowed.
  • It is necessary to sterilize the incision and the dressing would be removed 10 days after the surgery. Doctor consultation is necessary.
  • Please wear the brace while moving. The patient does need to wear the brace while lying down or sleeping.

  • Post operative 2 week
  • The patient may get back to work or school but avoid twisting or bending their back.
  • The patient may take shower or bath. When washing face and hair, you would better keep your back straighten up under shower machine.
  • The patient may drive by himself for only short distance.
  • Please start back stretching exercise two weeks after the operation.

  • Post operative 3 to 6 week
  • The patient may perform light works.
  • Sex-life is allowed.
  • On supine position, the patient may do flexion-extension back exercise. Climbing is more recommendable compared to the swimming.

  • Post operative 6 week
  • The patient does not need to wear the brace longer than 6 weeks. If you still want to protect your back while working or doing exercise, you may wear ASTROBACK (Cushion protector) instead of the brace.
  • Conservative therapy such as intensifying exercise (Medex program, Centaur program) and flexibility exercise (Gyrotonic program) are recommendable.

  • Post operative 3 months
  • The patient is recommended to take the CT or MRI in order to confirm the disc condition at this time. You had better consult with doctor to check your disc condition on 6 months, 1 year and 2 years after the operation, if possible.

  • Other
  • It is recommendable to pull back your seat to 135° while seated in a vehicle immediately after the discharge.
  • It is important to intake plenty of vegetable while controlling your calorie in order to avoid constipation.
  • Please reduce fat consumption and avoid overeating.
  • If you are taking medicine due to Diabetes, Hypertension or Cardiac diseases, you should consult with your physician for the medication schedule before and after surgery.
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+ Open Laser-assisted Lumbar Discectomy (OLD)

Open Laser-assisted Lumbar Discectomy (OLD) is the surgical technique that is a minimal invasive spinal surgery to preserve tissue as much as possible. This technique was introduced by Dr. Magana and Dr. Maroon in the USA. The Wooridul Hospital adopted this surgical technique in 1992 and has modified these early American techniques by adding the expertise from Switzerland.

Surgical technique
After 1.5~2cm incision, the surgeon partially removes the posterior vertebral structure with a high-speed diamond drill and observes the surgical field as much as 10~15 times magnification under the microscopic view. The surgeon removes the herniated disc, or thick ligaments with a laser that compresses the nerve. In addition, shrinking and modulating the posterior annulus fibrosis, by the flexible Holmium-YAG laser and radiofrequency can improve the back pain.

Severe lumbar disc herniation that has showed no improvement by the conservative therapy or even the percutaneous endoscopic laser treatment
Abnormal spinous process, joint problems and complicated disc disease with spinal stenosis
Those patients with intractable and recurrent disc disease

When the nerve root is compressed due to herniated
disc, it could cause either back pain or leg pain.
Microlaser is precise enough to mark a 0.3mm spot between fingerprints.

It takes a long time for surgeons to perform conventional open surgery that disrupts much of the vertebral body. However, Open Laser-assisted Lumbar Discectomy (OLD) takes approximately 1~2 hours at most so that it is applicable to old and weak patients who cannot stand long duration of general anesthesia or open surgery.
The conventional open surgery is performed under the naked eye that it requires a huge incision. Meanwhile there is less bleeding and a smaller incision with Open Laser-assisted Lumbar Discectomy, because the doctors perform the surgery under a microscope. Two surgeons also assist the operation and the nurses observe the patient's condition through the monitors.
The early spinal stenosis surgery have required screw fixation, in case that there is damage to the muscle or the bones because of instability. On the other hand, Open Laser-assisted Lumbar Discectomy is performed with a microscope and a fine laser that it minimizes the normal tissue damage. Therefore the bone fusion is not necessary.

Hospital stay and success rate
The success rate of the Open Laser-assisted Lumbar Discectomy is 95% and most patients (75%) stay at the hospital for 24 hours to 72 hours and at most 1 week.
2~4% of patients, who did not show improvement by this surgical technique, are likely to have the instability; then, those patients might need the additional nerve decompression, screw fixation or fusion.
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+ Posterior Lumbar Interbody Fusion (PLIF)

The first posterior lumbar interbody fusion (PLIF) was reported by Jaslow in 1946 when he utilized a bone peg that was placed within the lumbar interspace after discectomy. He augmented this with autogenous bone chips harvested from the posterior elements placed posteriorly.
Posterior lumbar interbody fusion (PLIF) is a surgical technique for placing bone graft between adjacent vertebrae (interbody). Typically, screws and rods or other types of spinal instrumentation are used to hold the spine in position while the bone heals. Indications for this procedure may include pain and spinal instability resulting from spondylolisthesis, degenerative disc disease, or when a discectomy is performed to relieve nerve compression and the patient has associated mechanical low back pain. Spinal fusion uses bone graft to promote specific vertebrae to grow or fuse together into a solid and stable construct. Instrumentation, also called internal fixation, incorporates the use of rods, screws, cages, and other types of medical hardware to provide immediate stability to the spine and facilitate fusion.
In minimally invasive procedures, the surgical incisions are small, there is no need (or minimal need) for muscle stripping, there is less tissue retraction, and blood loss is minimized. Special surgical tools allow the surgeon to achieve the same goals and objectives as the open surgery while minimizing cutting and retracting of the paraspinous muscles. Therefore, tissue trauma (injury) and post-operative pain are reduced, hospital stays are shorter, and patients can recover more quickly.
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+ Anterior Lumbar Interbody Fusion (ALIF)

Anterior Lumbar Interbody Fusion (ALIF) is first introduced by Hodgson and Stock in 1956.
ALIF is an operation that involves approaching the spine through an incision in the abdomen. A portion of the affected disc space is removed from the spine and replaced with an implant. Titanium or stainless steel screws and rods may be inserted into the back of the spine to supplement the stability of the entire construct.
Patients who are suffering from back and/or leg pain which are generally caused by natural degeneration of the disc space.
The ALIF operation is performed with the patient lying on his or her back. The surgeon makes an incision in the patient's abdomen to access the spine. To have a clear view of the spine, the surgeon then retracts the abdominal and vascular structures. Once the spine is in view, the surgeon removes a portion of the degenerated disc from the affected disc space. After this disc material is removed, the surgeon inserts bone graft material into the disc space, such as autograft or INFUSE Bone Graft contained in a LT-CAGE Lumbar Tapered Fusion Device ?to restore the normal anatomic condition of the spine. After the surgery, the patient will normally stay in the hospital between 2 to 5 days. The specific time of stay in the hospital will depend on the patient and the surgeon's specific post-operative treatment plan.
Previous reports have documented that anterior lumbar interbody fusions (ALIF) decrease perioperative blood loss and eliminate nerve root retraction compared to posterior procedures. It has also been shown that ALIF procedures have shorter operating times than posterior lumbar interbody fusions (PLIF) with or without pedicle screw instrumentation. These advances have led to shorter hospitalization times and comparable fusion rates.
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+ Open pedicle screw fixation (OPF)

Percutaneous pedicle screw fixation (PPF):
For a degenerative spondylolisthesis case, a blunt probe is inserted through the pedicle and into the vertebral body. Once the pedicle canals are prepared and the screw length determined, the screws are sequentially inserted.
PPF can be performed after induction of general anesthesia. Thereafter, the patient is positioned prone on top of chest rolls with the abdomen free. A C-arm fluoroscopy device is used for guidance of percutaneous screw placement. A 15-mm-long incision was made for each screw at the appropriate skin entry point. A 14G vertebroplasty needle was inserted toward the pedicle and vertebra body and then the stylet replaced by 200-mm-long K-wire. A series of sequential dilation was performed along a K-wire and a 16-mm-diameter tunnel sleeve was inserted. The pedicles were tapped and then K-wire removed. Uncannulated screws can easily be placed as the tapped bone guided its passage. A soft tissue tunnel which connected two pedicle screw heads was made using a bended passer, and the pedicle screws were connected with bended round rod through the soft tissue tunnel. Final tightening of the pedicle screw-rod constructs were given under the fluoroscopic guidance. While tightening a screw-rod construct the remaining screw path was used to give antitorque and some compression force. Just one deep stitch was needed at each screw entry incision.
Although conventional fluoroscopy can be used for this purpose, it has certain disadvantages: the inability to visualize more than one plane of view at a single time (when using a single fluoroscope), the ergonomic challenges of working around a C-arm, and radiation exposure. It is important to check that adequate AP and lateral fluoroscopic images of the lumbar spine can be obtained before preparing and draping the patient.
Compared to open techniques, the presumed benefit of the percutaneous technique is avoidance of muscular tendon detachment, elimination of largescale muscle retraction, diminished postoperative pain, less blood loss, and improved cosmetic result.
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+ Percutaneous facet screw fixation (PFF)

Posterior instrumentation is often performed to stabilize unstable vertebral segments, often as supplementation to an interbody fusion. The most commonly used posterior instrumentation system in use today is open pedicle screw fixation. The disadvantage to this technique is the major muscle dissection necessary and the related morbidity and scarring. Facet screw fixation offers the advantage of placing a single screw across each articulating joint to immobilize a motion segment, thereby reducing the amount of hardware (and therefore exposure) necessary. Recent studies have shown this type of fixation, for single level stabilization of an anterior (interbody) fusion construct is equally as stable as a pedicle screw construct. Percutaneous facet fixation system uses framed fluoroscopic navigation and small-diameter access channels and instruments to place screws through small incisions, obviating the need for wide muscle exposure. Accurate placement of the facet screws can be determined using radiography and/or neurophysiologic (EMG) screw placement testing. This integrated system maximizes the efficiency of creating a stable fusion construct, while incorporating the advantages of minimal access surgery.
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+ Transforaminal Lumbar Interbody Fusion (TLIF)

Transforaminal Lumbar Interbody Fusion (TLIF) is an operation where the lumbar spine is approached from the side through an incision in the back. A portion of bone and disc are removed from the spine and replaced with an implant that is inserted into the disc space. Titanium or stainless steel screws and rods are inserted into the spine to ensure the stability of the entire construct. Patients who are suffering from back and/or leg pain which may range from a natural degeneration of the disc space to some type of traumatic event. The operation is performed with the patient lying on his or her stomach. An incision is made in the patient's back to allow the surgeon access to the spine. The surgeon separates the muscle and tissue to be able to have a clear view of the spine. Once the spine is in view, the surgeon will remove a portion of bone from the appropriate areas of the spine to allow the surgeon to access the disc space. The surgeon will remove the disc material to allow the surgeon to insert an implant into the disc space. The surgeon will also insert titanium or stainless steel implants into the spine. The implant and the screws will help to restore the spine back to its normal anatomic condition. After the surgery, the patient will normally stay in the hospital between 3-5 days. The specific time of stay in the hospital will depend on the patient and the surgeon's specific post-operative surgical plan. The patient will normally be up and walking in the hospital by the end of the first day after the surgery. Your surgeon will have a specific post-operative recovery / exercise plan to help you return to normal life as soon as possible.
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+ Percutaneous Vertebroplasty

Percutaneous vertebroplasty is the injection of acrylic bone cement (polymethylmethacrylate; PMMA) into the vertebral body through a trocar needle in order to relieve pain and/or stabilize the fractured vertebra and in some cases, restore vertebral height. Percutaneous vertebroplasty is usually performed under conscious sedation with local anesthetic
Vertebral compression fractures are a common cause of pain and disability.
Percutaneous vertebroplasty may provide pain relief for patients with vertebral fractures caused by osteoporosis, but may also provide relief for patients with vertebral hemangiomas and pathological fractures from vertebral body tumors.
Evidence indicates that percutaneous vertebroplasty is efficacious for the treatment of pain associated with vertebral compression fractures and symptomatic hemangiomas. Percutaneous vertebroplasty appears safe with a low complication rate, although if complications occur, they can be major, including pulmonary embolism and spinal cord compression caused by extravasation of cement into the spinal canal.
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+ Kyphoplasty

Kyphoplasty is a minimally invasive procedure designed to stabilize and reduce pain from pathological vertebral compression fractures.
Kyphoplasty, developed in 1997, has evolved from the vertebroplasty technique, where acrylic bone cement, polymethylmethacrylate (PMMA) is injected percutaneously into the fractured vertebral body, stabilizing the vertebra as it sets. Kyphoplasty includes an additional step of inserting and inflating a bone tamp inside the vertebral body to restore vertebral height and create a cavity into which PMMA can then be injected.
Pathological vertebral compression fractures can be caused by osteoporosis, a malignancy in the underlying bone, or more rarely a benign blood vessel tumor in the vertebra known as a vertebral haemangioma. The traditional conservative treatment for pathological vertebral compression fractures, including bed rest and analgesics, has been unsatisfactory for many patients who are left with chronic pain, immobility and deformity. In the management of osteoporotic vertebral compression fractures, the use of open reduction and internal fixation has a limited place. The fixation of the osteoporotic spine is usually inadequate to correct the deformity occurring as a result of crush fractures. Open surgical techniques have also had little success.
Kyphoplasty, developed in 1997, has evolved from the vertebroplasty technique, where acrylic bone cement, polymethylmethacrylate (PMMA) is injected percutaneously into the fractured vertebral body, stabilizing the vertebra as it sets. Kyphoplasty includes an additional step of inserting and inflating a bone tamp inside the vertebral body to restore vertebral height and create a cavity into which PMMA can then be injected. Current research evidence (case series) shows that kyphoplasty appears efficacious, with studies showing that most patients gained significant pain relief and increased mobility.
Complication due to vertebroplasty includes spinal cord compression, radiculopathy, fractured ribs and pulmonary embolus (sometimes fatal). Complications resulting from kyphoplasty include nerve root or spinal cord compression, epidural hematoma, transient fever and hypoxia. Overall complication rates appear low, with complications due to kyphoplasty probably slightly less common than for vertebroplasty.
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+ Total disc replacement (TDR)

Total Disc Replacement (TDR) is a surgical method to treat the symptoms caused by degenerated discs and to maximally preserve the mobility of the spine. The method was developed by Karin Butner-Yantz in the early 1980s and was introduced to the Wooridul hospital in 1999. Due to the development of surgical instruments and surgical techniques, the patients?degree of satisfaction is very high.

Surgical Techniques
As a minimally invasive transfusionless surgery, it enables less bleeding and injury to the muscle since the surgery approaches the lesion by making a 4~5 cm long incision in the abdomen. The diseased disc is quickly and safely removed by using an automated nucleotome to insert an artificial disc. The surgery does not require blood transfusion, and the surgery is finished by confirming the location of the inserted artificial disc.

1. Inserting an artificial disc
2. an artificial disc

Since TDR maintains the mobility of joints, the movement of the spine is more flexible. Patients who receive the surgery can walk the day after. Since the surgery does not cut lumbar vertebrates and does not open the waist muscles, patients do not have pain and quicker rehabilitation is possible due to less hospitalization. They also return to their normal and social lives much faster. It also reduced the chances of spinal surgery by minimizing the degenerative changes in peripheral vertebrates in the surgery area.

The X-ray results of a patient who received TDR surgery on September 12, 2002 between Lumbar spine No. 3 and 4. The patient returned to normal work within one week of the surgery.

Success Rate
The success rate of TDR surgery reaches up to 95%, and most patients?hospitalization period is from three to seven days.

Complication and sequelae
Lower back pain and numbness in the legs can be immediately improved after the surgery, but some patients require a certain period of recovery time. The possibility of bleeding is less than 0.1%. Inflammation and infection can be found in less than 0.2% of patients. However, retrograde ejaculation can be found in 2% of males when the artificial disc insertion is made between Lumbar spine No. 5 and Sacral spine No. 1.

Applicable Subjects
The surgery is recommended for patients who have experienced lumbar pain for more than two years due to degenerative disc diseases, internal disc disruption, disc herniation accompanied with spine instability due to recurrent disc diseases, degenerative disc instability after bone fusion, and for patients who require spinal reconstruction from spinal cord stenosis. It is also applicable for patients with spine deformities without having damage in joints after spinal cord stenosis surgery.

1. Before
2. After

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