A brief history of endoscopic spine surgery

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Few neurosurgeons practicing today have had training in the field of endoscopic spine surgery during residency or fellowship. Nevertheless, over the past 40 years individual spine surgeons from around the world have worked to create a subfield of minimally invasive spine surgery that takes the point of visualization away from the surgeon's eye or the lens of a microscope and puts it directly at the point of spine pathology. What follows is an attempt to describe the story of how endoscopic spine surgery developed and to credit some of those who have been the biggest contributors to its development.

ABBREVIATIONSVATS = video-assisted thoracoscopic surgery.

Abstract

Few neurosurgeons practicing today have had training in the field of endoscopic spine surgery during residency or fellowship. Nevertheless, over the past 40 years individual spine surgeons from around the world have worked to create a subfield of minimally invasive spine surgery that takes the point of visualization away from the surgeon's eye or the lens of a microscope and puts it directly at the point of spine pathology. What follows is an attempt to describe the story of how endoscopic spine surgery developed and to credit some of those who have been the biggest contributors to its development.

The history of endoscopic spine surgery has involved 3 phases: inspiration, invention, and innovation. The inspired early practitioners sought a means of accessing lumbar disc herniations that would be less invasive than traditional open techniques. The early endoscopic surgeons targeted disc pathology through a corridor that would become known eponymously for its originator, Dr. Parvis Kambin. Invention would then be required to make endoscopic discectomy a feasible and then a successful procedure: better working-channel rigid endoscopes, high-definition cameras, drills, trephines, articulated graspers, and other instruments (Fig. 1). With 50 years of groundwork on which to build, the innovators now have the tools and background knowledge to treat a myriad of spine pathologies beyond the herniated lumbar disc for which the technique was intended. The story of endoscopic spine surgery is far from complete, but it demonstrates the interplay of imagination and technology in developing new surgical techniques.

FIG. 1.
FIG. 1.

Instruments used in and developed for endoscopic spine surgery. A: Craig needle set and cannula. B: Working-channel endoscope with channels for irrigation and suction. C: Crown reamers for foraminal bone removal. D: Endoscopic graspers and Kerrison punches. E: Endoscopic drill (left) and chisel (right; arrow points to exiting nerve root). F: Semibendable grasper reaching cranial (right) and cephalad (left) in a foraminal decompression after placement of instrumentation.

Percutaneous Endoscopic Discectomy

The current position of the field of endoscopic spine surgery is the result of two directions of evolution: big-to-small and small-to-big. As in other surgical fields, the progression of surgical techniques from open to more and more minimally invasive procedures has required visualization and instruments that would be endoscope based. However, the foundation for transforaminal endoscopic spine surgery was really the result of the evolution of a needle-based technique: percutaneous endoscopic discectomy.

A technique for percutaneous nonvisualized indirect spinal canal decompression—percutaneous nucleotomy— through a posterolateral approach was described by Parvis Kambin (Fig. 2) in 197326 and Hijikata et al. in 1975.12 Kambin described using a Craig cannula (Fig. 1) and Hijikata a 2.6-mm cannula. The technical challenge of achieving sufficient removal of nucleus pulposus material through a needle was addressed by Kambin and coworkers in 1986 and 1987 with the introduction of working cannulas possessing diameters up to 5 mm and flexible forceps.27,30

FIG. 2.
FIG. 2.

Photographs of some of the inventors and innovators in the field of endoscopic spine surgery. A–F: Parvis Kambin, Michael Schubert, Thomas Hoogland, Sebastian Ruetten, Anthony Yeung, and Kevin Foley.

The next step in the advancement of the percutaneous discectomy technique was the addition of the endoscope. The first endoscopic views of a herniated nucleus pulposus were published by Kambin et al. in 1988,29 and the first reported introduction of a modified arthroscope into the intervertebral disc space was reported by Forst and Hausman in 1983.11 Schreiber et al.47 and Suezawa et al.50 published their bilateral approach for a percutaneous nucleotomy under endoscopic control and described injecting indigo carmine into the disc space to stain the abnormal nucleus pulposus and anular fissures.

Percutaneous endoscopic discectomy certainly must receive a great portion of the credit for advancing endoscopic spine surgery, but it also must likely take responsibility for endoscopic spine surgery's slow rate of acceptance as a feasible technique by most orthopedic and neurosurgical spine specialists. The surgical goal of percutaneous endoscopic discectomy is to indirectly decompress the neural elements by selectively removing the nucleus pulposus from the posterior one-third of the disc space. From its origin, the technique showed promising results: Kambin and Gellman reported a 72% success rate in 136 patients with their percutaneous technique in 1983, but it has been difficult to quantify the impact of such results because they were not matched with nonoperative controls.28 Thus, percutaneous endoscopic discectomy represented what is only an indirect spinal decompression, but a direct and very powerful new surgical approach to spinal pathology.

Kambin's Triangle

In 1990, Parvis Kambin described a triangular safe zone bordered by the exiting root anteriorly, the traversing root medially, and the superior endplate of the lower lumbar vertebra inferiorly.26 The anatomical description of this safe zone allowed the field of endoscopic spine surgery to outgrow the technique of percutaneous nucleotomy, which was limited by the use of small needlelike instruments. Kambin's triangle was a working corridor that allowed larger instruments and working channels to be introduced in even closer proximity to foraminal pathology without injuring the exiting nerve.

Foraminoscopy

With the idea of a safe working triangle between the exiting and traversing roots in the foramen, endoscopic spine surgery started to leave the safety of the indigo carmine blue–stained nucleus and explore the foramen. In 1993 Mayer and Brock used an angled lens scope that allowed more dorsal visualization of anular pathology.38 Foraminoscopy was described by Mathews in 199637 and Ditsworth in 1998.9 In 1996 Kambin and Zhou described lumbar nerve root decompression by anulectomy and decompression of lateral recess stenosis with the use of forceps and trephines.31 In 2005 Schubert and Hoogland (Fig. 2) described their technique for transforaminal endoscopic removal of a sequestered disc fragment using reamers to expand the foraminal window by removing the ventral portion of the superior articular process.48 Multichannel endoscopes with larger working channels were introduced by Tsou et al. in 199755 and Ruetten (Fig. 2) et al. in 2007.46 A number of reports of the clinical success of direct endoscopic decompression of foraminal pathology would follow: Yeung (Fig. 2) and Tsou in 2002,59 Ruetten el al. in 2007,46 Ruetten et al. in 2008,44 and Jasper et al. in 2013.20

Microendoscopic Surgery

In 1999 Foley (Fig. 2) et al. published their surgical experience treating far-lateral L3–4 and L4–5 herniated discs using a 25° rod-lens endoscope placed through a 16-mm-diameter tubular retractor.10 Instruments used in a traditional microdiscectomy procedure could now be applied under endoscopic visualization. The procedure was performed through an incision 5 cm off the midline. Mixter and Barr received credit for being the first authors to treat lumbar herniated discs by an open laminectomy and discectomy approach.39 With the introduction of the surgical microscope, Caspar and Yaşargil refined the open posterior approach, and they are credited with introducing the microdiscectomy procedure.2,57 Microendoscopic surgery offers several novel advantages over even the microdiscectomy procedure: the incision is smaller, the tubular retractor dilates and spreads tissue rather than destroying it, the paramedian approach spares the midline tension band, and endoscopic visualization allows the point of vision to be only a few millimeters away from the pathology due to the location of the camera lens, as opposed to the 20–50 cm that is the case with microscopic visualization.

Anterior Endoscopic Approaches

In the 1990s laparoscopic surgical techniques began to be adopted clinically; anterior endoscopic approaches were considered by some to offer possible advantages for the treatment of thoracic and lumbar disc disease.49,60 Laparoscopic lumbar discectomy was performed with an approach similar to laparoscopic abdominal surgery: pneumoperitoneum was established, and the small bowel and colon were retracted to provide access to the lumbar disc.49,60 A retroperitoneal laparoscopic lateral approach to the lumbar spine was also reported as a way to avoid laminectomy and disturbance of the facet.7,41 The disadvantages of peritoneal cavity retraction and the potential dangers of injuring the sympathetic chain, genitofemoral nerve, segmental lumbar arteries and veins, ureter, and superior hypogastric plexus made these approaches less feasible for widespread adoption.7,41

Thoracoscopy and later video-assisted thoracoscopic surgery (VATS) were adapted for thoracic spine surgery in the early 1990s.43 Reports have demonstrated the capacity of VATS to provide exposure for thoracic discectomy similar to that obtained with a transthoracic approach.42 However, in addition to a steep learning curve, the use of VATS for the treatment of thoracic spine disease is limited by the morbidity associated with working through the chest cavity.8,43 These limitations have hindered the widespread use of VATS for thoracic discectomy and have motivated the development of minimally invasive posterior approaches, including the endoscopic lateral extracavitary36 and transpedicular approaches.24

Innovations in Endoscopic Spine Surgery

The development of improved endoscopes and instruments, the increased experience of endoscopic spine surgeons, and the continued demand by patients for spinal surgery procedures that are as minimally invasive as possible have led to an explosion of innovation in endoscopic spine surgery. Published experience is available on transforaminal versus interlaminar endoscopic approaches,5,19,32 cervical approaches,56 thoracic approaches,6 and approaches to the thoracolumbar junction,1 as well as the treatment of far-lateral disc herniations,16,34,35 reherniations,13,45 extruded discs,3,21,54,58 spondylolisthesis,17,23 radiculopathy in the setting of instrumented fusion,51,53 discitis,14 discogenic back pain,55 and spinal tumors.25,52 Other studies published include the treatment of geriatric22 and obese18 populations and the use of intraoperative MRI,4 lasers,33 and interbody fusion devices15,40 in endoscopic spine surgery. In the fields of nonendoscopic surgery (surgery performed with the naked eye, loupes, or a microsocope) and endoscopic spine surgery, the spinal pathologies and goals of treatment are converging. The clearest difference in the two fields appears to be the method of visualization.

Direct Visualization

In order for an object to be “seen,” its image must be focused on the back of the retina. The retina is to the eye what film is to the camera. Endoscopic cameras allow us to move the “eye's” lens remotely to the site of the surgical pathology. Two dramatic examples of the technological innovation that implements this simple idea can be seen in space exploration and military combat: unmanned probes on Mars and military drones in remote areas of conflict bring our eyes “directly” but remotely to the points of interest. Innovation enables us to work at such sites from a remote location. The history of endoscopic spine surgery is indeed brief, and although many around the world justly can take credit for its inception and early development, the greatest credit will always likely go to the surgeon for whom Kambin's triangle is named.

References

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    Ahn YLee SHLee JHKim JULiu WC: Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration. Acta Neurochir (Wien) 151:1992062009

  • 2

    Caspar W: A new surgical procedure for lumbar disk herniation causing less tissue damage through a microsurgical approach. Adv Neurosurg 4:74801977

  • 3

    Choi GLee SHLokhande PKong BJShim CSJung B: Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976) 33:E508E5152008

  • 4

    Choi GModi HNPrada NAhn TJMyung SHGang MS: Clinical results of XMR-assisted percutaneous transforaminal endoscopic lumbar discectomy. J Orthop Surg 8:142013

  • 5

    Choi GPrada NModi HNVasavada NBKim JSLee SH: Percutaneous endoscopic lumbar herniectomy for high-grade down-migrated L4–L5 disc through an L5-S1 interlaminar approach: a technical note. Minim Invasive Neurosurg 53:1471522010

  • 6

    Choi KYEun SSLee SHLee HY: Percutaneous endoscopic thoracic discectomy; transforaminal approach. Minim Invasive Neurosurg 53:25282010

  • 7

    Dezawa AYamane TMikami HMiki H: Retroperitoneal laparoscopic lateral approach to the lumbar spine: a new approach, technique, and clinical trial. J Spinal Disord 13:1381432000

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    Dickman CARosenthal DKarahalios DGParamore CGMican CAApostolides PJ: Thoracic vertebrectomy and reconstruction using a microsurgical thoracoscopic approach. Neurosurgery 38:2792931996

  • 9

    Ditsworth DA: Endoscopic transforaminal lumbar discectomy and reconfiguration: a posterolateral approach into the spinal canal. Surg Neurol 49:5885981998

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    Foley KTSmith MMRampersaud YR: Microendoscopic approach to far-lateral lumbar disc herniation. Neurosurg Focus 7:5e51999

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    Forst RHausmann B: Nucleoscopy—a new examination technique. Arch Orthop Trauma Surg 101:2192211983

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    Hijikata SYamagishi MNakayma T: Percutaneous discectomy: a new treatment method for lumbar disc herniation. J Todenhosp 5:5131975

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    Hoogland Tvan den Brekel-Dijkstra KSchubert MMiklitz B: Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine (Phila Pa 1976) 33:9739782008

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    Ito MAbumi KKotani YKadoya KMinami A: Clinical outcome of posterolateral endoscopic surgery for pyogenic spondylodiscitis: results of 15 patients with serious comorbid conditions. Spine (Phila Pa 1976) 32:2002062007

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    Jacquot FGastambide D: Percutaneous endoscopic transforaminal lumbar interbody fusion: is it worth it?. Int Orthop 37:150715102013

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    Jang JSAn SHLee SH: Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. J Spinal Disord Tech 19:3383432006

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    Jasper GPFrancisco GMAghion DTelfeian AE: Technical considerations in transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis: Case report. Clin Neurol Neurosurg 119:84872014

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    Jasper GPFrancisco GMChoi DBCielo DDoberstein CE: Clinical benefits of ultra-minimally invasive spine surgery in awake obese patients in an outpatient setting: a retrospective evaluation of transforaminal endoscopic discectomy with foraminotomy. JSM Neurosurg Spine 2:10412014

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    Jasper GPFrancisco GMTelfeian A: Outpatient, awake, ultra-minimally invasive endoscopic treatment of lumbar disc herniations. R I Med J 2013. 97:47492014

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    Jasper GPFrancisco GMTelfeian AE: Clinical success of transforaminal endoscopic discectomy with foraminotomy: a retrospective evaluation. Clin Neurol Neurosurg 115:196119652013

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    Jasper GPFrancisco GMTelfeian AE: Endoscopic transforaminal discectomy for an extruded lumbar disc herniation. Pain Physician 16:E31E352013

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    Jasper GPFrancisco GMTelfeian AE: A retrospective evaluation of the clinical success of transforaminal endoscopic discectomy with foraminotomy in geriatric patients. Pain Physician 16:2252292013

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    Jasper GPFrancisco GMTelfeian AE: Transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis. Pain Physician 17:E703E7082014

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    Jho HD: Endoscopic transpedicular thoracic discectomy. J Neurosurg 91:2 Suppl1511561999

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    Joo YCOk WKBaik SHKim HJKwon OSKim KH: Removal of a vertebral metastatic tumor compressing the spinal nerve roots via a singleport, transforaminal, endoscopic approach under monitored anesthesia care. Pain Physician 15:2973022012

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    Kambin P: Arthroscopic Microdiscectomy: Minimal Intervention Spinal Surgery Baltimore, MDUrban & Schwarzenberg1990

  • 27

    Kambin PBrager MD: Percutaneous posterolateral discectomy. Anatomy and mechanism. Clin Orthop Relat Res 2231451541987

  • 28

    Kambin PGellman H: Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop Relat Res 1741271321983

  • 29

    Kambin PNixon JEChait ASchaffer JL: Annular protrusion: pathophysiology and roentgenographic appearance. Spine (Phila Pa 1976) 13:6716751988

  • 30

    Kambin PSampson S: Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res 20737431986

  • 31

    Kambin PZhou L: History and current status of percutaneous arthroscopic disc surgery. Spine (Phila Pa 1976) 21:24 Suppl57S61S1996

  • 32

    Kim CHChung CK: Endoscopic interlaminar lumbar discectomy with splitting of the ligament flavum under visual control. J Spinal Disord Tech 25:2102172012

  • 33

    Knight MTEllison DRGoswami AHillier VF: Review of safety in endoscopic laser foraminoplasty for the management of back pain. J Clin Laser Med Surg 19:1471572001

  • 34

    Lew SMMehalic TFFagone KL: Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations. J Neurosurg 94:2 Suppl2162202001

  • 35

    Liao ZChen WWang CH: Transforaminal percutaneous endoscopic surgery for far lateral lumbar intervertebral disk herniation. Orthopedics 37:e717e7272014

  • 36

    Lidar ZLifshutz JBhattacharjee SKurpad SNMaiman DJ: Minimally invasive, extracavitary approach for thoracic disc herniation: technical report and preliminary results. Spine J 6:1571632006

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    Mathews HH: Transforaminal endoscopic microdiscectomy. Neurosurg Clin N Am 7:59631996

  • 38

    Mayer HMBrock M: Percutaneous endoscopic lumbar discectomy (PELD). Neurosurg Rev 16:1151201993

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    Mixter WBarr J: Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 211:2102151934

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    Morgenstern RMorgenstern CJané RLee SH: Usefulness of an expandable interbody spacer for the treatment of foraminal stenosis in extremely collapsed disks: preliminary clinical experience with endoscopic posterolateral transforaminal approach. J Spinal Disord Tech 24:4854912011

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Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: all authors. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Telfeian. Administrative/technical/material support: all authors.

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Article Information

INCLUDE WHEN CITING DOI: 10.3171/2015.11.FOCUS15429.

Correspondence Albert Telfeian, Department of Neurosurgery, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903. email: atelfeian@lifespan.org.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Instruments used in and developed for endoscopic spine surgery. A: Craig needle set and cannula. B: Working-channel endoscope with channels for irrigation and suction. C: Crown reamers for foraminal bone removal. D: Endoscopic graspers and Kerrison punches. E: Endoscopic drill (left) and chisel (right; arrow points to exiting nerve root). F: Semibendable grasper reaching cranial (right) and cephalad (left) in a foraminal decompression after placement of instrumentation.

  • View in gallery

    Photographs of some of the inventors and innovators in the field of endoscopic spine surgery. A–F: Parvis Kambin, Michael Schubert, Thomas Hoogland, Sebastian Ruetten, Anthony Yeung, and Kevin Foley.

References

1

Ahn YLee SHLee JHKim JULiu WC: Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration. Acta Neurochir (Wien) 151:1992062009

2

Caspar W: A new surgical procedure for lumbar disk herniation causing less tissue damage through a microsurgical approach. Adv Neurosurg 4:74801977

3

Choi GLee SHLokhande PKong BJShim CSJung B: Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976) 33:E508E5152008

4

Choi GModi HNPrada NAhn TJMyung SHGang MS: Clinical results of XMR-assisted percutaneous transforaminal endoscopic lumbar discectomy. J Orthop Surg 8:142013

5

Choi GPrada NModi HNVasavada NBKim JSLee SH: Percutaneous endoscopic lumbar herniectomy for high-grade down-migrated L4–L5 disc through an L5-S1 interlaminar approach: a technical note. Minim Invasive Neurosurg 53:1471522010

6

Choi KYEun SSLee SHLee HY: Percutaneous endoscopic thoracic discectomy; transforaminal approach. Minim Invasive Neurosurg 53:25282010

7

Dezawa AYamane TMikami HMiki H: Retroperitoneal laparoscopic lateral approach to the lumbar spine: a new approach, technique, and clinical trial. J Spinal Disord 13:1381432000

8

Dickman CARosenthal DKarahalios DGParamore CGMican CAApostolides PJ: Thoracic vertebrectomy and reconstruction using a microsurgical thoracoscopic approach. Neurosurgery 38:2792931996

9

Ditsworth DA: Endoscopic transforaminal lumbar discectomy and reconfiguration: a posterolateral approach into the spinal canal. Surg Neurol 49:5885981998

10

Foley KTSmith MMRampersaud YR: Microendoscopic approach to far-lateral lumbar disc herniation. Neurosurg Focus 7:5e51999

11

Forst RHausmann B: Nucleoscopy—a new examination technique. Arch Orthop Trauma Surg 101:2192211983

12

Hijikata SYamagishi MNakayma T: Percutaneous discectomy: a new treatment method for lumbar disc herniation. J Todenhosp 5:5131975

13

Hoogland Tvan den Brekel-Dijkstra KSchubert MMiklitz B: Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine (Phila Pa 1976) 33:9739782008

14

Ito MAbumi KKotani YKadoya KMinami A: Clinical outcome of posterolateral endoscopic surgery for pyogenic spondylodiscitis: results of 15 patients with serious comorbid conditions. Spine (Phila Pa 1976) 32:2002062007

15

Jacquot FGastambide D: Percutaneous endoscopic transforaminal lumbar interbody fusion: is it worth it?. Int Orthop 37:150715102013

16

Jang JSAn SHLee SH: Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. J Spinal Disord Tech 19:3383432006

17

Jasper GPFrancisco GMAghion DTelfeian AE: Technical considerations in transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis: Case report. Clin Neurol Neurosurg 119:84872014

18

Jasper GPFrancisco GMChoi DBCielo DDoberstein CE: Clinical benefits of ultra-minimally invasive spine surgery in awake obese patients in an outpatient setting: a retrospective evaluation of transforaminal endoscopic discectomy with foraminotomy. JSM Neurosurg Spine 2:10412014

19

Jasper GPFrancisco GMTelfeian A: Outpatient, awake, ultra-minimally invasive endoscopic treatment of lumbar disc herniations. R I Med J 2013. 97:47492014

20

Jasper GPFrancisco GMTelfeian AE: Clinical success of transforaminal endoscopic discectomy with foraminotomy: a retrospective evaluation. Clin Neurol Neurosurg 115:196119652013

21

Jasper GPFrancisco GMTelfeian AE: Endoscopic transforaminal discectomy for an extruded lumbar disc herniation. Pain Physician 16:E31E352013

22

Jasper GPFrancisco GMTelfeian AE: A retrospective evaluation of the clinical success of transforaminal endoscopic discectomy with foraminotomy in geriatric patients. Pain Physician 16:2252292013

23

Jasper GPFrancisco GMTelfeian AE: Transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis. Pain Physician 17:E703E7082014

24

Jho HD: Endoscopic transpedicular thoracic discectomy. J Neurosurg 91:2 Suppl1511561999

25

Joo YCOk WKBaik SHKim HJKwon OSKim KH: Removal of a vertebral metastatic tumor compressing the spinal nerve roots via a singleport, transforaminal, endoscopic approach under monitored anesthesia care. Pain Physician 15:2973022012

26

Kambin P: Arthroscopic Microdiscectomy: Minimal Intervention Spinal Surgery Baltimore, MDUrban & Schwarzenberg1990

27

Kambin PBrager MD: Percutaneous posterolateral discectomy. Anatomy and mechanism. Clin Orthop Relat Res 2231451541987

28

Kambin PGellman H: Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop Relat Res 1741271321983

29

Kambin PNixon JEChait ASchaffer JL: Annular protrusion: pathophysiology and roentgenographic appearance. Spine (Phila Pa 1976) 13:6716751988

30

Kambin PSampson S: Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res 20737431986

31

Kambin PZhou L: History and current status of percutaneous arthroscopic disc surgery. Spine (Phila Pa 1976) 21:24 Suppl57S61S1996

32

Kim CHChung CK: Endoscopic interlaminar lumbar discectomy with splitting of the ligament flavum under visual control. J Spinal Disord Tech 25:2102172012

33

Knight MTEllison DRGoswami AHillier VF: Review of safety in endoscopic laser foraminoplasty for the management of back pain. J Clin Laser Med Surg 19:1471572001

34

Lew SMMehalic TFFagone KL: Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations. J Neurosurg 94:2 Suppl2162202001

35

Liao ZChen WWang CH: Transforaminal percutaneous endoscopic surgery for far lateral lumbar intervertebral disk herniation. Orthopedics 37:e717e7272014

36

Lidar ZLifshutz JBhattacharjee SKurpad SNMaiman DJ: Minimally invasive, extracavitary approach for thoracic disc herniation: technical report and preliminary results. Spine J 6:1571632006

37

Mathews HH: Transforaminal endoscopic microdiscectomy. Neurosurg Clin N Am 7:59631996

38

Mayer HMBrock M: Percutaneous endoscopic lumbar discectomy (PELD). Neurosurg Rev 16:1151201993

39

Mixter WBarr J: Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 211:2102151934

40

Morgenstern RMorgenstern CJané RLee SH: Usefulness of an expandable interbody spacer for the treatment of foraminal stenosis in extremely collapsed disks: preliminary clinical experience with endoscopic posterolateral transforaminal approach. J Spinal Disord Tech 24:4854912011

41

Obenchain TGCloyd D: Laparoscopic lumbar discectomy: description of transperitoneal and retroperitoneal techniques. Neurosurg Clin N Am 7:77851996

42

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