The history of herniated disc recognition (III): from open to minimally invasive

MRI was invented in the 1980s and began to be popularized for spinal examinations in the 1990s, providing clearer imaging of the discs, nerves, and soft tissues than CT. MRI quickly became an important diagnostic tool for lumbar disc herniation, and the absence of clear herniation and compression on MRI became a contraindication to surgery. At the same time, the high resolution of MRI also made doctors realize that not all MRI manifestations of herniated discs matched the patient's symptoms.

As awareness of herniated discs has increased, there has been a quest for less invasive ways to address the problem. In 1951, Hult performed a nucleotomy through an anterolateral extraperitoneal approach, introducing the first concept of indirect decompression of the spinal canal.

In 1973, Kambin performed percutaneous medullary resection under nonstraightforward vision using the Craig channel, and Hijikata et al. introduced another nonstraightforward percutaneous posterior posterolateral approach medullary resection in 1975. Then in 1983, Kambin, along with colleagues, reported a 72% success rate in 136 patients using a working channel that was expanded to 5 mm in diameter.

To achieve direct endoscopic visualization and adequate decompression, imaging and flushing systems need to be incorporated, which requires a larger working channel. In 1990, Kambin proposed the triangle of safety, with the traveling nerve root at the upper boundary, the penetrating nerve root at the inner boundary, and the superior border of the inferior vertebral body at the lower boundary. This anatomical safety triangle allowed spinal endoscopy to build on the original endoscopic discectomy technique, breaking through the limitations imposed by the small size of the instrumentation; Kambin's triangle allowed for larger instrumentation and working channels, allowing endoscopic techniques to be applied in the foraminal region without damage to the traveling nerve root.

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Figure 10 Kambin's triangle

In 1993, Mayer and Brock used an angled endoscope that allowed better visualization of the dorsal aspect of the diseased annulus fibrosus. mathews in 1996. Ditsworth in 1998. in 1996, Kambin and Zhou reported lumbar nerve root decompression by fibrous annuloplasty and decompression of lateral saphenous stenosis through the use of grasping forceps and circular saws. in 1997, Yeung introduced a complete spinal endoscopy system called the Yeung Endoscopy Spine System (YESS). in 2005, Yeung introduced the Yeung Endoscopy Spine System (YES). In 2005, Schubert and Hoogland described the use of their transforaminal endoscopic technique to remove free disc fragments by using a reaming drill to enlarge the foramen by grinding away the ventral aspect of the superior articular process of a portion of the inferior vertebral body.Tsou et al. in 1997, and Ruetten et al. in 2007 described multichannel endoscopes that have a larger diameter working channels of a multichannel endoscope. More reports of direct decompression of intervertebral foraminal lesions using endoscopy followed: Yeung and Tsou in 2002, Ruetten et al. in 2007 and 2008, and Jasper et al. in 2013.

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Figure 11 Photographs of several inventors and innovators in the field of spinal endoscopic surgery.A-F: Parvis Kambin, Michael Schubert, ThomasHoogland. Sebastian Ruetten, Anthony Yeung, and Kevin Foley.

These experts have pushed the boundaries of minimally invasive spine surgery, resulting in ever-reducing trauma to patients, faster recovery times, and less expense. Herniated discs are now treated using minimally invasive endoscopy with just a small incision in the skin of less than 1 cm, and patients can be discharged from the hospital at the end of the day's surgery, which was virtually unthinkable just a few decades ago.

Looking back at the entire history, mankind has gone from nowhere to finally understanding, and from open surgery to comprehensive, minimally invasive treatments, with many great doctors and scientists emerging in the process. But the struggle with low back pain is far from over, and the heavy burden it places on both individuals and society requires more people to fight for it in the future, and tomorrow will surely be better.