1. This space reserved for the Presentation Timer: Do Not Alter Clinical Results of Percutaneous Rigid Endoscopic Lumbar Discectomy for Various Types of the Lumbar Disc Herniations Clinical Results of Percutaneous Rigid Endoscopic Lumbar Discectomy for Various Types of the Lumbar Disc Herniations 1Hurisarang Hospital, Department of Neurosurgery, Daejeon, Republic of Korea 2College of Medicine, Chosun University, Department of Neurosurgery, Kwangju, Republic of Korea Hyeun Sung Kim(neuros@dreamwiz.com)1 Chang Il Ju2, Seok Won Kim2, Seung Myung Lee2, Ho Shin2 Hyeun Sung Kim(neuros@dreamwiz.com)1 Chang Il Ju2, Seok Won Kim2, Seung Myung Lee2, Ho Shin2

2. This space reserved for the Presentation Timer: Do Not Alter Primary Intradiscal Aproach –1977 - Hijikata : Percutaneous manual discecotmy (non-selective, not concurrent with surgical identification) –1983 - Kambin & Gellman : Non-visualized posterolateral percutaneous nucleotomy –. 1984 - Ascher : Percutaneous laser discectomy(nonspecific depressurization) Modification of intradiscal approach : Visualized –1987 - Schreiber : transdiscoscopic percutaneous nucleotomy – 1988 - Kambin : arthroscopic microdiscectomy : Published the first intraoperative discoscopic view of a HNP. – 1989 - Mayer : percutaneous endoscopic lumbar discectomy –1991 - Davis : percutaneous endoscopic laser disc decompression –1991 - Kambin : Described & illustrated the triangular working zone & the midpedicle line Transforaminal approach –1996 - Kambin : Foraminal arthroscopic decompression of lateral recess stenosis : annulectomy & osteophtectomy –1996 - Mathews : transforaminal endoscopic microdiscectomy –1996 - Siebert : endoscopic laser disc surgery : the foraminal app. –1996 - Lew : percutaneous foraminoscopy –1996 - Casper : foraminal laser endoscopic disc ablation Foraminoplasty approach –1996 - Knigh : endoscopic laser foraminoplasty – 1997 - Yeung : YESS : Introduced a rigid rod-lens, integrated, multichannel, wide-angle operating spinal endoscope. –1997 - Hoogland : percutaneous endoscopic discectomy – 1998 - Yeung : selective endoscopic discectomy –1999 - chiu : microdecompressive percutaneous discectomy with laser thermodiskoplasty Further advance approach –2002 : Yeung : Transforaminal endoscopic decompression : intracanal noncontained lumbar disc –2004 : Ahn : Percutaneous Endoscopic Lumbar Discectomy for Recurrent Disc Herniation –2005 : Ruetten : Extreme lateral access : full-endoscopic uniportal transforaminal approach –2006 : Lee : Percutaneous endoscopic lumbar discectomy for migrated disc herniation –2006 : Lee : Operative Failure of Percutaneous Endoscopic Lumbar Discectomy Historical Review Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

3. This space reserved for the Presentation Timer: Do Not Alter Introduction Various types of lumbar disc herniation Far lateral type Foraminal type Paracentral type Central type Migration type Difficulties of percutaneous rigid endoscopic lumbar discectomy Anatomical limitation Excessive foraminal migration A centrally located large calcified disc Presence of bony osteophytes Presence of residual epidural scarring Limitation of operative view Anatomical limitation Excessive foraminal migration A centrally located large calcified disc Presence of bony osteophytes Presence of residual epidural scarring Limitation of operative view High grade migrated type disc High canal compromised type disc Stenosis combined type disc Far lateral and Foraminal type disc High grade migrated type disc High canal compromised type disc Stenosis combined type disc Far lateral and Foraminal type disc Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

4. This space reserved for the Presentation Timer: Do Not Alter Material and Methods Material Cases456/458 disc herniation patients PeriodAugust 2004 – October 2007 Material SexM : 252F : 204 Age48.95 ± 12.71 Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

5. This space reserved for the Presentation Timer: Do Not Alter Methods : Endoscopic Approach Preoperative 3D image and targeting Semi-rigid flexible Curved Probe Suprapedicular Approach Decompression for Spinal Stenosis Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

6. This space reserved for the Presentation Timer: Do Not Alter Methods : Endoscopic Approach Preoperative 3D imaging and targeting Indication Superior or inferior migrated disc Foraminal disc Far lateral disc Ruptured disc Indication Superior or inferior migrated disc Foraminal disc Far lateral disc Ruptured disc Semi-rigid flexible Curved Probe Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

7. This space reserved for the Presentation Timer: Do Not Alter Methods : Endoscopic Approach Suprapedicular Approach Indication Far down inferior migration type High canal compromised type Stenosis combined type Indication Far down inferior migration type High canal compromised type Stenosis combined type Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

8. This space reserved for the Presentation Timer: Do Not Alter Results Age Distribution Adolescence6 20s24 30s76 40s125 50s98 60s109 70s18 Level L2-35 L3-464 L3-4-55 L4-5236 L5-S1142 L4-5-S14 VAS PreoperativePostoperative 8.58 ± 0.431.84 ± 0.71 Macnab’s Criteria excellent242 (53.1%)91.7% Good176 (38.6%) Fair22 (4.8%)8.5%Central type7 Paracentral type23 Poor17 (3.7%)Foraminal type5 Far lateral type4 Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

9. This space reserved for the Presentation Timer: Do Not Alter Results Types of Disc Herniation Central types (n=103)L2-32High canal compromise type63 L3-419 L3-4-52 Non-high canal compromise type40 L4-575 L5-S15 Paracentral type (n=295)L2-32 L3-429 L3-4-53 L4-5134 L5-S1123 L4-5-S14 Foraminal type (n=32)L2-31 L3-410 L4-516 L5-S15 Far lateral type (n=26)L3-46 L4-511 L5-S19 Combined with stenosis (n=46) Central stenosis43 Foraminal stenosis3 Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

10. This space reserved for the Presentation Timer: Do Not Alter Results Residual disc Posterolateral approach67 (14.7%)19.7% Interlaminar approach23 (5.0%) Relapsed disc herniation Posterolateral approach 13 (2.9%)4.17% Interlaminar approach 16 (3.5%) Revision Open Surgery2 (0.4%)2.4% Repeated PELD9 (2%) Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

11. This space reserved for the Presentation Timer: Do Not Alter Cases Inferior Migration Type Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com Preoperative Postoperative Preoperative Postoperative

12. This space reserved for the Presentation Timer: Do Not Alter Cases Central Protrusion Type Far Lateral Type Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com Preoperative Postoperative

13. This space reserved for the Presentation Timer: Do Not Alter Cases Superior Migration Type Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com Preoperative Postoperative

14. This space reserved for the Presentation Timer: Do Not Alter Cases Foraminal Type Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com Preoperative Postoperative

15. This space reserved for the Presentation Timer: Do Not Alter Cases HNP L5-S1 : Interlaminar Approach Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com Preoperative Postoperative

16. This space reserved for the Presentation Timer: Do Not Alter Cases Stenosis Combined Type Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com Preoperative Postoperative

17. This space reserved for the Presentation Timer: Do Not Alter Discusssion Outcome of lumbar discectomy Lewis PJ, Weir BK, Broad RW, Grace MG. Long-term prospective study of lumbosacral discectomy.. J Neurosurg. 1987 Jul;67(1):49-53. 62% of patients had complete relief of back pain and 62% had complete relief of leg pain. 96% were pleased that they had submitted to surgery and 93% were able to return to work. 9% reported that their back pain at 5 to 10 years was as severe as or worse than preoperatively and 11% reported that their leg pain was as severe as or worse than preoperatively. The reoperation rate was 18%. Loupasis GA, Stamos K, Katonis PG, Sapkas G, Korres DS, Hartofilakidis G. Seven- to 20-year outcome of lumbar discectomy. Spine. 1999 Nov 15;24(22):2313-7. The late results were satisfactory in 64% of patients. The mean Oswestry disability score was 18.9. Of the 101 patients who had primary procedures, 28% still complained of significant back or leg pain. Sixty-five percent of patients were very satisfied with their results, 29% satisfied, and 6% dissatisfied. The reoperation rate was 7.3% (8 patients), about one-third of which was due to recurrent disc herniation. Disc space narrowing was common at the level of discectomy, but was without prognostic significance. Pappas CT, Harrington T, Sonntag VK. Outcome Analysis in 654 Surgically Treated Lumbar Disc Herniations. Neurosurgery. 1992 Jun;30(6):862-6. Almost 11% of the patients had complications, and there was one death caused by abdominal arterial bleeding. Patients were also rated according to the Prolo Functional-Economic Outcome Rating Scale to improve the ability to compare series in the future. Almost 80% of the patients had good outcomes as defined by scores on this scale of 8 (16.2%), 9 (33.2%), and 10 (26.9%). Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

18. This space reserved for the Presentation Timer: Do Not Alter Eliminating the possibility of resection of bone and ligament Performing selective evacuation of the intervertebral space Preventing surgery-induced instabilities Avoidance of Scarring Conservation of intact intra-epidural lubricant structures No need for general anesthesia Less complications and morbidity in the elderly Shorter hospital stays Faster rehabilitation Earlier return to work or sports Higher patient satisfaction Discusssion Advantages of Percutaneous endoscopic lumbar discectomy Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

19. This space reserved for the Presentation Timer: Do Not Alter Discusssion Difficulties in percutaneous rigid endoscopic lumbar discectomy Lee SH, Kang BU, Ahn Y, Choi G, Choi YG, Ahn KU, et al : Operative failure of percutaneous endoscopic lumbar discectomy : a radiologic analysis of 55 Cases. Spine 31 : E285-E290, 2006 the possibility of failure was increased in high grade migration and high canal compromise-type cases Lee S, Kim SK, Lee SH, Kim WJ, Choi WC, Choi G, et al : Percutaneous endoscopic lumbar discectomy for migrated disc herniation : classification of disc migration and surgical approaches. Eur Spine J 16 : 431-437, 2007 divided the level of disc migration by 4 grades, and among them, satisfactory results in the cases of the far-downward migrated type (zone 4) were merely 78.9%. Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

20. This space reserved for the Presentation Timer: Do Not Alter Discusssion Choi G, Lee SH, Raiturker PP, Lee S, Chae YS. Percutaneous endoscopic interlaminar discectomy for intracanalicular disc herniations at L5-S1 using a rigid working channel endoscope. Neurosurgery. 2006 Feb;58(1 Suppl):ONS59-68 Kim MJ, Lee SH, Jung ES, Son BG, Choi ES, Shin JH, Sung JK, Chi YC. Targeted percutaneous transforaminal endoscopic disckectomy in 295 patients: comparison with results of microscopic diskectomy. Surg Neurol. 2007 Dec;68(6):623-31. Choi G, Lee SH, Bhanot A, Raiturker PP, Chae YS. Percutaneous endoscopic discectomy for extraforaminal lumbar disc herniations: extraforaminal targeted fragmentectomy technique using working channel endoscope. Spine. 2007 Jan 15;32(2):E93-9. Choi G, Lee SH, Lokhande P, Kong BJ, Shim CS, Jung B, Kim JS. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine. 2008 Jul 1;33(15):E508-15. Kim HS, Ju CI, Kim SW, Kim JG. Endoscopic transforaminal suprapedicular approach in high grade inferior migrated lumbar disc herniation. J Korean Neurosurg Soc. 2009 Feb;45(2):67-73. Ahn Y, Lee SH, Lee JH, Kim JU, Liu WC. Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration. Acta Neurochir (Wien). 2009 Mar;151(3):199-206. New techniquies for percutaneous rigid endoscopic lumbar discectomy Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com

21. This space reserved for the Presentation Timer: Do Not Alter Conclusion Compared to traditional microdiscectomy, percutaneous endoscopic lumbar discectomy is regarded as difficult, with a poor outcome, and a high recurrence rate. In our hands, however, the results of percutaneous endoscopic lumbar discectomy for all patients with discogenic radiculopathy were satisfactory and the recurrence rate was not high. Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)neuros@dreamwiz.comwww.ilovespine.com