The source of Back pain can be clearly defined by aware state surgical examination. Patient feedback guides the surgeon to the point in the lumbar spine responsible for the pain. Pre-operative guesstimation by clinical examination, X-rays and MRI scans or CAT scans is rendered obsolete. This “live” approach allows the causal level to be defined immediately or by Differential Discography and then visualised endoscopically. Thus neural anomalies and strange nerve combinations can be detected and diagnostic errors avoided. Subsequent endoscopic examination with the patient awake then leads the surgeon to the precise source of the pain at that specified intervertebral level. This can then be treated specifically and precisely with the minimum of collateral damage to tissues, reduced risk to the patient and enhanced long-term outcome.
Above all the use of “overkill” multi-level surgery can be avoided and single targeted surgery appropriately deployed. Only transforaminal endoscopic surgery can perform effective total foraminal clearance and treatment (Foraminoplasty) and provide treatment for back pain, buttock and leg pain. Minimalist procedures using the posterior, anterior or lateral approaches fail to address the foramen and its copious sources of pain effectively.
These pain sources are inadequately treated by non-foraminal procedures such as microdiscectomy, open decompression, solid or flexible fusion, Total Disc Replacement or interspinous spacers with the consequence that clinical benefit is limited. Endoscopic Minimally Invasive Spine Surgery does address these pain sources and consequently achieves high rates of amelioration of back, buttock and leg pain. It acts as a filter protecting patients from the more dangerous complication prone open procedures. If it fails to provide sufficient back pain relief then the more risk prone procedures can still be employed and because the foramen has been cleared , the results of the traditional techniques may thereby be enhanced. The use of minimalist techniques now may allow time for more innovative minimalist techniques to come on stream.
The treatment of Back pain, Buttock pain and Leg pain by Endoscopic Minimally Invasive Spine Surgery through the foramen also incorporates endoscopic discectomy thus provides an effective means of treating the myriad of clinical presentations associated with Degenerative Disc Disease because they usually involve a distortion or tethering or pinching of the nerve or malfunction of the foramen and its contained structures. Thus these techniques can treat back pain arising from disc protrusion, extrusion, sequestration, lateral recess stenosis, Spondylolytic Spondylolisthesis, anterior olisthesis (slippage), retrolisthesis, settlement, instability, facet joint disease, and some forms of axial (central) stenosis, discitis, osteophytosis, degenerative scoliosis, radial tears etc.
The results of treatment are described Endoscopic Lumbar Decompression and Foraminoplasty and Endoscopic Lumbar Decompression
The foramen and contents are subject to flexion, extension and rotatory motion. These are distorted by loss of disc turgor, retrolisthesis and anterior olisthesis. The nerve is subjected to combinations of traction and impaction within the same foramen. The nerve itself can produce BACK PAIN when the medial border is irritated and a mixture of conventional dermatomal patterns from the core.
Failure to appreciate and treat these mechanisms and pathological entities may account for persisting symptoms following midline surgery. Their presence raises the possibility of effective diagnosis by probing the foraminal structures and effective remedy of BACK PAIN and referred PAIN by their discrete and precise treatment.
The provocative effect of these foraminal pathologies calls in to question the conventional precept that a posterolateral disc protrusion at the level above the exiting nerve root foramen is causal of particular dermatomal symptoms. This is particularly likely to result in misdiagnosis in cases of multilevel degeneration. The clinical relevance of these factors and diagnostic benefits of Spinal Probing & Discography and Differential Discography are evaluated in the following sections.