ENDOSCOPIC INTERLAMINAR DISCECTOMY. USE OF SWINE CADAVERS AS A TRAINING MODEL

José Gabriel Rugeles,Gabriel Oswaldo Alonso Cuéllar

doi:10.1590/s1808-185120171602147361

Abstract

ABSTRACT Objective: To analyze the possibility of using cadavers of pigs for training in endoscopic interlaminar discectomy. Methods: Five young pigs were used. The necessary instruments and equipment were used, and the endoscopic transforaminal and interlaminar percutaneous approach was performed at the L7-S1 level. A specialist surgeon performed the procedure. The points of entry, needle angulation, and subjective technical difficulties indicated by the surgeon were analyzed. Results: The mean weight of pigs was 42.2 kg. The posterolateral (transforaminal) entry point was, on average, 6.28 cm from the midline at an angulation of 32.8°. The posterior (interlaminar) entry point was on average 1.82 cm. Full-endoscopic interlaminar discectomy was possible in all animals of the sample. The structures described in the literature were visible endoscopically in 100% of the models. Conclusions: The demonstrated benefits and increased indications of endoscopic lumbar surgery created the need to establish safer and more efficient training processes. The authors raise the possibility of using experimental models to develop technical skills in endoscopy via interlaminar approach. The use of teaching tools such as animal models constitutes a new learning technique and give more confidence to surgeons. The use of cadavers of pigs, obtained according to ethics, avoids the use of human cadavers, and minimizes the development of the learning curve on patients.

Highlights

In recent years, the treatment of back pain has been positively impacted by advances in minimally invasive surgery, conferring a position of relevance to this type of technique in medical practice,[1,2,3] and allowing its benefits to be offered to more patients
One of the most recently described procedures is the percutaneous full-endoscopic interlaminar discectomy (PFEILD), indicated in the treatment of disc herniation at the L5 – S1 level, and an interesting alternative to avoid the technical difficulties associated with the transforaminal approach at this level.[17,18]
The animals were placed in a prone position with lumbar support in order to completely align the spine. (Figure 1) The surgical technique used in the models consisted of the insertion of an epidural needle at level L7-S1, in order to perform discography and staining under fluoroscopic control. (Figure 2) The site of entry for the PFEILD approach was established, achieved by anchoring the tip of the dilator over the spinolaminar junction, (Figure 3) confirming the position with the C-arm

Summary

Introduction

The treatment of back pain has been positively impacted by advances in minimally invasive surgery, conferring a position of relevance to this type of technique in medical practice,[1,2,3] and allowing its benefits to be offered to more patients. Within the broad spectrum of minimally invasive procedures, there is a group of surgical techniques that are performed via endoscopic approaches.[4,5,6] Endoscopic surgery of the spine allows, through the use of lenses, cameras, and other special equipment,[7,8] the visualization of structures and the treatment of degenerative pathologies like disc herniation, central and foraminal stenosis, facet joint cysts, and epidural hematoma[2,6,7,8,9,10,11,12,13,14] in the different vertebral segments: cervical, thoracic, and lumbar.[5,15,16]. The satisfactory outcomes of the technique, with reported improvement rates above 80%,21-27 are contrasted with the significant challenge of a difficult and relatively long learning curve and the potential for complications related to the lack of technical experience,[28,29] since in PFEILD, as in most minimally invasive procedures, the clinical results are closely linked to previous training.[30,31,32]

Methods

Results

Discussion

Conclusion