Low-Impact and Minimum-Invasive Treatment of Herniated Disks: Transforaminal Endoscopic Surgery (TES)

Advantages of TES at a glance

• The patient is only locally anaesthetized.
  A complete anaesthetic is not necessary.
• The surgical area is accessed by a small percutaneous incision, meaning a reduced risk of infections during or after the surgery.
• The risk of instability after the surgery is substantially reduced, since—unlike the microscopic technique—this foraminal access method requires no partial removal of the intervertebral cords, the vertebral substance or the vertebral in order to localise and thus remove the herniated disc.
  
• The dorsal muscles have not to be cut. This increases post-op stability and reduces wound healing pain.
• Less bony tissue is harmed, which reduces blood effusion and subsequent scar development in the nerve root area.
• The patient can leave the clinic already one day after the surgery. If necessary, the surgery can also be performed on an out-patient.
• Shorter rehabilitation time. This means earlier getting back to work and to quality of life.

The structure of a disk

Disks consist of an outer fibre ring (annulus fibrosus) and the inner gelatinous core (nucleus pulposus). They are responsible for the flexibility as well the shock absorbing and carrying capacity of the spine.

A prerequisite for this functionality is the constant motion of the different vertebral segments. Unilateral or static strain, immobility in daily life or a congenital weakness of the disc tissue is causing insufficient nutrition of the vertebral segments, thus reducing the flexibility of the outer fibre ring structure. The results are fissures and degenerative alterations of the tissue.   

Causes for herniated disks and the differences between prolaps and protrusion

disk protrusion (left), disk prolaps (right)

The affected disk is not longer able to absorb the punctually high mechanical strain, thus causing pain and resulting in reduced mobility and inactivity. This leads to a further weakening of the spine-stabilising muscular system.   

Caused by lack of the supporting function of the lower spine muscles, the disk core avoids increased pressure caused by unilateral strain (e.g.lifting) – and especially in connection with rotational movements (please refer to our brochure "Medical Taining Therapy"). The affected outer fibre ring is not able to fix the core in its former centred position any longer and is therefore pressed outwards, mostly towards the spinal cord channel and the nerve roots. 
The disk tissue will now be narrowing the space within the vertebral channel or of the lateral exits of the nerve roots (foramen intervertebrale). This puts a constant pressure on he spinal cord or the nerve roots respectively. Depending on the degree of affection, the spinal nerve concerned is aching (refer to fig. below).

And: the more severe the disk affection, the more the pain will be radiating first to the back, then to the gluteal region (buttocks) and finally to the legs and feet. 

A distinct indication for a surgery is the so-called Kauda-syndrome, i.e. the functionality of bladder and/or rectum is affected. In this case, surgery is urgently required. Of course, the surgery is preceded by thorough clinical and neuro-orthopaedic examinations in order to exactly localise the herniated disk.

Additionally, imaging processes - especially nuclear spin tomography (otherwise called Magnetic Resonance Imaging), less evident also computer tomography (CT) and to a certain extent X-ray films- have to be referred to for confirming the clinical diagnosis and for exactly identifying the size and position of the herniated disk.

Final confirmation is achieved by means of an intra-operative method, the so-called discography. By means of a digital pressure gauge and using a spinal syringe, a contrast agent is injected into the disk(s) to be operated on.

What does 'transforaminal
endoscopic surgery' mean?

Endoscopic surgery means removing tissue from the affected disk core by means of an endoscope.

The endoscope we use - equipped with an optical system, a micro-lamp, two rinsing channels and one operational channel –
has a width of 6.4 mm and is the smallest system of the world at present. It is introduced via a small percutaneous incision next to the spine and is directed to the affected disk through the intervertebral aperture (foramen intervertebrale).

This fully developed surgical method requires a surgeon with long years of endoscopic experience. Because of its exact nature, this surgical method is only performed in very few spine centres of Europe. Nevertheless and due to its numerous advantages,
it will be the prevailing surgical method in the future, similar to the well-established knee-arthroscopy.

What are the advantages of TES?

The Endoscopic Transforaminal Surgery is aimed at removing the displaced disk tissue in order to relieve the pressure on the narrowed aching nerve roots.

Other endoscopic methods for the removal of herniated discs so far will only allow the surgeon to reach more lateral affections. Most of the herniated discs though (more than 80 %) are either medio-lateral (towards the nerve root) or medial (towards the spinal cord). Up until now, these conditions have been operated on by means of the common open microsurgical methods.  

Using the Endoscopic Transforaminal Surgery, these disks can be operated very accurately through the intervertebral aperture (foramen intervertebrale) while leaving healthy tissue unaffected.  

This special surgical procedure is performed by using high-technology surgical instruments such as computer-linked micro-cameras, for example. A complete anaesthetic is not required. Only locally anaesthetized, the patient is fixed in a comfortable lateral position. Through a tubular system with an outer diameter of 6.4 mm, the herniated disc to be treated surgically is accessed. 

Fig: The endoscope we use is presently the smallest instrument worldwide, having a width of 6.4 mm

The herniated disk to be treated surgically is accessed through a tubular system. The endoscope is equipped with an optical system, a micro-lamp, two rinsing channels and one operational channel. The herniated disc and the surrounding structures are now visualised on the monitor. Now, the affected disc tissue can smoothly be removed using special precision instruments.

Post-Op Status

After the surgery, we recommend to spend the first night at the clinic. The day after the surgery, there will be a medical check-up. The patient will receive detailed information on the post-op status and recommendations on how to conduct.

Furthermore, the patient will be given our brochure “Post-op Status after an Endoscopic Transforaminal Nucleotomy”, where the corresponding post-op treatments are described in detail.    

After 6 weeks, the Medical Training Therapy should be started. You will find more detailed information on this therapy in our brochure “Medical Training Therapy” (MTT).

Further information:

• Here you will find all Brochures for Download. 
• Animation: How a TES is carried through.
  
• Read more about Post-Op Instructions.