The document describes a new endoscopic spine surgery system called "Easy GO" for performing lumbar discectomies. Some key points: - The Easy GO system uses a 1.5cm diameter working sheath and 30 degree endoscope for visualization, allowing standard microsurgical techniques to be used through a smaller incision compared to open surgery. - A study of the first patients treated with Easy GO found no complications and postoperative pain relief in 89% of patients at 10 months follow up on average, comparable to results from other techniques. - While the skin incision size is smaller than open surgery, the extent of decompression and neural tissue trauma is similar to standard microdiscectomy. The

1. Dr. Shahnawaz Alam
MCh-Neurosurgery; SR
Moderated by:
Dr. V. C. Jha
HOD, Dept. of Neurosurgery
A New Endoscopic Spine System:
“Easy GO”

2. Introduction
• Lumbar discectomy procedures have been introduced as early as the 1930s.
• About four decades later, the application of the microscope introduced by
Caspar improved the intraoperative illumination and postoperative results.
• This technique has represented the “gold standard” technique until today, and
a patient satisfaction rate of up to 90% can be achieved.
• The so-called Microendoscopic discectomy by Foley et al. is a frequently used
technique, claiming a smaller skin incision, less muscular damage, and less
irritation to the nerve root.

3. • Furthermore, many techniques require a tight patient selection. And last
but not least, most techniques require a significant learning curve, making
it difficult to proceed with the daily routine.
• The goal of the new surgical technique is to avoid the need for an extensive
training to become familiar with the technique and to reduce the additional
need for surgical time to a minimum.

4. Endoscopic system
• The “Easy GO” system consists of a
standard dilator system for muscular
dilation.
• The surgical procedure is performed
through a work sheath of an outer
diameter of 1.5 cm.
• While the work sheath is too small to
allow a good microscopic view, a full
endoscopic view is realized via a 30°
Hopkins optic.

5.  Various dilators for the subsequent dilation of the paravertebral muscles.
 Work sheath of about 1.5 cm diameter and two different 30° rod lens
Hopkins optics with a fixed and a flexible length (arrow) to adjust at the
intraoperative requirements.
 The endoscope and the work sheath are held by a standard endoscope
holder with a quick connection.

6. • During each procedure, a detailed record of the surgical case including all
problems, advantages, and disadvantages of the system was noted.
• Based on these data, the surgical technique was modified to fulfill the
prerequisites for an easily applicable sophisticated endoscopic system.
• All patients received a diagnostic work-up including MRI or CT.
• Inclusion criteria for an endoscopic procedure were: age of 18 years, informed
consent to the application of the endoscope, lumbar disc prolaps or lumbar
stenosis with clear radicular compression and unequivocal correlation to the
clinical symptoms, and no signs of spinal instability.
• Mean follow-up time scored 10 months with a range of 1 up to 21 months. At
the end of the follow-up period, patients were asked to describe their
satisfaction with the surgical results on a scale of 0 = unsatisfactory, 1 =
satisfactory/good, and 2 = excellent.

7. Surgical technique
• The surgical technique mainly corresponds to a standard microdiscectomy.
All procedures are performed under GA with the patient in the prone
position.
• After a 1.6-1.8 cm skin incision directly at the level of the disc prolaps
parallel to the disc space, the muscle fascia is punctured, the muscles are
subsequently dilated by the application of the various dilators, and the
endoscopic work sheath is inserted.
• A lateral fluoroscopic control is obtained. The endoscopic procedure is
performed with bimanual surgical technique and the work sheath fixed to
the endoscope holder.

8. • After insertion of the endoscope, the bony resistance of the lamina is
located, and tissue remnants at the interlaminar window are removed.
• The ligamentum flavum is visualized and incised. The interlaminar
fenestration is enlarged with a punch or a diamond drill if indicated.
• The dura is subsequently displayed. After identification of the prolaps and
the nerve root, the sequester is extracted with grasping forceps and the
disc space evacuated.
• If indicated, a nerve retractor can be used to mobilize the dura medially. At
the end of the procedure, decompression of the dural sac and the nerve
root is checked.

9. Interlaminar Approach
 a. Axial T2WI; a large right
mediolateral sequestered
disc prolapse at the level of
L5/S1; b. T2WI
demonstrating the
mediolateral sequestered
disc prolapse (arrow).
 c. Skin incision parallel to
the midline just next to the
spinous processes at the
direct trajectory to the disc
space; d. Puncture of the
muscle fascia.
 e. The smallest dilator is put
in direct contact to the
lamina. Subsequently, the
muscles are pushed away
by insertion of the various
dilators until the endoscopic
work sheath is inserted
(f,g).
 h. The correct position of
the work sheath is checked

10. Microsurgical technique
The endoscopic procedure is performed
with standard bimanual
microsurgical technique and the
work sheath fixed to the endoscope
holder.

11. Endoscopic
discectomy
 a. Remnant muscle
tissue is removed with a
forceps; b. The
ligamentum flavum
(arrow) is identified and
incised; c. The ligament
and neighboring laminar
bone are removed with a
punch.
 d. The dura and the
nerve root are identified;
e. The prolaps is found
and neighboring vessels
are coagulated.
 f. The prolaps (arrowhead)
is removed with a grasping
forceps with avoidance of
any tension on the nerve
root (arrow); g. The disc
space is evacuated.
 h. At the end of the
procedure, the
decompressed dural sac
and nerve root (arrow) are
seen; i. The skin incision is

12. Discussion
• At present, there is strong demand for minimally invasive and particularly
endoscopic procedures in spine surgery by the patients.
• While clear evidence that these new techniques lead to superior results is still
missing, the fact that technical developments in the past decade made lumbar
spine surgery less invasive cannot be doubted.
• The combination of the microsurgical technique with the endoscope allows
the surgeon basically to address all standard microsurgical pathologies with a
smaller skin incision and less tissue trauma.
• In the last 10 years, quite a number of different minimally invasive endoscopic
techniques have been introduced to the neurosurgical armamentarium.
• However, each of these systems has some special advantages and
disadvantages.

13. • The “EasyGO” system presented here allows the continuation of
established microsurgical techniques. There were no intraoperative
complications.
• It is a fact that the Easy GO technique requires a rather large skin incision
of about 1.5 to 1.6 cm. The size of the skin incision is still definitely smaller
than with a standard microdiscectomy.
• Particularly the application of a dilator system seems to reduce muscle
trauma, but a dilator system might as well be applied with a standard
microscopic discectomy, and successful microdiscectomies through tubes
of diameters down to 14 mm have been reported.
• Thus, at the first glance, there is no need for the application of an
endoscope with such a tube system at all, but the technique of
microscopic discectomy through a small tube is rather reserved for
experienced spine surgeons.

14. • In contrast, the Easy GO system with the high-definition camera system and
high magnification provide improved optical conditions that allow a better
differentiation of the anatomic structures.
• It further provide additional space for surgical handling since the complete
tube can be used for instruments and no “corridor” for the microscopic view is
required.
• Also, basically all surgical techniques including intensive drilling are available
through the work sheath without or with only minimal limitation.
• Thus, since no long and extensive learning curve to become adjusted to this
technique is required, even less experienced spine surgeons might be able to
perform a minimally invasive discectomy by application of the technique.

15. • Furthermore, with the Easy GO system, the extent of decompression and trauma
at the neural tissue is rather comparable to standard microdiscectomy than
rather reduced.
• Thus, the effect of “minimal invasiveness” might be small in comparison to other
techniques that only use a small endoscope.
• However, the brilliant image quality might allow a gentler manipulation of the
better recognized neural structures, which could result in a reduction of the
number of dural tears and nerve root injuries in the long run.
• Since there was no direct control group included in this study, a direct comparison
of the results with the standard microsurgical technique is not feasible.

16. • The authors have the impression that there is an additional need of 10 to 15
min surgical time compared with the standard technique.
• 5% recurrent disc prolapses within the first year follow-up require attention. A
large literature analysis published by McGirt et al. reported a range of 2 up to
18% recurrence rate.
• With respect to pain relief, 89% of patients continuing with their daily routine
without pain medication appears to be an acceptable result. Other recent
studies reported pain relief in 82% or, if again, the large literature analysis is
cited, from 57 up to 94%.

17. • Thus, also for postoperative pain subsidence, no definite conclusions can be
drawn, but the study results are within the range of the published data.
• In all, the Easy Go system has been shown to provide accurate, reliable, and
good conditions for endoscopic surgery with microsurgical skills.
• Whether the minimally invasive technique with the Easy GO system
leads to superior results compared with the microsurgical technique or
other endoscopic techniques will be the focus for further studies.

18. References
1. Caspar W (1977) A new surgical procedure for lumbar disc herniation causing less tissue damage through a microsurgical approach.
Adv Neurosurg 4:74–80
2. Destandau J (2004) Neurochirurgie 50:6–10. Technical features of endoscopic surgery for lumbar disc herniation: 191 patients.
French. doi:10.1016/S0028-3770(04)98300-2
3. Dollinger V, Obwegeser AA, Gabl M, Lackner P, Koller M, Galiano K (2008) Sporting activity following discectomy for lumbar disc
herniation. Orthopedics 31:756. doi:10.3928/0147 7447-20080801-05
4. Foley KT, Smith MM, Rampersaud YR (1999) Microendoscopic approach to far-lateral lumbar disc herniation. Neurosurg Focus 7 (5).
doi:10.3171/foc.1999.7.5.8 Article 5
5. Huang TJ, Hsu RW, Li YY, Cheng CC (2005) Less systemic cytokine response in patients following microendoscopic versus open lumbar
discectomy. J Orthop Res 23:406–411. doi:10.1016/ j.orthres.2004.08.010
6. Ikuta K, Tono O, Tanaka T, Arima J, Nakano S, Sasaki K et al (2007) Surgical complications of microendoscopic procedures for lumbar
spinal stenosis. Minim Invasive Neurosurg 50:145–149. doi:10.1055/s-2007-985152
7. Jang JS, An SH, Lee SH (2006) Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extra- foraminal
lumbar disc herniations. J Spinal Disord Tech 19:338– 343. doi:10.1097/01.bsd.0000204500.14719.2e
8. Katayama Y, Matsuyama Y, Yoshihara H, Sakai Y, Nakamura H, Nakashima S et al (2006) Comparison of surgical outcomes between
macro discectomy and micro discectomy for lumbar disc herniation: a prospective randomized study with surgery per- formed by the
same spine surgeon. J Spinal Disord Tech 19:344– 347. doi:10.1097/01.bsd.0000211201.93125.1c
9. Kawaguchi Y, Matsui H, Gejo R, Tsuji H (1998) Preventive measures of back muscle injury after posterior lumbar spine surgery in rats.
Spine 23:2282–2288. doi:10.1097/00007632- 199811010-00006
10. Kawaguchi Y, Matsui H, Tsuji H (1996) Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis.
Spine 21:941–944. doi:10.1097/00007632-199604150- 00007
11. Kawaguchi Y, Matsui H, Tsuji H (1997) Changes in serum creatine phosphokinase MM isoenzyme after lumbar spine surgery. Spine
22:1018–1023. doi:10.1097/00007632-1997 05010-00015
12. Kim JM, Lee SH, Ahn Y, Yoon DH, Lee CD, Lim ST (2007) Recurrence after successful percutaneous endoscopic lumbar discectomy.
Minim Invasive Neurosurg 50:82–85. doi:10.1055/ s-2007-982504
13. Others….

19. THANK YOU