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Foraminoplasty is a type of endoscopic surgery used to surgery the spine. Foramen is a general name given to canal-shaped holes in bone structures. Spinal Foramen has two on the right and left at each spinal level. Spinal nerves and root nerves exit from this structure with a proper distribution to the segment. The spinal nerve enters the foramen structure approximately one and a half cm (it may show variations) above by separating from the spinal cord and exits by entering the slight S-shaped foramen 2-3 cm. Since the foramen is a canal surrounded by the pedicle and cassette of an upper vertebra, the pedicle and the pedicle of the lower vertebrae are invaded by the problems developing in these structures, causing compression of the nerve. This condition is defined as “Foraminal stenosis-Foraminal Stenosis”. If the cause of foraminal stenosis is not eliminated, it impairs the function of the relevant nerve, for example, L4-5 level left foramenal stenosis Due to left L4-5 nerve dysfunction, pain in the form of sciatica spreading from around the knee and thigh to the foot, loss of sensation and muscle loss in severe cases. causes loss of power. Treatment of foraminal stenosis, evacuation of the occupied structures (discectomy, fasciitis cyst excision, cassette osteophyte excision) Expansion of the foramen is possible with foraminoplasty. Foraminoplasty is possible with surgical methods using the Transforaminal route. Traditional open and microscopic methods cannot clean the inside of my jersey. With foraminoscopy, foramen structures can be cleaned and nerve compression can be relieved by using an optical camera in the foramen and a surgical working channel. Endoscopic Foraminoplasty does not disrupt the spinal architecture and does not cause instability, so fixation between the vertebrae with a cage and screws is not required. Therefore, it is a surgery that does not require fusion. Endoscopic foraminoplasty is very effective in eliminating stenosis that develops in spinal fusion surgeries that are often neglected. Endoscopic Foraminoplasty is a successful and effective method in the treatment of Failed Back Spine Surgery. If necessary, it can be applied under local anesthesia in patients who cannot receive anesthesia in a hole smaller than one cm. There is little to no bleeding. You can return to normal life on the same day.

Abstract The aim of this study was to evaluate the outcomes of Arthroscopic release of priformis to treatment of Deep Gluteal Nerve syndrome (DGNS) and priformis syndrome. DGNS painful siting with or without radiculopaty. 19 patient applied our clinic 2014-2022 and that underwent Endoscopic Prfiormis release and sciatic nerve decompression. All patients was evaluated Radiologic of the series X-ray and MRI neuroconductive studies EMG and SSEP. Clinical outcomes of patients the preoperative and postoperative documentations were analyzed. Regarding clinical outcomes, were significantly improved. Arthroscopic priformis release provides a safe and effective treatment for deep gluteal syndrome. Keywords: Hip Arthroscopy; Deep Gluteal Syndrome; Priformis Endoscopic Release Introduction Priformis syndrome is the most common type of deep gluteal syndrome. It is characterized by numbness and pain radiating from the glueal region to the leg [1-3]. Metropolitan lifestyles increasing sitting habits, extremely intense sports activities, frequent and repeated social and sportive activities, incentives for new experiences can create eccentric loads in the external rotator and obturator muscle region, which is risky of strain in the hip region. Like the priformis, unexpected stretches and strains in the genellius superior, obturator internus muscles, healing tissue and fibrosis, which develop differently depending on the degree of injury, cause nerve entrapments [4,5]. Sciatica or pudendal entrapments, characterized by nondiscogenic pelvic pain, are developing under the title of “deep gluteal nerve syndrome = DGNS”. Priformis syndrome is a one of the deep gluteal syndrome disorders that increases with sitting right after the obtutator outlet where the sciatic nerve is trapped and should be differentiated from typical sciatic pain and discogenic pain causes [6]. The biggest challenge in the diagnosis of Prifromis syndrome is that it presents findings that are confused with discogenic pain. Although MRI techniques have been developed in non-discogenic pain, the absence of pathological signal in the muscle region in the chronic stage reveals the importance of examination in the diagnosis. In physical examination, provocative tests (fair, ober, faber, etc.) [7,8]. Fair test (in a side-lying patient, it is pathognomonic as it causes local pain by trapping the sciatic nerve at the fibrotic priformis dislocation when the hip is passively brought to 90 degrees while adduction and internal rotation is forced. A reproduction of the patient’s local buttock pain is a positive test for piriformis involvement. A fair test must be repeated dynamically during the EMG test and electrophysiological findings should be recorded. Endoscopic decompression is preferred in patients who are permanent, decrease a lot with rest, start immediately with light activity, have not benefited from conservative treatment or relapsed in a short time after treatment. A head of time, we were performing sciatic decompression by cutting the piriformis muscle using open or miniopen endoscopic techniques. As our experience in hip arthroscopy increased, we preferred separating the piriformis muscle from the musculotendinous junction due to its low mortality and patient comfort [7-17]. Materials and Methods Early surgical results of 19 patients you have treated with hip arthroscopy in our clinic in the last seven years; We evaluated the functional results of 19 patients, 7 male and 12 female, who were treated by the same single surgeon between 2014 and 2022, mean age 46: mean follow-up time: 11 months (6-18 months) All patients were evaluated preoperatively and postoperatively by radiological MRI and electrophysiological reassessment at 6 weeks and 6 months. Arthroscopic priformis release was performed via posterior proximal portal and accessory proximal portal lateral decubitus position or prone position. After cleaning the bursa around the K wire, which is placed under the scope of the 30-degree arthroscope from the proximal portal to the fossa priformis, the priformis tendon is separated from insertion which is near the gluteus medius neighborhood with a total tenotomy. Subsequently, adhesions are removed by following up to the priformis obturator foramen. The sciatic nerve is exposed and neurolysis is performed distally to ensure that there is no pressure up to the quadratus level. Results 18 patients’ single side one patient bilaterally was achieved Arthroscopic piriformis complete tenotomy. The tendon adheration of the capsule was released in all cases. No injuries to the sciatic nerve or inferior gluteal artery occurred. All patients were mobilized at the third hour postoperatively. Stretching exercises were applied to all patients for 3 weeks and heavy exercises were avoided. After six weeks, sports activities were allowed. Vitamin B1 supplementation was given for six months [18]. Discussion Priformis syndrome is diagnosed after the missdiagnosis of discopathy or spinal disorders and treatment of pelvic sacroiliac disorders due to difficulty sitting and coccidynia, which often progress with radiculopathy. Vallerian degeneration healing pain caused by delayed entrapment neuropathy may be a problem after these patients who have received dozens of treatments have benefited from best endoscopic treatment. Piriformis syndrome is an important differential diagnosis for Clinicians which consider medical management and conservative management in the initial treatment plan for piriformis syndrome. Patients exhausted to been recevived many options within the conservative management much promise regarding such as physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects [19,20]. Arthroscopic priformis tenotomy would be as gold standard, when conservative management has failed, and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with release of the piriformis tenotomy highest success and a low complication rate. Current literature shows that the endoscopic way over the open approach is due to improved outcomes and decreased complications. Conclusion Releasing the sciatic decompression from the priformis thoracanteric attachment is an effective and safe method in priformis syndrome. It has been reported that the risk of neurovascular injury is high due to different variations in the open or endoscopic methods that we loosen except for the tendinosis region of the priformis. Tolgay Satana* and Ali Ihsan Isik Department of Orthopedic and Trauma Surgery, Istanbul Aydin University, Turkey Submission: July 17, 2022; Published: July 25, 2022 *Corresponding author: Tolgay Satana, Department of Orthopedic and Trauma Ssdurgery, Istanbul Aydin University, Turkey References 1. Vij N, Kiernan H, Bisht R, Singleton I, Cornett EM, et al. (2021) Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review Review. Anesth Pain Med 11(1). 2. Miller TA, White KP, Ross DC (2012) The diagnosis and management of Piriformis Syndrome: myths and facts. Can J Neurol Sci 39(5): 577- 583. 3. Hicks BL, Lam JC, Varacallo M (2020) Piriformis Syndrome. Stat Pearls Publishing. 4. Kean Chen C, Nizar AJ (2013) Prevalence of piriformis syndrome in chronic low back pain patients. A clinical diagnosis with modified FAIR test. Pain Pract 13(4): 276-281. 5. Huang ZF, Yang DS, Shi ZJ, Xiao J (2018) Pathogenesis of piriformis syndrome: a magnetic resonance imaging-based comparison study. Zhonghua Yi Xue Za Zhi 98(1): 42-45. 6. Coulomb R, Khelifi A, Bertrand M, Mares O, May O, et al. (2018) Does endoscopic piriformis tenotomy provide safe and complete tendon release? A cadaver study. Orthop Traumatol Surg Res 104(8): 1193- 1197. 7. Dezawa A, Kusano S, Miki H (2003) Arthroscopic release of the piriformis muscle under local anesthesia for piriformis syndrome. Arthroscopy 19(5): 554- 557. 8. Kay J, de Sa D, Morrison L, Fejtek E, Simunovic N, et al. (2017) Surgical Management of Deep Gluteal Syndrome Causing Sciatic Nerve Entrapment: A Systematic Review. Arthroscopy 33(12): 2263- 2278. 9. Han SK, Kim YS, Kim TH, Kang SH (2017) Surgical Treatment of Piriformis Syndrome. Clin Orthop Surg 9(2): 136- 144. 10. Jackson TJ (2016) Endoscopic Sciatic Nerve Decompression in the Prone Position-An Ischial-Based Approach. Arthrosc Tech 5(3): e637- 642. 11. Ilizaliturri VJ, Arriaga R, Villalobos FE, Suarez-Ahedo C (2018) Endoscopic release of the piriformis tendon and sciatic nerve exploration. J Hip Proserv Surg 5(3): 301-306. 12. Byrd JW (2015) Disorders of the Peritrochanteric and Deep Gluteal Space: New Frontiers for Arthroscopy. Sports Med Arthrosc Rev 23(4): 221-231. 13. Ham DH, Chung WC, Jung DU (2018) Effectiveness of Endoscopic Sciatic Nerve Decompression for the Treatment of Deep Gluteal Syndrome. Hip Pelvis 30(1): 29- 36. 14. Aguilera-Bohorquez B, Cardozo O, Brugiatti M, Cantor E, Valdivia N (2018) Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: Clinical results. Rev Esp Cir Ortop Traumatol 62(5): 322-327. 15. Hwang DS, Kang C, Lee JB, Cha SM, Yeon KW (2010) Arthroscopic treatment of piriformis syndrome by perineural cyst on the sciatic nerve: A Case Report. Knee Surg Sports Traumatol Arthrosc 18(5): 681- 684. 16. Todd Pierce P, Casey Pierce M, Kimona Issa, Vincent McInerney K, Anthony Festa, et al. (2017) Arthroscopic Piriformis Released. A Technique for Sciatic Nerve Decompression Arthroscopy Techniques 6(1): e163- e166. 17. Huang ZF, Lin BQ, Torsha TT, Dilshad S, Yang DS, et al. (2019) Effect of Mannitol plus Vitamins B in the management of patients with piriformis syndrome. J Back Musculoskelet Rehabil 32(2): 329- 337. 18. Gulledge BM, Marcellin-Little DJ, Levine D, Tillman L, Harrysson OL, et al. (2014) Comparison of two stretching methods and optimization of stretching protocol for the piriformis muscle. Med Eng Phys 36(2): 212- 218. 19. Terlemez R, Ercalik T (2019) Effect of piriformis injection on neuropathic pain. Agri 31(4): 178- 182. 20. Misirlioglu TO, Akgun K, Palamar D, Erden MG, Erbilir T (2015) Piriformis syndrome: comparison of the effectiveness of local anesthetic and corticosteroid injections: a double-blinded, randomized controlled study. Pain Physician 18(2): 163-171.

ABSTRACT Epidural brosis are common reason of back pain, usually related with failed back spine surgery with or without neurological de cits. Traditional open surgeries for surgical release and decompression have some poor results and complications. Our aim is to nd to pain generators and prospect of eliminating the pain with epiduroscopic treatment. is study presents 360 patients caused by Failed back Spine Surgery symptoms leading backpain. e patients underwent epiduroscopic adesiolysis restore epidural neural stucrtural release. Following the procedure, our patient’s satisfaction is very high and experienced signi cant improvements in pain, numbness, and muscle strength. Magnetic resonance assessments con rmed successful decompression of the spinal canal. Previous studies have used a measure of successful outcome≥ 50% of original pain relief as a successful outcome. Measure our study also included this point. e study emphasizes the bene ts of epdiuroscopic adesionolysis in enhancing patient recovery for failed back spine surgery. us, this report acknowledges certain limitations of visual and optic devices need for further development utilizing this approach. In conclusion, epiduroscopy promise as a valuable treatment of Failed Back spines surgery instead of traditional open surgeries, o ering potential advantages in terms of complications and recovery pain management. Epiduroscopic management enhances a multimodal philosophy and opens up new treatment strategies for patients. If used early on, it can control pain well before chronicity sets in. Introduction Epidural brosis are mostly part of failed back spine surgery, usually related with failed back surgery. Traditional open surgeries for surgical release and decompression have some poor results and complications but epiduroscopic adesiolysis has very successful results reported that current literature results. It has reported that a clinically relevant reduction in pain and disability a er mechanical adhesiolysis in FBSS patients [1]. Epiduroscopy is the endoscopic visualization of epidural structures. e epidural space is part of spinal canal; It is the space above the dural membrane, anteriorly, directly bounded by the Flavum, containing the Posterior Longitudinal ligament, periosteum, and posteriorly, adipose tissue, venous plexus. Marchesini M et al. reported that presence of the dorsomedian ligamentous strand (DLS), which divides the epidural space. e possible existence of this structure still in uences some clinical practice, such as locoregional anesthesia and pain therapy [2]. ere is normally no uid circulation in this negative pressure space. e epidural space is surrounded by the periosteum in the cranium and contains the venous sinuses in a dense structure. e epidural venous plexus is a valveless system that communicates with the basivertebral vein, the intracranial sigmoid, occipital, and basilar venous sinuses, and the azygous system. In this respect, the optic nerve, which has venous ow associated with the cavernous sinuses, is sensitive to changes caused by pressure increases in the epidural space [3]. ere may be retinal hemorrhages and visual loss due to increased venous pressure. Ocular ndings in epidural cranial hemorrhages are pathognomonic in this respect. Epiduroscopy is a treatment option and as kind of spinal endoscopy allows targeted epidural brosis to release and addionally to deliver analgesic pharmacologic therapy for a ected nerve roots or other painful regions in the epidural space. Treatment options provided by epiduroscopy include laser-assisted adhesiolysis or resection of pain-generating brosis, catheter placement, as well as support with other invasive procedures for pain relief and Failled back Spine Surgery (FBSS) [4]. Professional Endoscopy of Spine management enhances a multimodal philosophy and opens up new treatment strategies for patients. If used early on, it can control pain well before chronicity sets in. By the way patient’s history, physical examination, diagnostic modalities (Xray, MRI, Medulagraphy), nerve conduction studies should be completed blood count, coagulation tests, urinalysis very important desicion making and patient selection and might be Ophthalmoscopy should be noted before intervention. Diagnostic algoritm is the key of treatment. Physical examination, to distinguish sclerotmal and radicular pain, motor de sits. Simple xray has never been underestimated than it is the most important way to understand mechanic skeletal problems. MRI is very usefull to evaluate neural comprimise and axial neural channel problems Computerized Tomography and for some cases myelography is also very helpful. Percutaneous discography and foraminal injections could be performed neurologic compromised. Material and Methods 360 patients were included prospective study. All patients are selected Failled Back Spine Surgeries (FBSS). Evaluate responsible reason of FBSS mechanic and neurologic compromise Etiology of FBSS would be poor selection for surgery of the patient have had a psychological pro le or pathophysiology. It could be related improper selection and misdiagnosis with inadequate preoperative evaluation and diagnostic work-up. is siuttion w-may leaded improper or inadequate surgery, which is resulted FBSS. Our series main age is 58 years old, 97 men, 263 women, follow up 8 months (range 3-36 months). 346 patients are treated single epiduroscopic way, 8 patients combined with open surgery remove hardware and limited decompression without fusion and in additional two surgical procedure have been performed, 2 patient have fusion surgery because of recurrent spondilolysthesis a er one level discectomy,4 patient had extremely spinal stenosis, and hardware occupation, excesive decompression and posterior short fusion. All patients be performed epiduroscopic treatment beside 4000- 10000 IU Hylase injection immediate a er surgery. During epiduroscopy procedure, such as epidural release with mechanic baloon and/or laser adesionolysis performed. Surgical Technique Patient position must be properly pop up maximum pelvic posterior inclination with lumbar exion 30 degrees, hip Flexion 45 degrees, knee and abdominal cushion support should be provided. Under local skin anesthesia and C Arm Xray image intensi er locating of hiatus sacral than insertion of 18 gauge needle. e guide wire must be screened on C-Arm radiography each step. A er make sure guide wire intra channel position, to removal needle and deliver obturator on wire. Removal of the sheath obturator than take out of guide wire from channel. A er removal obturator of working sheet to Insert of endoscope and make connection camera and other devices. Results Previous studies have used a measure of successful outcome≥ 50% of original pain relief as a successful outcome. Measure our study also included this point. e rst VAS and Questionnaire score had been taken respectively high before surgery. ese two scores (preoperative and postoperative) were then used to provide absolute di erencemorethan50percent.Wehavenocomplicationsexcepts mild headache, neckpain some cases. No hematoma, no infection, no retinal hemohage and no temporal blindness inspected. Our results suggest that although all ages have the potential to bene t from epiduroscopy and with or without interventional techniques. I highly encourage future research into the healing nature of our CSF to include an examination of it’s groundable electrical, conductive properties as well as an examination of any impact the earth’s pulsatile electrical eld may have on the pulsatile movement of CSF within our own brains. Discussion Combined to endoscopic diagnostic and treatment methods immediately or very soon. Spinal cord stimulation and Neuromodulations (permanently painfull) Treatment options for patients with chronic low back pain with a neuropathic and/or mixed neuropathic/nocioceptive pain component are o en limited and unsatisfactory. Possible explanations proposed in the literature include neuroplasticity. Treatment strategies are varies in order distinguished main and satelite problems. It is di ucult to identi ed or recti ed main problems (visible changes) like Instability. We strongly recommend visible skeletal problems that hardware failure, pseudoarthrosis must be resolved beside stenosis and impingement. Back pain is not satellite problem of radiculopathy. Muscle Atrophy and weakness would be associated epidural brosis and medullopathy. Faset arthropathy should be considered in the di erential diagnosis and eliminated. Tricks rst stage avoid to new iatrogenic injury that beginner surgeons should be trained by simulators. Lee JJ et al. designed a simulator for enhance to learning curve of epiduroscopy training skills [5-7]. Skilled surgeons intervention will be reduced to problem palliative treatment results instead of terminal treatment. Epiduroscopy protected massive surgical treatments, which is not enough to relieve failed back’s pain. Main philosophy that avoid open surgical treatment and never lead to create a new generator for this cohort has o en been discounted or has failed, leaving patients with few treatment options) Osteoporotic fractures must be treated with vertebraplasty. Vymazal et al. combined vertebra- lastly with epiduroscopy [8]. Combined to endoscopic diagnostic and treatment methods very useful essepicially persistent cases. We performed some cases transforaminal endoscopic procedures for neglected foramina stenosis. Avellanal et al. reported transforaminal epiduroscopic treatments and good results [4]. Spinal cord stimulation and Neuromodulations (permanently painfull) would be performed failed epiduroscopic results. Postoperative nausea or retinal problems have been reported. Suzuki et al. reported that use of dexmedetomidine during epiduroscopy procedures may reduce the required fentanyl dose during surgery and the incidence of postoperative nausea and vomiting [9]. Conclusion Epiduroscopy is an option, which is signi cantly reduced pain in almost all patients with FBSS. Pain relief was signi cantly and highly correlated with reduced analgesic intake and patient satisfaction. Epiduroscopy should be considered as a potential treatment option for FBSS. It is not palliative treatment in which terminal stage of all other options. Epiduroscopy has proven to be a safe, efficient and future-oriented interventional endoscopic procedure for everyday clinical use in diagnosing and managing pain syndromes. Epiduroscopy can be used in the sacral, lumbar, thoracic and even cervical regions of the spine to identify pathological structures, carry out tissue biopsies and perform epidural pain provocation tests to assess the pain relevance of visualized anomalies, making it an excellent diagnostic tool. Spinal endoscopy allows targeted epidural analgesic pharmacologic therapy for a ected nerve roots or other painful regions in the epidural space. Treatment options provided by epiduroscopy include laser-assisted adhesiolysis or resection of pain-generating brosis, catheter placement, as well as support with other invasive procedures for pain relief. Epiduroscopic management enhances a multimodal philosophy and opens up new treatment strategies for patients. If used early on, it can control pain well before chronicity sets in. American Journal of Neurology Research Ali Ihsan Isik and Tolgay Satana References 1. Geudeke MW, Krediet AC, Bilecen S, et al. E ectiveness of Epiduroscopy for Patients with Failed Back Surgery Syndrome: A Systematic Review and Meta-analysis. Pain Pract. 2021; 21: 468-481. 2. Marchesini M, Schiappa E, Ra aeli W. e Dorsomedian Ligamentous Strand: An Evaluation In Vivo with Epiduroscopy. Med Sci Basel. 2022; 10: 18. 3. Tire Y, Çöven İ, Cebeci Z, et al. Assessment of Optic Nerve Sheath Diameter in Patients Undergoing piduroscopy. Med Sci Monit. 2019; 25: 6911-6916. 4. Avellanal M, Diaz-Reganon G, Orts A, et al. Transforaminal Epiduroscopy in Patients with Failed Back Surgery Syndrome. 2019; 22: 89-95. 5. Lee JJ, Ko J, Yun Y, et al. Feasibility of the Epiduroscopy Simulator as a Training Tool: A Pilot Study. Pain Res Manag. 2020; 2020: 5428170. 6. Choi YK. Spinal epiduroscopy as an educational tool.Korean J Pain. 2018; 31: 132-134. 7. Ko J, Lee JJ, Jang SW, et al. An Epiduroscopy Simulator Based on a Serious Game for Spatial Cognitive Training EpiduroSIM: User-Centered Design Approach. JMIR Serious Games. 2019; 7: e12678. 8. Vymazal J, Kříž R. Vertebroplasty and epiduroscopy as seen by interventional radiologist. Cas Lek Cesk. 2018; 157: 203-207. 9. Suzuki T, Inokuchi R, Hanaoka K, et al. Dexmedetomidine use during epiduroscopy reduces fentanyl use and postoperative nausea and vomiting: A single-center retrospective study. SAGE Open Med. 2018; 6: 2050312118756804.

Treatment of impingement syndrome Before we provide any information on shoulder impingement treatment, let's first answer the question "What is shoulder impingement? Shoulder impingement (impingement impact syndrome) is a condition that occurs as a result of the narrowing of the space (subacromial space) between the acromioclavicular-bony-ligament complex that surrounds the shoulder rotator muscle group and the joint occurs where the bursa is located and the muscle. Conditions such as previous innocent shoulder trauma, recurrent shoulder dislocations, subacromial space in people working on their hands; The thickening of the bursa narrows due to osteophyte protrusions developing in the bones, and the inflammation (inflammation) that arises due to injury to the muscular structures in this space is known to compress over the years along with the healing tissue developed. How do you treat shoulder impingement? Shoulder compression involves cleaning and flattening the bony prominences under the acromion that narrow the subacromial space (acromiaplasty), removing the thickened muscle-bone pad (bursectomy), and repairing any muscle tears (rotator cuff). Repair). Medicines such as cortisone should not be administered before or after these procedures. In which situations is arthroscopy preferred for shoulder impingement syndrome? Arroscopic decompression is the gold standard for shoulder impingement. In rare cases, open surgery may be considered. Arthroscopic treatments are at the forefront of modern orthopedic surgery. How to perform shoulder impingement arthroscopy? Standard shoulder arthroscopy is performed through a new subacromial portal in addition to entry holes. After the bursectomy, the bone is leveled and muscle tears are checked. It is standard to penetrate the joint and control the joint structures. How long does an arthroscopy operation take? It takes 30-60 minutes. How is the recovery process after the operation? Immediate action begins. If there is a rotator muscle tear, the rotator muscle tear protocol is used. Does it come back after the surgery? This is not possible, as inflammation that has lasted for decades can lead to a recurrence. What is the operation fee? It depends on the patient's budget.

EVERY PERSON CAN LIVE ONCE IN A LIFETIME. SPRING CAN LIVE Regardless of the type of injury, if it did not cause cartilage and joint problems, it can heal without a trace in a short time. Sprains can cause injuries at various stages, from straining to rupturing ligaments. Severe sprains can lead to fractures, cartilage tears, and muscle and tendon tears. WHAT ARE THE MOST COMMON INJURIES? Ligament strains and tears are the most common injuries. With severe strains and tears, the ligaments stretch and heal, which can lead to an ankle sprain. In this case, joint structures and cartilage surfaces begin to wear out, their surfaces become irregular with fractures and lead to calcification. When the cartilage injured in habitual sprains heals to form a raised structure above the surface, movement causes pain in the form of pressure in the joint. This situation occurs mostly in the anterior outer angle of the joint and in the posterior corners. Due to the sudden pain in the form of a stabbing pain when walking or doing sports, the load cannot be carried out and the balance is disturbed. Especially in situations like goalkeeping, basketball, volleyball, and defense sports that require sudden jumps and shifts, balance can be upset and the game lost.< strong>READ MORE...

PriMera Scientific Medicine and Public Health - 2 September 2022 Laser and Radiofrequency Energy Applications in the Percutaneous Endoscopic Surgical Treatment of Degenerative Disc Disease: Should be abandoned? The word LASER stands for Light Amplification by Stimulated Emission of Radiation. According to this abbreviation that summarizes the energy generation; it is the light that occurs when the crystal between two full and semi reflective mirrors is exposed to intensified energy amplification the type of laser is named with the substance in the liquid crystal [1, 2]. Laser was first applied in the musculoskeletal system w by Whipple in 1984 using C02 laser. Classification according to the laser optic parameters (wavelength, power and dose) was developed in clinical trials after that date [1, 3]. Laser is known to change cell proliferation, motility and secretion at different doses. Tissue interaction can occur in the form of destruction, liquification, heating and evaporation depending on dose. The type of laser commonly used for the musculoskeletal system is resonance type which can be classified as follows [2]; 1. UV Laser (Excimer). 2. Visible Laser (Argon). 3. IR Laser (Ionization Resonance). C02 YAG: (Yttrium-Aluminum Garnet) o Neodmium o KTP Doubled Neodmium (Potassium-titanyI-Phosphate) o Holmium, Erbium. Argon laser is absorbed well by hemoglobin and creates effect by exerting heat in the tissue. This effect results in the apoptosis after oxygen is activated in cell nucleus. This is the basis of photodynamic treatment. Excimer does not create heat, breaks molecular connections; that’s why it is called cold laser. With C02, high power is generated at low frequencies, it is absorbed by water. Superficial effect occurs without penetration. Nd YAG has the highest penetration and coagulation effect.

CPQ Orthopaedics - 22 June 2022 Distal radius fractures concomitant with carpal instability have been studied and treatment options have been suggested by several authors in previous and recent years. Widespread use of motor vehicles, regular exercise habits and increased interest in alternative sports have increased the risk of trauma and thus the incidence of fracture. Given the fact that 47% of the limb fractures occur in upper limbs while 22% of upper limb fractures occur in the distal radius [1] radius distal, the extent of labor loss and national wealth can be understood. Failure to treat these fractures in the right way will result in additional morbidity while concomitant soft tissue pathologies will further increase morbidity [2,3]. While the incidence of carpal instability concomitant with distal radius fractures was formerly around 7% [4-7], it was then demonstrated to rise up to 36% according to the multi-centre studies using arthroscopy [4,5,7-13].

The Surgical Closure of Neglected Ulnar Deficiency of the Hand; Unclassified Phenomenon Research Article Abstract Cleft hand classified as central deficiencies of the hand. We present a patient who had cleft hand between the fourth and fifth ray at ulnar side which was not be classified in current classification of congenital hand deformities neither in central cleft hand anomalies nor ulnar deficiencies. Eventually we defined it as ulnar cleft hand. Twenty-six years old man examination revealed fifth ray of the hand was divided from carpometacarpal joint to ulnar sides about forty-five degrees. The fifth fingers rotated to dorsoradial from Metacarpophalengeal joint about ninety degrees. Little finger was hypoplastic and hypotenar side of the hand completely divided therefore the palm was narrow and shallow. Range of motion of distal and proximal interphalangeal joint was limited by ankylosis. The aims of the surgery are to improve grasping function, to keep the palmar continuity and obtain acceptable cosmesis. The cleft closure was performed with volar and dorsal skin flaps. Fifth metacarp released from flexor carpi ulnaris tendon, capsule and muscles. FCU was transferred distal of ulnar carpal bone, which seemed triquetro-hamate coalition bone. We defined this deformity as ulnar cleft hand. It is indisputable that treatment of congenital deformities before development ends will provide acceptable and more successful outcomes. At older ages, treatment of such rare hand deformities should be planned in stages with functional outcomes in mind according to patient’s needs while cosmetic appearance should be tackled at the second stage. Source: https://actascientific.com/ASMS/ASMS-07-1429.php Other Research Articles

CELL CELL CULTURE Cartilage Regeneration Therapy; Since cartilage tissue has limited ability to regenerate itself, when it disappears with aging, they leave their places to cells that cannot function as cartilage cells, which we call fibrocytes. However, the cartilage cell that forms the cartilage structure is "Chondrocyte". Its task is to provide lubricity and smooth the joint surface. For this function, the cell mechanically settles in the collagen connective tissue called matrix in chambers called lacunae. Its chemical task is to produce the continuously renewable matrix in which it is contained, thus ensuring the production of collagen, and most importantly, to produce substances that regulate fluid dynamics by exchanging with joint fluid. In this respect, cartilage is the basic cells of the joint structure. From this point of view, if the cartilage damage is a loss at the matrix level, that is, if the cartilage cell protected in the lacunae is not damaged by a simple crush, the cartilage replaces the damaged matrix immediately and makes a new one, and the cartilage is overcome without loss. If the cell loss is at the millimeter level and less, those regions are covered with a matrix even if new cells do not form. Other cells can develop to take over the functions of the lost cells. If the cartilage loss to be searched is over 1mm, there is no repair with the matrix and fibrocytes come to the area and make the repair, but the cartilage structure formed is "fibrous" and does not produce matrix like cartilage tissue and causes an irregular formation in that area as a non-slippery structure in regeneration. This is not a preferred healing way as it causes abrasion on the opposite surface. Here, the healing form created by the "enriched plasma" cells that we call PRP provides such a cartilage repair and only slows down the erosion. The only way to repair cartilage with cartilage cells is to bring cartilage cells to the area. We call this cartilage transplantation. If we transfer our own cell, "autologous" cells of another human being, "allo" is called "Xenograft" if we take it from another species (cattle, etc.). Since applying allo and xenografts at the cellular level requires risks such as tissue rejection or long regeneration time, we only use antigen-removed crystals at the matrix level. These can be given as an example of hyaluronic acid injected into the joint. These items are for supporting the matrix. It is called (viscosupplementation). "Autologous chondrocyte transplantation", which is used in the treatment of cartilage damage especially in the joint areas, is a safe, biological and effective method. Cartilage Regeneration Therapy Autologous Chondrocyte does not necessarily require cartilage cells, but it is the easiest and ethical method of obtaining permissions. Therefore, the cartilage cells of the patient must be surgically removed by arthroscopic method. Cartilage cells are taken and extracted from Lakuna in the laboratory and the ability to multiply is gained. Within a week, thousands of cells can be produced and ready for transfer. The material obtained in this method is cartilage cell culture and not cartilage. In some laboratories, these cells can be frozen and stored. For example, the cartilages produced in specialized GPS centers such as the FloenCell laboratory are delivered to the operating room in this way. In the meantime, the production of personalized chondrocytes is continued. The newly obtained chondrocyte cells are frozen and stored in liquid nitrogen tanks at -196 ° C to be used as the 2nd and 3rd dose when desired. Cellular products taken out from FlorenCell Laboratories to be applied to the patient are delivered to the patient to the place of application within 24 hours at the latest in transport boxes that can be monitored with a GPS module and a software. We use chondrocyte usage areas to close cartilage defects. Since the defects do not consist of cells only, a matrix is ​​needed and a barrier to prevent the cells from mixing with the joint fluid is essential. If the cartilage prepared in the laboratory is not embedded in such a matrix (composite cartilage graft), we place it on the cartilage defect with open joint surgery and close it with a collagen membrane.

The frequency of carpal instability after distal radius fractures The functional results of 34 wrists of 33 patients who were treated conservatively at the Department of Orthopedics and Traumatology at Gazi University between 1994-97 were evaluated according to the Brujin criteria. According to the Mayo classification, ten were type I, three were type II, eighteen type III, and three were type IV. Carpal instability was detected in 9 (26.4%) of 34 fractures. Of the nine fractures, eight involved the joint ...

1st Edition, February 2008 Birkenmaier, J. Chiu, A. Fontanella & H. Leu Login With endoscopic back surgery, it is aimed to reduce tissue trauma, prevent iatrogenic problems, and preserve spinal segmental motion and stability. The most interesting advantages of endoscopic procedures compared to open surgery are; Smaller incision and less tissue trauma, Minimal blood loss Early return to daily activities and work Easier surgical approach in obese patients Conscious sedation and local and regional anesthesia can be used together Less need for post-operative pain management in many cases As a result, they are procedures in which outpatient treatment is possible. Summary The International Society for Minimal Intervention in Spine Surgery (ISMISS) is an association of professionals dealing with back surgery from all continents, with the general aim of reducing interventional trauma and iatrogenic problems in spinal interventions. Members of the ISMISS founding members are pioneers of endoscopic spinal surgery, while members include experts from all areas of spinal treatments, from minimally invasive pain interventions to disc arthroplasty and fusion surgery. Since its inception in 1989, ISMISS has worked to improve the understanding of the underlying pathology as well as the development of tools and techniques for endoscopic spinal surgery. ISMISS is affiliated with SICOT (International Society of Orthopedic Surgery and Traumatology) and supports SICOT, which aims at clinical skills, training and scientific advancement in the field of spinal procedures. As new procedures, instruments and techniques are discovered, published and marketed faster than ever, ISMISS recognizes that adequate evaluation of treatments in this area is becoming increasingly difficult. ISMISS has begun to prepare independent and diverse guidelines on minimally invasive procedures in order to gain some habits to waist health professionals who want to improve their clinical practice with the latest and best information. These guidelines have been prepared on the basis of a thorough and detailed evaluation of the existing literature and the experiences of experts selected from ISMISS members all over the world and accepted as experts in their fields. The primary focus of the ISMISS guidelines is endoscopic spinal surgery. Correction The field of endoscopic spinal surgery is still very new and developing rapidly. As a result, experiences and observations may differ markedly across cultures, beliefs, and surgical practices. Therefore, we do not claim that these guidelines are whole or specific to any particular case. This work is still evolving and will continue to be updated regularly as new techniques and technologies are introduced, studied and improved. Although updates are planned twice a year, new updates will be made at shorter intervals when necessary. We invite you to participate in this study and share your clinical experiences or research with us. Gold Standards The majority of endoscopic spinal procedures relate to the surgical treatment of lumbar and spinal disc herniations, where microsurgery using the operating microscope is the gold standard when conservative treatments have failed or are not indicated. Microscopic disc surgery with microsurgery, also called microdiscectomy, should be taken as a reference in comparison with endoscopic disc surgery. For many other conditions, such as spinal canal stenosis or painful degenerative disc disease, an undisputed gold standard treatment has yet to be defined. In any case, the main concern of the technical advantages of endoscopic spinal surgery should be patient safety. As a result, all endoscopic spinal procedures aim to increase patient comfort, decrease invasiveness and not increase the complication rate and risk profile when compared with traditional procedures applied for the same indications. Indications Endoscopic strategies have been and are predominantly used in the treatment of the following conditions: Lumbar, thoracic and cervical disc herniations with radicular symptoms Lateral spinal canal (recess) and foraminal stenoses with radicular symptoms Degenerative facet joint cysts with radicular symptoms Contraindications Clinically consistent instabilities central spinal canal stenosis Relative contraindication: Large disc herniations and concomitant cauda equina syndrome or new motor deficit. In these cases, adequate decompression may not be achieved except for those with large interlaminar space and good interlaminar endoscopic access. Diagnostic Standards for Determining Indication In each of the above-mentioned cases, a clear clinical profile completed using patient history and physical and neurological examination is the minimum standard. While degenerative changes seen in radiography and magnetic resonance imaging (MRI) determine the prevalence in asymptomatic cases, evaluation with imaging methods alone can be extremely misleading in such cases when pathological findings do not clearly match with specific clinical symptoms. Physical examination of cervical and lumbar spinal pain syndromes should include the shoulder region, upper extremity, pelvis, sacroiliac joint, and hip joints, respectively. It is not uncommon for painful conditions in these adjacent areas to mimic symptoms resulting from spinal events. In doubtful cases, we recommend contrast assisted diagnostic injections under fluoroscopy guidance to detect the condition that can be treated with endoscopic spinal surgery. A current MRI with adequate and new imaging studies, or computed tomography (CT) is required for surgical procedures in patients with a history of less than 3 months and in whom MRI would not be preferred for imaging. In cases with a change in symptoms, a repeated imaging study is recommended before surgery. If the diagnosis of the monoradicular lesion is doubtful despite the history, physical examination, and imaging studies, additional neurophysiological studies (electromyography, neurography, etc.) may be helpful. Evaluation of Imaging Studies Plain Radiographs Plain radiographs taken in bidirectional and upright position are still considered standard examination for 2 reasons: On the one hand, plain radiographs allow rapid assessment of spinal structure, bone integrity, and potential instability. On the other hand, it allows the evaluation of vertebrae when radicular symptoms do not match the level of the affected disc observed on MRI or CT. Functional radiographs may also be necessary in cases of suspected or identified instability. In selected cases, functional myelography can be a highly valuable test even today (see below). Computed Tomography (CT) Although MRI has replaced CT in evaluating soft tissues, edema, infection, cysts, and other fluid-induced tissue changes, CT still has significance in some diagnostic situations. Apart from MRI, CT can also create images in alternative and also non-standard planes using the original data, thus helping to evaluate foraminal events. Many foraminal problems arise from bony structures, and these bony structures often cannot be adequately evaluated with available MRI resolution and images. This is especially observed in the cervical spine. In cases where MRI cannot be applied, post-myelography CT is a valuable imaging method superior to MRI. Hyperbaric contrast agent application, which is entered from the lumbar level in cervical problems, is an alternative option to the suboccipital technique. Magnetic Resonance (MRI) Many modern magnets (!) Get very good and detailed images when it comes to disc space, ligaments, fluid compartments, neural structures and adipose tissue. On the other hand, sagittal sections often fail to show the posterior foramen enough to assess extraforaminal disc sequestration. When combined with axial slices not parallel to the level of the affected disc, this may miss extraforaminal sequestrations. With the exception of some exceptional centers where functional MRI is used, CT and MRI imaging are usually performed in the supine and sometimes prone position, without axial loads and positional effects on the spine. In some cases, as an effect of body weight, instability, and posture, standing images may appear quite different on CT or MRI than images taken in the supine position. When this condition is suspected, a functional myelogram followed by post-myelography CT is a good option. The fact that functional MRI is an alternative imaging method seems promising for the future. Due to the limited position tolerance in patients suffering from pain today, image noise may occur and therefore the image quality may be adversely affected. Anesthesia Although general anesthesia is preferred by many surgeons for traditional techniques, local anesthesia with or without sedation is an important option for most endoscopic approaches. However, one of the issues that should be emphasized is that a patient lying prone and undergoing local anesthesia may need to completely abandon the technique used and switch to general anesthesia, as well as the need for endotracheal intubation, repositioning the patient and re-preparation of the operation field. Especially in cervical applications, unconscious head and neck movements are very difficult to control and may cause additional risks. Endoscopic Approaches to the Lumbar Spine Anatomical and Technical Evaluation Endoscopic spinal surgery uses dilatation technology instead of making a skin incision in order to minimize tissue trauma in providing the transition from soft tissues (eg skin, subcutaneous adipose tissue and muscle/fascia tissue). Beyond the entry trauma to the tissue, the main difference between endoscopic and microscopic microsurgery is; It provides a 2D view versus a 3D view, and a near view angle versus a far view angle, even though it’s flat. Many instrument sets for endoscopic back surgery are available on the market, and they come in a wide variety according to their technical features and indications for use. Each surgeon is responsible for using the most appropriate surgical set for his/her own surgical technique. While the endoscopic surgical approach to the spine reduces visible surgical trauma, this minimally invasive procedure comes at a cost; a reduced and 2-dimensional field of view and a limited field of view in the surgical field. The surgical approach and access route are chosen largely depending on the regional anatomy for entry into the foramen or spinal canal. These anatomical restrictions are usually caused by bone structures such as facet joints, pedicles and laminae, however, branches originating from nerve roots in foraminal approaches and vertebral arteries in cervical approaches are also important structures that cause restrictions. The properties of the optical system (viewing angle, magnification, etc.), together with the size of the treated canal and the instruments used, determine the precise limits such as which areas can be seen and which lesions can be treated safely. Burr, promotion, etc., which allow endoscopic bone resection from the operation area and enable a larger view by enlarging the operation area. surgical instruments such as. On the other hand, when it is necessary to change the location of the instruments used from the additional access cannulas, blinding augmentation and a large amount of bone resection are required with the terfin. For these reasons, a clear surgical strategy and precise targeting are very important. Double-arm fluoroscopy is a prerequisite for the approach used to be directed to the right place, intraoperative control and recording of the technique used. If the techniques that cause tissue change such as laser or bipolar radiofrequency devices are to be used in endoscopic spinal surgery, the instruments considered to be used and their complications should be fully known. Interlaminar Approach This approach is very similar to the traditional microsurgical approach. The spinal canal is entered through a limited flavotomy and the risk of damage to the dura or neural structures is similar to the microsurgical approach. Depending on the angle of entry into the interlaminar space in the sagittal axis and the level of treatment, reaching the posterior part of the disc may be easy or difficult. Since the interpedicular area is on the opposite side of the ventral epidural area, it is very difficult to reach. When the interlaminar window is too small, this approach cannot be applied without resecting the laminar edge and / or the medial part of the facet joint. This is particularly important for newer and more modern endoscopes with a wider working channel as well as a larger outer diameter. An important advantage of this approach is that it can easily be converted to the open approach. Posterolateral Approach The posterolateral approach is the best known approach for interventions on the lumbar spine and can be used in foraminal and extraforaminal disc herniations as well as intradiscal procedures. In this approach, an angle of approximately 60 degrees is made to the sagittal plane and the foramen is entered from the disc level. It can be applied when the patient is in a prone or lateral decubitus position. In this approach, the main intraoperative risks are damage to the root originating nerve (especially in the presence of severe disc height loss) and damage to the blood vessels. In patients with short pedicle structures and osteophytes in the facet joints, the lateral edge of the superior articular process may need to be shaved to provide sufficient transition clearance. The ventral epidural space can only be reached from this side. Far or Extreme Approach This approach is one of the most recently developed approaches, and it was developed especially under the leadership of Ruetten. Using this approach, in addition to the foraminal and extraforaminal areas, the ventral epidural space other than the interpupicular area can be accessed. This approach provides access to the foramen by making an angle of less than 90 degrees to the sagittal plane, at the level of the facet joints in the coronal plane and through the skin in the prone position. Therefore, it is less likely to encounter facet joints than the posterolateral approach, but in this approach, short pedicle structures and large herniated discs may make it difficult to pass to the ventral epidural area. The risks of surgical intervention are generally the same as for the posterolateral approach, but there is an increased risk of dural injury and an additional risk of injury to the retroperitoneal organs at the upper lumbar levels. Therefore, the retroperitoneal anatomy of the CT or MRI related level should be examined before applying this approach to the upper lumbar levels. Endoscopic Approaches to the Cervical Spine Anterior Approach The anterior approach is very similar to the traditional microsurgical method in which the neurovascular sheath is taken to the outer part of the working canal and the visceral structures to the inner part of the studied canal. The tip of the working arm is placed opposite the end of the anterior longitudinal ligament and the anterior part of the adjacent vertebral body. Unlike traditional microsurgery, disc space can be passed without any discectomy. Cleaning of the herniated disc and osteophytes, if necessary, is accomplished by using a wide variety of special tools, including chisels, pitchers, microresectors, various forceps, drills, hooks and bipolar microelectrodes. Using this approach, the foraminal areas and spinal canal can be reached with perfect control of the operation area, while the same accessibility is not valid for the interpupicular space. The anterior endoscopic approach in the cervical spine relative to other parts of the spine facilitates effective decompression of the spinal canal and / or nerve roots (in addition to the vertebral arteries in selected cases) without the need for disc removal using fusion or arthroplasty. In general, there is no need for drains or immobilization for the wound in the postoperative period. Posterior Approach The posterior approach is advantageous in central spinal canal stenoses caused primarily by posterior structures (primarily by the ligamentum flavum or a collapsed laminar edge) or distant lateral disc herniations. The approach and surgical technique are quite similar to the traditional surgical technique, but in practice, tubes of various diameters and typical endoscopic instruments that pass through them and mentioned in the anterior approach are used. Complications Minimally invasive surgery does not have to bring minimal complications, the learning curve of endoscopic low back surgery tends to be flat and longer than traditional approaches. Dural tears, nerve root damage, bleeding and infection, applications to the wrong level or the wrong side of the hernia can be seen in endoscopic techniques as well as in open techniques. There is also a risk of pneumothorax in thoracic approaches. In addition, some injuries such as dural tears may not be taken seriously or even noticed due to the low pressure washing system of the endoscopic system. When a surgeon begins to perform endoscopic spinal surgery, careful selection of appropriate cases, careful surgical technique, administration of a single perioperative antibiotic (1), and careful postoperative follow-up are highly recommended. When complications occur, it is necessary to evaluate the cases with the same technique as it is applied in open techniques and, if necessary, to switch to open technique. Surgeon’s Qualifications Only surgeons who have sufficient experience in their traditional techniques should apply endoscopic techniques. On the one hand, sufficient experience is required to properly manage potential complications, on the other hand, surgeons with sufficient experience in both techniques can decide whether the open technique or the closed endoscopic approach is better in each case. Adequate training in endoscopic techniques, technical resourcefulness with the instruments used are a priority for the procedures to be applied in clinical situations. Evidence A recent update on the systematic review of the Cochrane study on lumbar disc prolapse found that surgical discectomy (open and microsurgical) applied to carefully selected patients provided faster regression in sciatica pain than conservative treatment (2). It was also mentioned in the same review that there is insufficient evidence to draw correct conclusions on all types of percutaneous discectomy (there is sufficient evidence for chemonucleolysis only). In a systematic review by Maroon, it was reported that none of the minimally invasive techniques developed to be used in the treatment of symptomatic lumbar disc disease had a significant superiority over microdiscectomy (3). It is understood from this that well-designed random studies are needed to compare endoscopic techniques with microsurgical microscopic disc surgery. Most of the publications on endoscopic spinal procedures include the results of case series (usually retrospective), technical developments or personal experiences. However, there are few controlled and randomized controlled studies that can provide evidence about the potential benefits of endoscopic disc surgery. In a randomized controlled study performed in a selected patient group (cases with a single level herniation not exceeding ın of the spinal canal in the sagittal plane, cases without spinal canal stenosis) similar clinical results were obtained in terms of performing endoscopic and open discectomy, however, patients who underwent endoscopic surgery had less postoperative pain and It has been found to have a shorter rehabilitation period (4). In another controlled study, endoscopic disc surgery was found to be superior to microsurgery technique in terms of sciatica pain, low back pain and return to work (5). It has been proven that endoscopic lumbar surgery not only causes smaller incisions, but also causes less tissue damage and a lower systemic inflammatory response (6). In a controlled study in which intraoperative electromyographic monitoring was used and endoscopic and open techniques were compared, it was found that significantly less intraoperative nerve root irritation occurred in patients who underwent endoscopic technique (7). Resources Dimick JB, Lipsett PA, Kostuik JP. Spine update: antimicrobial prophylaxis in spine surgery: basic principles and recent advances. Spine. 2000 Oct 1;25(19):2544-8. Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007(1):CD001350. Maroon JC. Current concepts in minimally invasive discectomy. Neurosurgery. 2002 Nov;51(5 Suppl):S137-45. Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg Am. 1999 Jul;81(7):958-65. Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg. 1993 Feb;78(2):216-25. Huang TJ, Hsu RW, Li YY, Cheng CC. Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orthop Res. 2005 Mar;23(2):406-11. Schick U, Dohnert J, Richter A, Konig A, Vitzthum HE. Microendoscopic lumbar discectomy versus open surgery: an intraoperative EMG study. Eur Spine J. 2002 Feb;11(1):20-6. Additional Resource Chiu JC, Hansraj KK, Akiyama C, Greenspan M. Percutaneous (endoscopic) decompression discectomy for non-extruded cervical herniated nucleus pulposus. Surg Technol Int. 1997;6:405-11. Chiu JC, Clifford TJ, Greenspan M, Richley RC, Lohman G, Sison RB. Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty. The Mount Sinai journal of medicine, New York. 2000 Sep;67(4):278-82. Chiu JC. Anterior Endoscopic Cervical Microdiscectomy. In: Kim D, Fessler R, Regan J, editors. Endoscopic Spine Surgery and Instrumentation. New York: Thieme Medical Publisher; 2004. p. 48-55. Fontanella A. Endoscopic microsurgery in herniated cervical discs. Neurol Res. 1999 Jan;21(1):31-8. Kambin P. Arthroscopic microdiskectomy. The Mount Sinai journal of medicine, New York. 1991 Mar;58(2):159-64. Kambin P. Arthroscopic microdiscectomy. Arthroscopy. 1992;8(3):287-95. Kambin P. (Editor) Arthroscopic and Endoscopic Spinal Surgery Text and Atlas, Second Edition, Humana Press, Totowa, NJ Leu H, Schreiber A. [Percutaneous nucleotomy with discoscopy: experiences since 1979 and current possibilities]. Revue medicale de la Suisse romande. 1989 Jun;109(6):477-82. Ruetten S, Meyer O, Godolias G. Endoscopic surgery of the lumbar epidural space (epiduroscopy): results of therapeutic intervention in 93 patients. Minim Invasive Neurosurg. 2003 Feb;46(1):1-4. Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine. 2005 Nov 15;30(22):2570-8. Schreiber A, Suezawa Y, Leu H. Does percutaneous nucleotomy with discoscopy replace conventional discectomy? Eight years of experience and results in treatment of herniated lumbar disc. Clinical orthopaedics and related research. 1989 Jan(238):35-42.

Even twenty years ago, medicine and physicians, which were expected in front of them with endless respect and whose post-treatment debt of loyalty could not be paid with expensive gifts and money, do not exist anymore… In fact, it would not be wrong to say that everything started with Hippocrates… The father of Egyptian medicine, Hermes Trismegistus, the representative of Toth’s teachings on earth, drew the surgical borders of Imhotep in 460 BC in Kos in Anatolia. While the principle of “first do no harm – primum non nocere” instilled the cult of Hippocrates in the Anatolian people, the option of treatment with drugs and the demonstration that abscesses can be healed without causing wounds brought surgical treatment to a level that almost made them forget. Then, in the centers of Pergamon built with temple architecture, medicine ceased to be a kind of alchemy-sorcery, and treatment of diseases was planned with certain formulas, as today’s medicine accepted as reference. In these years, medicine still retained the title of divine wisdom, because recognizing the disease and choosing the right Galenic preparation required an intuitive ability as well as knowledge. The accuracy of diagnosis by using this intuitive ability of medicine is still valid today, but the last fortress in divinity was broken by computer technology, “wisdom for effective accurate diagnosis”. The newly developed computer-based generation can easily reach from disease symptoms to diagnosis and from there to the most accurate treatment option… Yes, physicians are not gods, they are even technicians, moreover, they are too flawed to need their knowledge… This profession group is no longer able to diagnose without engineering miracles. becomes defective and helpless. Advanced electronics, navigation, robotic technologies are about to add nanotechnological devices, in which case it seems not too far for the physician to be replaced by mechanical robots that take more information, go to diagnosis using the genetic code and do this with a small sample of palate-salivary fluid without the need for examination. . Our genetic code is soon to be deciphered. Considering that a genetic defect is responsible for almost all diseases, it is not necessary to be psychic to predict that treatments will descend to the cellular level. Many developments follow one after the other, from cellular level treatment options, from the widespread use of “stem cell-stem cell” therapy to organs obtained by cloning, to nanotechnological pharmaceuticals that are effective at the cellular level. Although it dates back long before stem cell cloning, it has had its share of ethical debates. Discussions about the ineffectiveness of the treatment have almost reached the level of forgetting the bone marrow treatment, which is used extensively in blood cancer treatment. I think that it is a waste of time to look for the ethical basis of transforming the cell into another cell, or even into tissues formed in advanced cells such as nerves, cartilage, and muscles that do not have the capacity to regenerate. While the ethical foundations of genetic treatments, cloning and stem cell treatments were rapidly established, the increase in high revenues from ‘off-shore’ treatments was inevitable and impossible to control. Classical medicine has been in the process of extinction as long as it has received different trainings apart from a classical medical education and did not include trainings that have mastered engineering technologies. The name Asklepion, which was divided by breaking his divine staff long ago, has become unforgettable. It seems extremely risky to leave technologies with a high learning curve, such as endoscopic devices, which require a lot of skill to use, with or without the development of navigation technologies in recent years, only to physicians who have received classical medical education. While the thought that it would be more accurate to practice medicine with an ultra-modern robot, all under the control of a good medical engineer, becomes widespread, I involuntarily take a nostalgic glance at our diplomas on the wall… While divine medicine ended thousands of years ago, in these years when classical medicine came to an end, minimally invasive surgery with less trauma was defined in surgery, where Hippocrates’ expectations with endoscopic technologies have fallen short for now. With this method, which we have been using for decades, not only is the surgical wound smaller, but surgical trauma is reduced and magnified with optical devices, as well as the ability to perceive far beyond the limits of the human eye is gained. Even in this moribund period of medicine, “minimally invasive surgery” is a valuable development in terms of being a good reference for robots in the future. One of the pioneers of minimally invasive surgery, “endoscopy” is actually the feat of an internist who performed thoracoscopy in the 1920s. After the oral and laryngeal endoscopic examinations over time, despite the developing optical technologies in the Second World War, endoscopic surgery has been stalled by the increasing number of brutal warfare surgeries. With the use of optical systems by urological surgery under endoscopy, arthroscopy began to be used in infancy, while endoscopies of body cavities, abdomen, chest, and skull ventricles followed it without delay. By 1980, endoscopic percutaneous (piercing the skin) spine surgery had completed its experimental work with Hijikata in Japan and defined its safety margins in the United States with Kambin. The use of laser energy in the intervertebral disc was described and applied by Daniel Choy, an internal medicine cardiologist. Thus, the combination of endoscopy and laser energy began to be used in treatments. The laser has been boldly used as an energy to complement the scanty endoscopic instruments that have been attempted to be used in spite of the crude surgical instruments. However, its negative effects on the tissue have shown that its use will be more effective in experienced hands. While percutaneous surgery was developing rapidly, French Deramond was not a neuroradiology specialist and surgeon who first applied the cementing technique in spinal fractures. In this respect, minimally invasive surgery has filled the gap between interventional radiology and invasive internal surgery. The tendency of endoscopic and minimally invasive surgical internal branches to surgical interventional techniques must be a kind of betrayal or an irony to the Hippocrates cult. In fact, all types of interventional treatment, even percutaneous, should be performed by people with surgical training. It is a requirement of the philosophy of the intervention that the interventional physician should be ready for the necessary surgical intervention to manage a possible complication. Minimally invasive surgery is a small temple that shows the divine and human qualities of medicine when technology is not always sufficient and intuitive ability is required. Although not as much as the Jedi knight who turns off all his computers and uses his intuition, I emphasize this approach that will forever bless the physician who has humanitarian qualities, and I emphasize the minimally invasive surgery by recalling Gandhi’s motto “science that has pushed human love down the ground” from the dangers that will destroy humanity. In this respect, I hope that minimally invasive surgery will leave the wand of the divine physician Asklepion, who continues to use his intuitive ability, in the hands of surgeons for a while. Let’s not deny divine medicine, but wish it to use technologies that allow him to use his human qualities without making the physician a god…