Surgical Guideline - Max-more

THE NEW SAFE AND EASY SPINALENDOSCOPIC DECOMPRESSION SYSTEMSAFE, PRECISE & EFFICIENTA complete endoscopy system for herniatedand degenerative disc pathology and foraminotomy.Transforaminal decompression, total fragmenttectonic disc abrasion, disectomy, endoplasty.developed by THOMAS HOOGLAND M.D.©by Hoogland Spine Products GmbH

THE HOOGLAND SPINE PRODUCTS COMPANYwas founded October 2006 inMunich, Germany. The aim ofthe company is to develop, produceand distribute instrumentsand software for minimal invasivespine intervention and surgery.The company is built upon over20 years of experience in the fieldof arthroscopy, endoscopy, instrumentengineering and spinesurgery.Dr. Hoogland is looking back atover 13.000 cases of spine surgery,most of them minimal invasive. Starting in the 80‘s withscoliosis surgery and laminectomy for disc herniation the surgicalspectrum has moved into target surgery for herniateddiscs, disc degeneration and facet joint pathology. In the 90‘she developed a spine scope with adequate working chaneland aqiured a patent on instruments to enlarge the spinalforamen.Production and distribution of an adequate set of instrumentsand documentation equipment appeared difficult in terms ofmanufacturing of the proper elements. These first instrumentsyielded significant technical difficulties with a steep learningcurve. Therefore a physician controlled company was foundedin 2006, new, safe and easy instruments were developed andthe software was improved.The young innovative team of Hoogland Spine Productsensures best high tech standards by combining a closeefficient cooperation with leading doctors and centers fromall over the world. Our Research and Development Team constantlylooks for more efficient and simpler solutions but moreimportant listens to the needs of the surgeons. By listening andunderstanding we can quickly adapt the customers needs andwe are able to implement safe, precise, intelligent and practicalinstruments without prolonged developing processes knownfrom bigger companies. This is appreciated by our customersand most important by the patients.Certified quality management is ensured by Johanna Miklitzand sales, product and software management is provided byBoris Miklitz. Early in 2007 the new complete spinalendoscopy set was introduced to the spine surgery communityand a training center was established adjacent to the AlphaKlinik in Munich, Germany. In June 2008 the System is alreadyused in more than 15 countries worldwide. More and moretraining centers will be established in the future to provide educationand to pass on the benefits of the “New Standard” inendoscopic Spine surgery.Hoogland Spine Products are confident that the now availablesystem will revolutionize the approach to the lumbar spine withcomparable systems to come for the cervical spine. The techniqueand approach allows also a complete new managementof disc degeneration and facet joint hypertrophy. The managementof modern intravenous anaesthetics allows extensivespinal procedures in local anaesthesia. This minimizes therisks of spine surgery and opens new windows of opportunityfor the steep increase of degenerative spine conditions.LITERATURE1. Die perkutane lumbale Nukleotomie mit Low-Dosis Chymopain,ein ambulantes Verfahren. T. Hoogland, C. ScheckenbachZ. Orthop. 133,106-113, 19958. Endoskopische transforaminale DiskektomieT. Hoogland, C. Scheckenbach, H. Dekkers, MünchenAmbulant operieren, 6, 4: 1-3, 19992. Out-Patient Endoscopic Lumbar Laserdiscectomy. T. Hoogland,Proceedings : International Symposium Laser in Orthopaedics,San Francisco, September 27-19, 19919. Ambulante perkutane Discoplastik bei RückenschmerzenT. Hoogland, B. MiklitzAmbulant operieren, 3: 77-80, 20023. Erfahrungen nach 2000 ambulanten BandscheibenoperationenT. Hoogland, C. Scheckenbach, Ch. Wagner, MünchenAmbulant operieren, 3, 1: 1-6, 199410. Transforaminal disctomy with foraminoplasty for lumbar discherniation T. Hoogland Surgical Techniques in Orthopaedics andTraumatology. 55-120-C-40,2003, 6p.4. Low-Dose Chemonucleolysis Combined with PercutaneousNucleotomy in Herniated Cervical DisksT. Hoogland, C. ScheckenbachJounal of Spinal Disorders, 8, 3: 228-232,19955. Endoskopische transforaminale Diskektomie erfolgreichDr. T. HooglandExtracta orthopaedica, 12: 12-16, 19976. Die endoskopische transforaminale Diskektomie bei lumbalenBandscheibenvorfällen. T. Hoogland, C. ScheckenbachOrthopädische Praxis, 34, 5: 352-355, 19987. New in Vivo Measurements of Pressures in the IntervertebralDisc in Daily Life H. Wilko, P. Neef, M. Coimi, T. Hoogland,L.Claes. Spine 24, 8, 775-762, 199911. Nukleotomie mit Foraminoplastik bei lumbalen Bandscheibenvorfällen.Endoscopic Transforaminla Nucleotomy withForaminoplasty für Lumar Disc HerniationHoogland, T., Schubert, M.,Oper Orthop Traumatolog 2005/5:641-66112. Transforaminal Posterolateral Endoscopic Disectomy With orWithout the Combination of a Low-Dose Chymopypain:A Prospective Randomized Study in 280 Consecutive Cases.Spine 2006;31(24) E:890-E89713. Endoscopic Transforaminal Discectomy for Recurrent LumbarDisc HerniationT. Hoogland, K. van den Brekel, M. Schubert, B. Miklitz,A. Ramirez Spine Journal 2008; Volume 33; Number 9

TECHNIQUE1 preoperative planning1 athe herniated fragment on the MRI is plotted into the lateralX-ray view of the lumbar spine1 bthe herniated fragment on the axial MRI view is plotted into theAP X-ray of the lumbar spine2 determination of the entrance point to the foramenon the lateral and AP X-ray view.

3 positioning of the patient in a stable lateral position on the radiolucent operating table4 disinfection of the skin and sterile draping5 marking of the skin 12 cm from the midline6 marking of the approach angle with C-arm guidance7 determination of the entrance point on the skin and local anaesthesia8 positioning of a spinal needle at the target area on the facet joint

9 facet joint injection of 5cc 1% xylocain with adrenaline10 insertion of the guide wire11 skin incision of 8 mm12 predilation with a 3.0 mm rod13 dilation with a 6.3 mm rod14 advancing of TOMshidi14 atargeting of TOMshidi in to the herniated fragment14 badvancing under C-arm control14 cadvancing of blunt drill under C-arm control

15 placement of the guide wire through TOMshidi16 straight line drilling with 1st canulated TOM bone drill, 4 mm16 a CAUTION! THE GUIDEWIRE STAYS IN PLACE17 enlargement of the drill hole/tunnel with 2nd canulated TOM bone drill, 6 mm18 tunnel enlargement with 3rd TOM bone drill, 7 mm19 tunnel enlargement with 4th TOM bone drill, 8 mm and angle correction, if necessary

20 insertion of dilitation over pilot guide wire and working canula21 positioning of working canula under C-arm control22 endoscopic inspection of spinal canal entrance23 endoscopic removal of the herniated fragment24 control of the position of workingcanula and forceps25 endoscopic inspection of thespinal nerve: confirmed by freemovement of previously compressednerve root

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