 It's called minimal invasive, but minimal invasive perhaps from the perspective of a surgeon is minimal invasive But for the patient I think it's not and we call it less invasive surgery So I present just a couple of techniques and it's again It's about anatomy that means so that you have to study before you're doing various approaches to the lumber Especially lumber spine you may think about the relation of the disc and perhaps their disc pathology to their laminar or to the flavum or to the foramen and It's just important to think about what is the level of their pedicles and how to access at a certain point in the less Invasive way the pathology and the nerve root which has to be decompressed Because the disc herniation may be lateral Mediolateral it can be medial it can be cranial or it can be caudal and it can affect the higher or the lower root and There are several techniques you can do So the most invasive technique which is rarely Necessary is a laminate to me so that you really take all the dorsal structures You can make a just a small laminate to me if you want to get a medialateral prolapse If it's just going caught you can make a inter laminary laminate to me It's possible for a cranial disc herniation that you really go trans laminar It may be just that it's a caudal herniation that you go just what we call a medial foramen to me that you Really leave the flavum and go down and of course you can take an extra for another approach and this is their Just straightforward to a case with their medialateral herniation Is it's a standard case? so and we try to leave all their Bony structures intact if it's possible of course you have to achieve for surgical goal and The skin incision is in general About a skin incision of three centimeters You can decide to reject or to just make a kind of flap of the flavum In this case the surgeon it's not me It was my colleague my co-worker which has been I think in in spring. I'm here at Christoph Bousa to make this job he decided to make Just a flower to me and in general if it's no not a stenosis and if it's not a large mass effect You can make really a very selective visualization of the nerve root and the disc as long as you use a microscope Yeah, if you take a headlamp, I think it's it's it may be difficult. You need a major exposure So it's not the the goal of doing less invasive for spine surgery is not that you make just a narrow space It's just that you think before doing a case What is the needed approach? It's like with a super orbital approach. So You don't need to or it's not about us doing just a small approach. It's just to Don't expose or reject tissue, which is not necessary to be resected or to be exposed then you can mobilize again the fat and fat tissue and even the flavum and It's good enough if it's a discination, which is just in the level of the disc And we feel that if you're doing a less invasive lumber disc microscopic technique It's a bit safer than doing for example an endoscopic disc surgery we didn't switch to yet. I don't know I'm not that convinced because you may save another 0.5 or centimeters and The visualization is enough and what's quite as we use in our glue for the patients Because they can take a shower the next day. So we don't have to change the wound wrestling and their costs are quite affordable and And The indication is that really you have to look if there's a herniation, which is on the level and What we always try that what has been the subject already in the cervical that you don't touch too much the the dozeal Structures to prevent an instability of the patient. This is a case of her appenduomal mix of papillolary appenduomal and Even these lesions are you can tackle without a laminatec to me Think skin incision should be something about six or eight centimeters you start with her flabectomy It depends or if you just have to make her interaccuracy interlaminary Decompression, but you don't have to really It's one on one side. You can make an undercutting of the midline But the the other side the spinous process and the Contraternal lamina is completely intact. Of course, it depends always the the kind of pathology For example in muxor if it's a suspected mix of papillolary appenduomal dissection is easier than if it's a true appenduomal or Yeah Yeah, fine. I'm terminale. It's just just cutting Yeah, and it gives you get good training for doing minimal and less invasive cranial neurosurgery If you make all these manual work in a small corridor Skin incision is midline, but then you have a quite a bit oblique view on their dual fecal sac So this is midline About here and then you make an undercutting which gives you access to the whole Dura But you didn't sacrifice the lamina on the other side and didn't touch their joint on the different side on the Contralater side and Especially in these kind of Discarnation in general if you make it start from the flavor you will Probably will do a hemi lamina to me and it's not forbidden But it has been described in 10 or 15 years ago in minus series that you can do this by a Translamina approach that means you make just a burr hole here in the lamina Without touching the joints and just tackle this Discarnation at that level because in general it's in there that in there in the exhilar and of the root and If you come from below, it's difficult to visualize the the nerve food Which is descending and if you're coming above you take make too much bone work, which is not necessary So in the video so this is cranial caudal Natural medial so we start This is the lamina. You just make a small burr hole Until you see the the fat on that level Then you make it a bit litter bigger with the cursants until you see the fat and if you dissect the fat and In general, you don't see the at the beginning the root you see the root after you Really removed the discarnation and you can even get larger disc fragments through a tiny bar burr hole in the lamina Yeah, and it's enough to make a one-centimeter Opening but it's really there's some contra-indications if you want to make a nuclear to me or if this quarter compression don't do it Yeah, and the exo-framinal approach we take it especially at the higher lumber levels from 203 as 3445 it's very nice to get the pathology from outside. Yeah, you see here is the discarnation Yeah, and you can really make an extra spinal approach to this and all the lateral. Yeah so this Pathology Always midline we do always midline because if for example if you have to do a redo case or it just Doesn't look good. They have people doing your horizontal So you see now we just marked it This is their foramen Yeah, this is medially, laterally. So we are at that level and you see in general the The level of the disc is about here yeah, and always Do a disc bone removal here and the Discarnation will be always not always but in most cases in the axilla There's always some flavellum covering This is the nerve and it's Here's the disc. There's a nerve and it's always in the axilla and you can reach of course or also intra spinal fragments from that perspective and There are two approaches. You can just make a midline approach and go make a periostal Dissection or you some people are doing a trans muscular approach Which may even minimize your your skin incision even even more when you take it to be a Retractor and make a pair of line skin incision. You could even make the approach smaller and On the upper and middle number spine is very nice as five as one works very well But you need some some practice. Yeah, because it's not typically you don't find a foramen in that sense And the advantage is really that you don't lose any instability and you can even Make a decompression of a formal osteopathic stenosis this is quite quite nice and For a decompression we all also use the one-sided approach and the idea behind that is that even stenosis if you Make a oblique Decompression that you can preserve most of the joint of the contralateral side Yeah, that means with the angulation of the microscope without Microsoft. It's difficult You may really make a undercutting of the spinous process and you can make a bilateral decompression Yeah So we start with drilling in general in a kind of youth form That means we take the medial aspect of the ipsilateral joint Because they're the flavor most net not visible Yeah, and we take a bit of the upper and lower third of the lamina But people would like to make quite everything with the exercise to refine your movements and spine for cranial drilling of course ipsilateral decompression is Quite fine and quite easy. It's in their Fashion you do it then you mobilize the fat and the dura from the flavor and this already about midline and Then you can make this unaccounting technique To the opposite side yes Yeah The only point where you need some drill is the the spinous process because it's too thick to decompress it with their With their kerosene So it's it's nothing very special It's just the idea that with proper planning and analyzes of the pathology you can minimize the size of the approach you can minimize the the bone loss of the loss of functioning Joints and you can do it even multi-level with incomplete removal of the lamina. Yeah, and the idea is that you have if you have a Good selected case that means it's a soft Discernation to our experience the other Firminal stenosis with ossified doesn't work that well It must be lateral it must be soft and the ideal time of the Patients should be less than two months if it's half a year it will be frustrating He will end up in an anterior cervical decompression infusion and this is nice if your user for example a tubular Retractor that can be nicely done. We use classic ones So this is medial lateral You just bite a bit from The lamina and it soon goes to the joint But don't remove too much from the joint people complain about neck pain if you do too much Then scission of the flavor. It's really slight incision and then it goes It opens on itself. Yeah, it's not like a lumber It's sufficient to see the lateral part of the dura and A part not completely of the nerve root Yeah, yeah, yeah and never never make a mobilization of the dura to middle I would never do it Yeah, because then you perhaps it was was not a good case selection and then you just go with the nerve hook under the Nerve root and this is nice about the sitting position that really you don't have venous congested and but of course it's a lot of work with a Anastasiology department But they don't complain they because if you make a larger approach and you You remove a lot of the joints. I think then there's no major advantage in this in this kind of surgery Of course, it's a nice in general the piece are not larger than that one piece like this This was a big one, but in general, it's only a small piece. We really think that's all and But in this case it was You key of course you can do some drilling But because if there's a really ossified this this disk is there's a disk disease which will be progressing Yeah, yeah So of course, there's no need for fusion that's nice It's a short time of surgery people can be dismissed quite fast the follow-up. There's nothing to do with x-ray and Unilateral for a minister knows this. Yeah, it is an indication, but not the best one. I would say it must really very short and clear thank you