 So next talk is about some things we are doing Maybe a little bit different or some nuances different than you do it in a daily work But the good thing is you do not need anything else You can go home and try it and if you fail or if you have to abandon you do your your common things so first again some anatomical Considerations you see a sore bone model of the lumbar spine You see this is something there was the dual psych and the nerve roots and the nerve roots are Passing along the superior pedigal. You see from a lateral view. These are the pedigals the nerve in this model is not not really like in real life because these roots are passing in a superior part of the foramen and This would be About the level of the disk space and as you all know the the disc fragments they can herniate superior inferior medial and lateral and In our thinking this leads us to different approaches to the different herniation. So if we have a Disc herniation at the level of the disc we already do a laminotomy. That means we are removing only this part of the bone or even the Ligamentum flavium if we have a slightly Inferior herniation if we have Superior herniation we either go trans lamina. That means we only do a burr hole in the lamina or if it's a little bit More upwards. We are coming from superior. That means we have a disc herniation For example at the level l45 upwards and so we are coming from the inter aqua space from L3 for to cover this herniation and Having extra formal or foraminal Disc fragment we are coming. We only have the approach from the lateral Extra spinal part. So I will show you some examples. So first video common medial lateral lumbar Disc herniation you see Right-sided at the level and a little below the disc. So we are doing at this area This is the lamina L5. This is the Ligamentum flavium and there's the sacrum so in this case we haven't removed the Ligamentum flavium, but we produced the flap and remember these these keyhole concept to to harm as less tissue as possible and We try to Overtake this also in the spine surgery and so you see this is a plant and sharp dissection to To create a flap of the Ligamentum flavium. Sometimes you can put it beneath your distractor or You you fix this flap with a with the suture and after that you can use this suture to bring it back and to fix it in the medial part So only a little bit of movement of the lamina and you see the nerve root there is the Herniation and it's coming almost those out by itself and This is the level of the disc and it was a young patient and so it was pretty stiff. This is the disc no fragment and there was a Continuity to the to the disc space so in this case we also performed this nuclear to me and Put the fat back to prevent scarring at the epidural space and you see the Ligamentum flavium is fixed back and Only I want to show some other thing and we this is the incision and We are very convinced by using this clue So we do not suture the skin, but we cover it with you with this clue So you don't need a tape and the patient can go for a shower immediately after surgery So and we have really good also cosmetic results with with this clue So we are using these flavec to me or lamina to me in soft heart disc herniation Cinevial cyst, but also tumors you can go for a inter aqua Exposure the result is that you have a minimal bony and facet resection though the instability is limited and you know do not have distractions of the posterior midline structures and we heard about the lever arm and it's if you see this crane and this would be the interspanial sligament and if you cut this the the crane will fall and so we are Very serious to protect the posterior structures and so if possible. We do not remove them and This is for example a tumor you see it's immediately behind the vertebral body It's about two point five centimeters and This is also unilateral approach. You see there is one lamina lamina. This is the Ligamentum flavum. There's the other lamina and only we do this flavec to me. These are the spinous prawns processes So the approach is about three centimeter So unilateral approach no touch the the posterior structures and The space is enough to do all this. Yes You do not have to perform a lamina laminactomy to to reduce in this case. It was a ependymoma So the dissection is the same So this is field phylum terminale and you have to cut it in these things and there's Almost always one vessel from the superior part of the phylum to the to the tumor So we first have to corgulate this vessel because if you cut it now the phylum will Retract and you will never reach it and if it's bleeding you you have to to widen your approach. So first Corgulate this vessel and it's close with a running suture and it's close with the clue as well so it's a procedure of one hour or something like that and To show an example for the trans lamina approach you see This is a disc herniation superior to the disc space and The approach would be here to reach this part and also the foramen We are right-sided this model is is is wrong So this is the lamina here and you cut it with a with a round trill the last lamella You can you can use these diamond trill You see there is fat and a part of the ligament and flavor So this fat and the ligament and flavor is reduced. There is the dual sex or the foramen would be here So the nerve root would be here and the disc base is here This is a 2 mm disector only to have some relation to the size Fragments and you really have a good control with the hook if you really have catch everything So it's not a blind fishing, but you really have control of what you're doing. So this is the burr hole It's about nine millimeters and Closure the same so we use it if we have these cranial disc herniations only a radiculopathy if you have a Couda compression and a huge fragment you have to first decompress and this is not a decompression procedure and It's You cannot do a nuclear to me So if you have you you think you have a need for a nuclear to me due to the MRI then you have to to open it a little bit more and Lateral foraminal disc fragments you see there are two parts one, which is really extra foraminal Left-sided and one is intra foraminal at the level L3 L4, which is the most easiest Level to perform this So also this is shifted. I don't know why so this is the incision is the same a midline incision But you cut the fascia a little bit para Spinal 1 centimeter something like that. This is the lamina here you we do this this x-ray always during surgery and Remember this picture now and Now looking on the model. We are dealing at this place here So this is what we call the incisor the lamina is here foramen nerve would come out here and on the lateral side you see We have to open this and remove only this part of the Lateral facet so this is the incisor you open it here and the slightly Removement of the of the facet part of the ligament and flavor here You see the nerve root running here and you see this was the extra foraminal part We have seen in the CT scan and now looking for the intra foraminal part And sometimes you have to open up to see the really the dura if necessary so same closure so The indications are radiculopathy and intra-extraforminal herniations or you can also widen foraminal Oseous foraminal stenosis Again the the advantages that you have minimal bone decompression and so the the instability is not a problem You also have access to interspinal parts of disc fragments You have limited possibility for a nucleotomy and you have to be aware that the situation at the L5 As one level is a little bit more complicated here. You have to go through the facet joint and our manner of decompression in Spinal stenosis you see this is a two-level spinal stenosis and the idea is first to come At the ipsilateral side and to decompress via Interacorea that means a lamino to me of the superior and inferior lamina to compress on the ipsilateral side and after that you tilt the table and the patient to the other side and You're looking with a microscope over the dura that means over the top To the to decompress the opposite side and you even can decompress you can sometimes see depending on the On the angle of the lamina you can even decompress control the control lateral foramen In those cases I prefer to begin with a drill To remove and to to thin the lamina So this is only lateral. This is the lamina This is the spinous process here. This is ligament and flavor So first the decompression on the ipsilateral side You see this is true with sake This is the nerve root here and there is The disc and then you go on the other side the patient is still to the control lateral side And you see first there is some fat and first you drive. There are no Adhesions and then you remove the Contraterals ligament and flavor sometimes you have to drill Some spurs and now you see going over the top. This is you will see the discs Opposite here, and you have control to the forearm on this side and this was the two level Decompression and this is the remaining lamina in between. So we are using this in in all Spinal stenosis mono or multi-segmental diseases. So the undercutting limits excessive bone Removement especially the the movement of the dozer parts again So there is no destabilization due to the surgery But this has less effect on back pain and if back pain persists or if it's increasing there is a fusion necessary and Last thing I want to show is what we call the dozer for aminotomy a technique to go for some lateral or medial lateral Cervical disc herniations, so this would be the approach So from from the dozer side you we remove a part of the superior lamina the nerve root is running Like this. This would be the level of the disc and This would be the approach you see the disc fragment here This would be the approach right-sided. So there is the lamina There is the ligament on flavor here and this is the superior facet and the inferior facet is here So first we reduce a part of the superior lamina then you can Do an incision along this the inferior lamina of the ligament on flavor and then you can perform partial Flavectomy and now you see there is the nerve root. This is the dual rosette for I'm and is here and the disc level is here and In between the nerve root and the dual the Dura You have good control to to remove those even bigger Disc fragments you see there was no pulsating of the nerve root at this moment These are all extra discol. So there's not we are not in the disc What's all let's say every dual so the first choice in the lateral disc herniation is this surgery This position is a sitting position You see there was no there was no black there and and if you have a in a prone position You it will always be it's not bleeding much, but you will always have some bleed there It is so we do it in a sitting position and so it becomes very easy But this is the problem. Yes, so this is a bad message but if possible we use it also in unilateral foraminal stenosis for decompression and in persistent stenosis after we've done an ACDF and so the Advantage there's no need for fusion no implants no risk of damaging ventral structures The procedure is about 40 minutes, but it's sitting position and the risk of embolism and so you need even you have a short time of surgery you need a little bit monitoring and all these before but We are very convinced Yes