Acta Neurochir (2009) 151:1027–1033
DOI 10.1007/s00701-009-0454-7
CLINICAL ARTICLE
A new endoscopic spine system: the first results
with “Easy GO”
Joachim M. K. Oertel & Yvonne Mondorf &
Michael R. Gaab
Received: 11 March 2009 / Accepted: 3 June 2009 / Published online: 24 July 2009
# Springer-Verlag 2009
Abstract
Purpose Endoscopy meets increasing interest by spine
surgeons. However, endoscopic results are diverging and
many spinal endoscopic systems are difficult to apply and
handle.
Methods A system for endoscopic spinal surgery was
developed where the main goals were: (1) easy intra-
operative handling with standard microsurgical techniques,
and (2) avoidance of a prolonged learning curve. The system
consists of various dilators, two different work sheaths, two
different 30° endoscopes, and an endoscope holder.
Results Between August 2006 and April 2008, 80 spinal
surgeries were performed in degenerative lumbar spine
cases (mean age 52 years, range 22-85 years). Intra-
operatively, the system was easy to handle. Standard
microsurgical techniques were used. Mean surgical time
scored 75 min (range 28–168 min). There was no intra-
operative complication, no new postoperative deficit and no
infection. In four cases, the endoscope was abandoned and
Electronic supplementary material The online version of this article
(doi:10.1007/s00701-009-0454-7) contains supplementary material,
which is available to authorised users.
No financial support was received for this study. MR Gaab is a
consultant to the Karl Storz company. Portions of the work were
presented in abstract form at the 2008 meeting of the Southern
Neurosurgical Society in Puerto Rico.
J. M. K. Oertel (*)
Neurochirurgische Klinik und Poliklinik, Universitaetsmedizin,
Johannes-Gutenberg-Universitaet,
Langenbeckstrasse 1,
55131 Mainz, Germany
e-mail: oertelj@freenet.de
Y. Mondorf : M. R. Gaab
Neurochirurgische Klinik, Nordstadtkrankenhaus, Klinikum
Region Hannover, Affiliated Hospital Hannover Medical School,
Hannover, Germany
the procedure microsurgically continued (5%). At the last
follow-up (mean FU 10 months, range 2 weeks up to
21 months), 89% of the patient were pain free (71/80). Four
patients suffered from recurrent disc prolapses (5%).
Another five patients (6%) were not satisfied without
evidence of re-prolaps. Of those who answered the
questionnaire of patient satisfaction, 83% (45/54) consid-
ered their postoperative status as excellent, 13% as good
(7/54), 4% were not satisfied (2/54).
Conclusions The Easy GO system was easy and safe to
handle with the standard bimanual microsurgical technique
and good postoperative results. Further studies are needed
to show a significant advantage of the technique in
comparison to the microsurgical standard procedure.
Keywords Endoscopic technique . Lumbar disc
surgery . “Easy GO” system . Interlaminar approach . Lateral
approach
Introduction
Lumbar discectomy procedures have been introduced as
early as the 1930s [17, 19]. About four decades later, the
application of the microscope introduced by Caspar
improved the intraoperative illumination and postoperative
results [1]. This technique has represented the “gold
standard” technique until today, and a patient satisfaction
rate of up to 90% can be achieved. Further development of
endoscopic optics and digital cameras led to the introduc-
tion of the endoscope for lumbar spine surgery in the 1990s
[4]. The so-called microendoscopic discectomy by Foley
and coworkers is a frequently used technique, claiming a
smaller skin incision, less muscular damage, and less
irritation to the nerve root [5, 25–28]. Many other
endoscopic techniques are available [2, 7, 13, 21–24].
1028
However, particularly problematic is that not only no
significant advantage of the endoscopic techniques over
the gold standard microdiscectomy has been found in many
studies [8, 21]; but an additional need of surgical time [21]
and a potentially higher complication [6] as well as failure
rate [12, 16] reduces the early enthusiasm with these
techniques. Furthermore, many techniques require a tight
patient selection [13, 22, 23]. And last but not least, most
techniques require a significant learning curve, making it
difficult to proceed with the daily routine (personal
experience of the authors with various systems). Based on
these data, the authors of the present paper developed a new
system for minimally invasive lumbar and dorsal cervical
spine surgery. The goal of the new surgical technique was
to avoid the need for an extensive training to become
familiar with the technique and to reduce the additional
need for surgical time to a minimum. The surgical
technique is presented in detail. Additionally, the authors
focus on the intraoperative peculiarities as well as on the
postoperative results with this device after 80 procedures
since August 2006.
Material and methods
Since August 2006, an endoscopic system for the application
in posterior lumbar and dorsal cervical spine surgery was
developed in close collaboration with the Karl Storz
Company (Karl Storz GmbH, Tuttlingen, Germany). The
primary goal was to develop an endoscopic spine system that
combines a microsurgical technique with minimum skin
incision and minimum muscular trauma. Additionally, easy
surgical performance even if only one or two procedures per
week or even month were performed, was mandatory. With
the use of rigid rod lens Hopkins optics and a high-definition
camera system, a superior image quality to minimize
surgical risk was expected. Finally, the application of the
system should only require a reasonable amount of addi-
tional surgical time and cause relatively low costs per case.
Endoscopic system
The “Easy GO [Gaab-Oertel]” system was developed with
respect to the above-mentioned requisites. The system consists
of a standard dilator system for muscular dilation (Fig. 1a).
The surgical procedure is performed through a work sheath of
an outer diameter of 1.5 cm (Fig. 1b). While the work sheath
is too small to allow a good microscopic view, a full
endoscopic view is realized via a 30° Hopkins optic (Fig. 1b).
Of the 30° Hopkins rod lens optic, two different lengths are
available to allow a more flexible position of the optic tip in
relation to the surgical field (Fig. 1b). The optic is fixed to the
work sheath, which is subsequently fixed to the surgical table
J.M.K. Oertel et al.
via a standard endoscope holder (Fig. 1c). An irrigation-
suction device is used for suction and irrigation/cleaning of
the optic during surgery. The system had been approved by
the regulatory authorities for surgical use in humans in
Germany prior to application.
Application experience/patient material
Between August 2006 and April 2008, 80 endoscopic
procedures were performed with this system for degenera-
tive lumbar diseases. During and directly after each
procedure, a detailed record of the surgical case including
all problems, advantages, and disadvantages of the system
was written. Based on these data, the surgical technique
was modified to fulfill the prerequisites for an easily
applicable sophisticated endoscopic system.
The patient group consisted of 80 patients (44 male, 36
female) with a mean age of 52 years (range 22 to 85 years).
Seventy-seven procedures were performed for a one-level
approach, three for two levels. The main presenting
symptom was sciatica with typical radicular pain. Seventy
percent of the patients reported subjective weakness (56/80)
with 61% of the patients (49/80) suffering from significant
monoradicular paresis. All patients received a diagnostic
work-up including MRI or CT. Inclusion criteria for an
endoscopic procedure were: age of 18 years, informed
consent to the application of the endoscope, lumbar disc
prolaps or lumbar stenosis with clear radicular compression
and unequivocal correlation to the clinical symptoms, and
no signs of spinal instability. After surgery, all patients were
followed. After one outpatient visit 3 months after surgery,
patients were contacted via a telephone interview prior to
this report. Mean follow-up time scored 10 months with a
range of 1 up to 21 months. At the end of the follow-up
period, patients were asked to describe their satisfaction
with the surgical results on a scale of 0=unsatisfactory, 1=
satisfactory/good, and 2=excellent.
Results
A total of 80 endoscopic lumbar procedures were included in
this study. Seventy-seven procedures were performed at one
level. In three cases, a two-level decompression was done. All
approaches were performed from one side only with 46 from
the right and 34 from the left side. In 68 cases, the underlying
pathology consisted of a lumbar disc prolaps (Fig. 2a, b); a
lumbar spinal stenosis was present in 12 patients.
Surgical technique
The surgical technique mainly corresponds to a standard
microdiscectomy. All procedures are performed under
A new endoscopic spine system: the first results with “Easy GO”
Fig. 1 The Easy GO System. a
Various dilators for the subse-
quent dilation of the paraverte-
bral muscles. b Work sheath of
about 1.5 cm diameter and two
different 30° rod lens Hopkins
optics with a fixed and a flexible
length (arrow) to adjust at the
intraoperative requirements. c
The endoscope and the work
sheath are held by a standard
endoscope holder with a quick
connection
general anesthesia with the patient in the prone position.
After a 1.6–1.8 cm skin incision directly at the level of the
disc prolaps parallel to the disc space (Fig. 2c), the muscle
fascia is punctured (Fig. 2d), the muscles are subsequently
dilated by the application of the various dilators (Fig. 2e, f),
and the endoscopic work sheath is inserted (Fig. 2g). A
lateral fluoroscopic control is obtained (Fig. 2h).
The endoscopic procedure is performed with bimanual
surgical technique and the work sheath fixed to the
endoscope holder (Fig. 3). After insertion of the endoscope,
the bony resistance of the lamina is located, and tissue
remnants at the interlaminar window are removed (Fig. 4a).
The ligamentum flavum is visualized and incised (Fig. 4b).
The interlaminar fenestration is enlarged with a punch or a
diamond drill if indicated (Fig. 4c). The dura is subsequent-
ly displayed (Fig. 4d). After identification of the prolaps and
the nerve root (Fig. 4e), the sequester is extracted with
grasping forceps and the disc space evacuated (Fig. 4f, g). If
indicated, a nerve retractor can be used to mobilize the dura
medially. At the end of the procedure, decompression of the
dural sac and the nerve root is checked (Fig. 4h). The size of
the skin incision after removal of the work sheath scores
about 1.5–1.8 cm (Fig. 4i).
Intraoperative observations
There were 32 procedures at L5/S1, 28 at L4/5, 13 at L3/4,
four at L2/3 and three at two adjacent levels. Surgical time
scored 75 min with a range of 28 to 168 min for a single
level procedure. A switch to the microscope was performed
in four (5%). In two cases, the nerve root was fixed in the
1029
lateral recess by the prolaps from underneath. Despite an
extension of the approach by cranial and caudal decom-
pression, the nerve root could not be moved medially
endoscopically through the work sheath. In both cases, a
switch to microsurgery was performed, the root was
mobilized medially, and the prolaps was extracted without
any difficulties. These two cases occurred early in the
series. In another case, the decompression of the nerve root
was considered to be too time-consuming. Because of the
tight time schedule of the surgeon, the endoscopic
technique was abandoned and the procedure microsurgically
continued without any problems. In the last case, a rather thin
nerve root was severely compressed by a ventral prolaps.
Under endoscopic view, the surgeon did not feel confident
enough to safely distinguish nerve root and prolaps. A switch
to the microsurgical technique was performed, the interlam-
inar fenestration was enlarged, and the nerve root was
identified directly at its exit from the dural sac. Despite the
four switches to microsurgical technique, no other intra-
operative complications due to the application of the system
occurred. There were no dural tears, no CSF fistulas, and no
nerve root injuries in this series.
Postoperative findings
Postoperative success rate with respect to immediate postop-
erative pain reduction scored 100%. An improvement of
preoperative paresis was found in 92% (45/49). At the last
follow-up visit (mean FU 10 months, range 2 weeks up to
21 months), a significant reduction of radicular pain allowing
the patient to continue normally in their daily activities
1030 J.M.K. Oertel et al.

Fig. 2 Interlaminar Approach. a

Axial T2-weighted MRI show-
ing a large right mediolateral
sequestered disc prolaps at the
level of L5/S1. b Sagittal T2
weighted MRI demonstrating
the mediolateral sequestered
disc prolaps (arrow). c Skin
incision parallel to the midline
just next to the spinous process-
es at the direct trajectory to the
disc space. d Puncture of the
muscle fascia. e The smallest
dilator is put in direct contact to
the lamina. Subsequently, the
muscles are pushed away by
insertion of the various dilators
until the endoscopic work
sheath is inserted (f,g). h The
correct position of the work
sheath is checked by lateral
fluoroscopy

without pain medication was observed in 89% (71/80). Five
patients (6%) reported recurrent lumbar or pseudoradicular
pain without evidence for re-prolaps or re-stenosis. Another
four patients suffered from a recurrent disc prolaps during the
follow-up period (5%) and were subsequently operated on
microsurgically. Patients returned to work after an average of
8 weeks postoperatively with a range of 1 up to 20 weeks. Of
those who answered the patient-satisfaction questionnaire,
83% (45/54) considered their postoperative status as excel-
lent, 13% as good (7/54), 4% were not satisfied (2/54).
Discussion
At present, there is strong demand—yet almost hysteria—
for minimally invasive and particularly endoscopic proce-
dures in spine surgery by the patients but also by quite a
few neurosurgeons. While clear evidence that these new
techniques lead to superior results is still missing, the fact
that technical developments in the past decade made lumbar
spine surgery less invasive cannot be doubted. The
combination of the microsurgical technique with the
endoscope allows the surgeon basically to address all
standard microsurgical pathologies with a smaller skin
incision and less tissue trauma [4, 20]. In the last 10 years,
quite a number of different minimally invasive endoscopic
techniques have been introduced to the neurosurgical
armamentarium [2, 4, 21]. However, each of these systems
has some special advantages and disadvantages.
The Easy GO system presented here allows the contin-
uation of established microsurgical techniques. There were
no intraoperative complications. Postoperative surgical
A new endoscopic spine system: the first results with “Easy GO”
Fig. 3 Microsurgical technique. The endoscopic procedure is per-
formed with standard bimanual microsurgical technique and the work
sheath fixed to the endoscope holder
results similar if not identical with the standard microsur-
gical technique were obtained. A video to demonstrate the
endoscopic technique in detail is included (video 1). Before
conclusions can be drawn, some peculiarities of the new
technique have to be discussed.
It is a fact that the Easy GO technique requires a rather
large skin incision of about 1.5 to 1.6 cm. The size of the
skin incision is still definitely smaller than with a standard
microdiscectomy. Particularly the application of a dilator
system seems to reduce muscle trauma [9–11, 15], but a
dilator system might as well be applied with a standard
microscopic discectomy, and successful microdiscectomies
through tubes of diameters down to 14 mm have been
reported. Thus, at the first glance, there is no need for the
application of an endoscope with such a tube system at all,
but the technique of microscopic discectomy through a
small tube is rather reserved for experienced spine
surgeons. In contrast, the Easy GO system with the high-
definition camera system and high magnification might
provide improved optical conditions that allow a better
differentiation of the anatomic structures. It might further
provide additional space for surgical handling since the
complete tube can be used for instruments and no
“corridor” for the microscopic view is required. Also,
basically all surgical techniques including intensive drilling
are available through the work sheath without or with only
minimal limitation. Thus, since no long and extensive
learning curve to become adjusted to this technique is
required, even less experienced spine surgeons might be
1031
able to perform a minimally invasive discectomy by
application of the technique. However, these thoughts
remain theoretical advantages since the present study
cannot support or exclude any of these arguments.
Furthermore, with the Easy GO system, the extent of
decompression and trauma at the neural tissue is rather
comparable to standard microdiscectomy than rather re-
duced. Thus, the effect of “minimal invasiveness” might be
small in comparison to other techniques that only use a
small endoscope [23, 24]. However, the brilliant image
quality might allow a gentler manipulation of the better
recognized neural structures, which could result in a
reduction of the number of dural tears and nerve root
injuries in the long run. Also, the technique is applicable
basically to any degenerative lumbar spine indication that is
in strong contrast to many other techniques that require a
tight patient selection [22, 23].
Of course, it appears appealing to reduce epidural
scarring to a minimum by the insertion of very small
instruments and endoscopes [23, 24] but success rates have
to be compared with the standard microdiscectomy. We all
have to keep in mind that the standard microsurgical
technique possesses a success rate of up to 90%, which
represents probably one of the most successful procedures
in degenerative diseases at all. Thus, sufficient decompres-
sion of the nerve root as easily accomplished with Easy GO
appears to be mandatory to obtain similar results.
Since there was no direct control group included in this
study, a direct comparison of the results with the standard
microsurgical technique is not feasible. The authors have
the impression that there is an additional need of 10 to 15
min surgical time compared with the standard technique. It
is the impression of the authors that this additional time will
not change much in the future despite a longer, more
intense experience. It is just more difficult to perform
surgery through a small work sheath with a bimanual
technique than via a larger open approach. Indeed, an
additional time need of 12 min is seen when the results are
compared with 50 consecutive microsurgical procedures of
the authors prior to this series. Definitely, this amount of
almost 20% of additional surgical requires attention. Future
studies with more patients and longer follow-up will have
to show that this additional economically very important
time need is justified by superior surgical results.
Currently, more worrisome appears to be the rather high
rate of recurrent disc prolapses in this series. Five percent
recurrent disc prolapses within the first year follow-up
require attention. In a recent publication on this topic for
microsurgical cases, the recurrence rate of lumbar disc
prolapses reached from 2 over 7 up to 18% depending on
the study cited [3, 14, 18]. A large literature analysis
published by McGirt et al. reported a range of 2 up to 18%
recurrence rate [18]. This rate seems to be highly dependent
1032
Fig. 4 Endoscopic disc prolaps removal. a Remnant muscle tissue is
removed with a forceps. b The ligamentum flavum (arrow) is
identified and incised. c The ligament and neighboring laminar bone
are removed with a punch. d The dura and the nerve root are
identified. e The prolaps is found and neighboring vessels are
upon the study design and the surgical technique provided
[18]. Based on these data, the present study results appear
to be comparable.
With respect to pain relief, 89% of patients continuing
with their daily routine without pain medication appears to
be an acceptable result. Other recent studies reported pain
relief in 82% [3]—or, if again, the large literature analysis
is cited, from 57 up to 94% [18]. Thus, also for
postoperative pain subsidence, no definite conclusions can
be drawn, but the study results are within the range of the
published data. Again, since a control group is missing, no
definite conclusions can be drawn. A randomized con-
trolled trial has to be performed in the future to give
evidence for clinical superior results with this endoscopic
system and to exclude a higher incidence of recurrences.
In all, the Easy Go system has been shown to provide
accurate, reliable, and good conditions for endoscopic
J.M.K. Oertel et al.
coagulated. f The prolaps (arrowhead) is removed with a grasping
forceps with avoidance of any tension on the nerve root (arrow). g
The disc space is evacuated. h At the end of the procedure, the
decompressed dural sac and nerve root (arrow) are seen. i The skin
incision is about 1.6 cm
surgery with microsurgical skills. The possibility to apply
all microsurgical skill is bought for a rather large skin
incision in comparison with some other techniques [23, 24].
But nevertheless many other minimally invasive techniques
require a similar-sized skin incision [4, 5]. Whether the
minimally invasive technique with the Easy GO system
leads to superior results compared with the microsurgical
technique or other endoscopic techniques will be the focus
for further studies. In those also the rather high number of
recurrent disc prolapses (5%) within the first year follow-
up needs further evaluation. Indeed, a direct comparison
of the Easy GO technique with a microdiscectomy
technique through a small tube system might be the next
study that has to be done. If in such a study, no evidence
for superior results can be given, the endoscopic technique
should be abandoned since there is most likely an
additional need of surgical time, and—in any case—there
A new endoscopic spine system: the first results with “Easy GO”
are additional costs for the system which are not justified
under these circumstances.
Acknowledgments The authors gratefully acknowledge the expert
assistance in requiring the patient data of Mrs. Bode.
Disclosure / Disclaimer The authors have no conflict of interest
concerning the material or methods used in this study or the findings
specified in this paper. MR Gaab is a consultant to the Karl Storz
company.
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