Biportal Endoscopic Spine Surgery :

Cervical

Wawan Mulyawan
Brain and Spine Center
Rumah Sakit Umum Bunda - Jakarta

Pertemuan Ilmiah Tahunan (PIT) ke-5 Indonesian Neurospine Society (INSS)

Bandung - 2023
 BESS in Cervical Area ?
Cervical signs and symptoms can manifest as axial
neck pain and radiculopathy

Surgical treatments should be considered when patients have

failed conservative strategies.

Surgical approaches : anterior or posterior approaches.

Posterior : Cervical Foraminotomy (PCF), Cervical Decompression.

Discektomy ?

New Alternative : Biportal Endoscopc Spine Surgery (BESS) in Cervical

• small surgical sites
• less bleeding
• less retraction of the surrounding muscles
• shorter hospital stay
• speedy recovery.
Advantage of BESS

Less incision
& bleeding
MIS without
Microscopy No infection
(Economy)

Wider view
compared to Less hospi-
microscopic talization
surgery
Benefits of BESS for neurosurgeon
• If have device system of arthroscopy, it can be
done.
• Not necessary of special spine equipment for
endoscopy
• High speed drill is a necessity, but not absolute (5.000 – 20.000
rpm requirement).
• 1 mm Kerrison punch is absolute
• Learning curve : << (neurosurgeon : microsurgery)
Facility and instrument 1.7 M Gravity
Used Saline

Arthroscopic system
C-arm

Shaver
High-speed burr
Caudal Cranial
Radiofrequency

BESS instrument
 Corner stone of BESS
Keep stable hydrostatic pressure !!!!
1.Obtain definite water flow (inflow and outflow !!)
2. The balance of inflow and outflow is importantsoft tissue swelling (-)
3. Obtain clear surgical view
4. Clearance of debri
5. Prevention
Inflow of infection Outflow
30mmHg 30mmHg

Water flow
Maintain ideal hydrostatic pr
Corner stone of BESS
Anatomy Considerations

Neuroforamina
 Anatomical Approach : Posterior Cervical

A. the exiting root

Surgical Instruments
Surgical Steps
Patient’s Position.
• Neck Flexed, abdomen relaxed
• Entry point Landmark :
• +/- 2cm lateral to spinous process,
• Ipsilateral to the targeted site
• Targeted site : V-shape (20-30 degree)
• C-arm guided : AP and Lateral position
 Surgical Steps
• Antiseptic solution and draped in Posterior neck
• Surgeon stands on the side of the lesion. C-arm must be placed contralateral to
the surgeon.
With C-arm fluoroscopy guided :
• 2 skin incisions of 0.5 cm long were made vertically along the lateral margin of the
spinous process (about 2 cm lateral to spinous process).
V – Shape :
• 1st skin incision (0,5 cm) for a cranial portal was made at the level of the upper
cervical spinous process related to the target.
• 2nd skin incision (0,5 cm) for a caudal portal was made at the level of lower
cervical spinous process.
• The distance between these 2 portals was about 3 cm
 Surgical Steps
• Serial dilators to dissect the neck muscle.
• A 0° endoscope inserted through the left portal after inserting the cannula.
• A saline irrigation system was applied with a natural drainage system (2 m high
from operation room floor).
• Surgical instruments were inserted through the right working portal.
• After triangulation with the endoscope and instrument on the margin of the
superior laminar, inferior laminar, and medial point of the facet joint (V-point),
minor bleeding was controlled with a radiofrequency probe.
Entry point landmark
 Surgical Steps
Bony Decompression
• After identifying V-point, the inferolateral portion of the upper lamina, superolateral part
of the lower lamina and medial point of the facet joint (V-point) was drilled out with
endoscopic drills (as we do in microsurgery)
• Drilling around the V-point was continued till the caudocranial margin of ligamentum
flavum was exposed.
• More wide decompression of distal root, the cranial tip of the superior articular process
(SAP) was also removed by using 1 or 2-mm punches
 Surgical Steps
Flavectomy
• Direction of root (usually more horizontally) using 1-mm Kerrison’s punches. It is
important not to use 2-mm Kerrison’s punches.
• Bleeding control was performed while removing the ligamentum flavum by using the
small radiofrequency ablator.
• By using disector, sufficient foraminal decompression was verified through the foraminal
canal without any resistance and dura pulsation.
• The wound was closed directly using simple skin suture.
Radiologic View : MR and CT
THANK YOU