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Orthopaedic Surgery SURGICAL TECHNOLOGY INTERNATIONAL XIX

Evolving Minimally Invasive Spine Surgery: A Surgeon's Perspective on Technological Convergence and Digital OR Control System JAMES T. THACKER, M.D. INTERVENTIONAL PAIN MANAGEMENT SPECIALIST CALIFORNIA SPINE INSTITUTE THOUSAND OAKS, CA

JOHN C. CHIU, M.D., D.SC., F.R.C.S. DIRECTOR, NEUROSPINE SURGERY DEPARTMENT OF NEUROSURGERY CALIFORNIA SPINE INSTITUTE THOUSAND OAKS, CA

BRENT LIU, PH.D. ASSOCIATE PROFESSOR OF RADIOLOGY IMAGE PROCESSING AND INFORMATICS LAB (IPILAB) UNIVERSITY OF SOUTHERN CALIFORNIA LOS ANGELES, CA

ALI M. MAZIAD, M.D., MSC. SPINE SURGERY AND SURGICAL INFORMATICS FELLOW CALIFORNIA SPINE INSTITUTE - IPILAB UNIVERSITY OF SOUTHERN CALIFORNIA LOS ANGELES, CA

JORGE DOCUMET, PH.D. POST DOCTORATE FELLOW IMAGE PROCESSING AND INFORMATICS LAB (IPILAB) UNIVERSITY OF SOUTHERN CALIFORNIA LOS ANGELES, CA

GEORGE RAPPARD, M.D. NEURO-INTERVENTIONAL RADIOLOGIST LOS ANGELES BRAIN AND SPINE INSTITUTE LOS ANGELES, CA

ABSTRACT

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egenerated spinal disc and spinal stenosis are common problems requiring decompressive spinal surgery. Traditional open spinal discectomy is associated with significant tissue trauma, greater morbidity/complications, scarring, often longer term of convalescence, and even destabilization of the spine.

Therefore, the pursuit of less traumatic minimally invasive spine surgery (MISS) began. The trend of spinal surgery is rapidly moving toward MISS. MISS is a technologically dependent surgery, and requires increased utilization of advanced endoscopic surgical instruments, imaging-video technology, and tissue modulation technology for performing spinal surgery in a digital operating room (DOR). It requires seamless connectivity and control to perform the surgical procedures in a precise and orchestrated manner. A new integrated DOR, the technological convergence and control system SurgMatix®, was created in response to the need and to facilitate MISS with "organized control instead of organized chaos" in the endoscopic OR suite. It facilitates the performance, training, and further development of MISS. - 211 -


Evolving Minimally Invasive Spine Surgery: A Surgeon's Perspective on Technological Convergence and Digital OR Control System CHIU/MAZIAD/RAPPARD/THACKER/LIU/DOCUMET

INTRODUCTION Minimally invasive surgery is an emerging surgical concept that has been applied in various subspecialties over the past three decades. The need to develop smaller access portals and advanced tools for precise targeting of the pathology has been the main challenge to convert a conventional open procedure into a less traumatic and tissue-sparing surgery. The same applies to spinal surgery with the emergence of minimally invasive spinal surgery (MISS). Conventional open-spine surgery and spinal fusion/fixation surgery (Fig. 1) for the treatment of degenerative disc disease are much more traumatic and tend to destabilize spinal segments, which requires further surgery of fusion and fixation. These have also been associated with a wide range of postoperative complications, including accelerated degeneration of adjacent discs (i.e., “adjacent segment disease,” or ASD) or significant herniation of discs (i.e., “post fusion junctional disc herniation syndrome,” or JDHS), in 19% to 52% of postfusion patients 4 to 5 years after fusion surgery, as reported in various studies.5–11 Many of them are treated with additional extension of spinal fusion surgeries. Obviously, the viscous spinal fusion cycle is a surgical

nightmare but it can be prevented with MISS.8 However, the new minimally invasive surgery is technologically dependent on the advancement of bio-computer technological developments, spinal dilation technology, advanced sophisticated optic-endoscopic spinal instruments, imaging-video technology, tissue modulation technology, and laser technology. The utilization of these technologies for MISS creates a complex technological surgical environment.1–4 In response, the SurgMatix® Surgical EMR (electronic medical record) Control System (SECS; SurgMatix Inc., Wilmington, DE) was designed and developed to facilitate the precise MISS with the “digital surgical technology convergence and OR control system.” It provides a complete clinical picture with live “real-time” data of a surgical patient in a digital operating room (DOR), being “patient centric” and “patient transparent.” Most importantly, it enhances and improves the quality and safety of the surgical patient care, and provides significant data for further clinical analysis. WHYWHY AND WHAT AND WHAT IS IS MISS? The urgent need for less or minimally invasive surgical technology is

obvious and has lead to the development of MISS. It is an advanced technologically driven surgical procedure requiring various sophisticated and advanced delicate spinal surgical instruments and more complex technology than the traditional and more traumatic open spinal surgery. MISS involves the use of various technological modalities to achieve its surgical goals, including advanced imaging, an endoscopic laser system, and specially designed mini-spinal surgical tools for “tissue dilatation” and spinal decompression (Fig. 2).6–15 MISS is an outpatient endoscopic microdecompressive procedure performed under local anesthesia and conscious sedation, using only a small 4 mm to 10 mm surgical skin incision. The mini-spinal surgical instruments are introduced through small tubular retractors and are aided by the introduction of surgical instruments with “dilatation technology” instead of cutting technology (Fig. 3).5–21 These instruments avoid the complications from both general anesthesia and traumatic tissue dissection. The MISS surgeon does not have direct visualization of the gross anatomy in the surgical field like conventional surgery, except viewing of the surgical anatomy through the endoscope, and must depend on the interpretation of pathology in relationship to x-rays, magnetic resonance imaging (MRI), computed tomography (CT), threedimensional CT aided by C-arm fluoroscopy, endoscopic visualization, intraoperative neurophysiological monitoring, and electromyogram (EMG) and real-time x-ray imaging as well as preoperative imaging studies.15–35 Prior MISS training and education guide the surgeon in performing the endoscopic decompressive MISS (Fig 2).35–42 IS SURGMATIX®®?? WHATWHAT IS SURGMATIX Although there have been many advances in the surgical instruments and techniques for MISS procedures, the development of integrated surgical monitoring systems lagged behind. This accounted for some surgical complications that could have otherwise been avoided if proper monitoring was utilized.43–47

Figure 1. Traditional lumbar fusion/fixation with multiple screws and rods.

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d Figure 2. Endoscopic MISS surgical instruments and equipment. (a) Endoscopes, cutting forceps, grasping forceps, tubular working channel, trephine, spinal needle, flex forceps, and bone cutting rongeur. (b) Endoscopic discectomy, microdiskectomy for extruded disc fragments, and smart endoscopic operating system with rongeur in place. (c) Endoscopic cutting forceps, bone punches/rongeurs of various sizes, removal of disc fragments, and drills. (d) Tissue modulation surgical equipment: Holmium YAG laser generator, side fire laser probe (including inverted cone shape maneuver), and radiofrequency machine

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Evolving Minimally Invasive Spine Surgery: A Surgeon's Perspective on Technological Convergence and Digital OR Control System CHIU/MAZIAD/RAPPARD/THACKER/LIU/DOCUMET

Figure 3. Steps of MISS: (a-c) Microdiskectomy with grasping forceps through endoscope, drill, and laser probe. (d-g) Fluoroscopic images of microdiskectomy with forceps, curette, drills, and laser probe. (h-i) Endoscopic view of microdiskectomy with cutting forceps and laser probe. (j) Tiny MISS incision closed with one stitch.

As a joint project between the California Spine Institute and IPILAB at the University of Southern California, we developed a complete monitoring system specially designed for MISS under the brand name “SurgMatix®,” or simply, a “digital surgical technology convergence and OR control system” or an OR “Surgical EMR Control System” (SECS) (Figs. 4a, 4b, & 5).40–44,46,47 The system involves monitoring the display of all three phases of the surgical procedure, namely the preoperative, intraoperative, and postoperative phases (Fig. 6).43–47 This integrated digital image data EMR convergence and control system converges all MISS-related digital monitoring information to be displayed on two large 52-in. high-definition (HD) LCD monitoring screens (Figs. 4a & 4b): Preoperative 52-in. LCD HD screen Intraoperative 52-in. LCD HD screen

PREOPERATIVE PHASE PREOPERATIVE PHASE MISS requires many preoperative imaging studies, investigations, and analysis of x-rays, MRI, CT, and threedimensional virtual CT scans, displayed on a large “Preoperative 52-in. HD LCD monitoring screen” (Figs. 4a, 4b, & 7). Sometimes, the imaging studies are repeated to detect the progression of the pathology or for special scans, such as weight-bearing or contrast images. This can result in hundreds of images for a patient, which makes retrieving the important specific image very cumbersome and difficult. If printed films are used, this is even more difficult in sorting them and viewing them from a distance. They are often scattered around the OR without the ability to zoom in to magnify a small lesion for clear and better viewing during surgery, as with the SurgMatix ® system neuro-navigation device (Figs. 7, 8a, 8b, & 8c). - 214 -

With the new SECS system, the surgeon can select key digital images preoperatively, the day before surgery, from x-rays, MRI, and CT studies. These key images can be annotated and highlighted precisely to identify the lesion in location and size during preoperative planning for the MISS including the surgical approach, correct level, and the correct side to be operated upon for precise endoscopic microdecompressive spinal surgery. A surgical “whiteboard” is available that provides pertinent information including the patient’s name, gender, age, weight, height, and any allergies or comorbidities as well as the surgical procedure, level and side of lesion, and site of pain (Fig. 8a). It is available at all times for quick reference immediately before and during the surgery by the surgical team to facilitate the MISS procedure. As an additional safety feature, the patient’s biometric information (fingerprint) is available in the OR on the pre-


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b Figure 4.(a) Schematic drawings for the SurgMatix® system with (1) preoperative 52-in. LCD HD monitoring screen displays for preoperative information and (2) intraoperative 52-in. LCD HD monitoring screen displays for intraoperative information related to MISS surgery. (b) Second generation of SurgMatix®, surgical mobile IU.

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Evolving Minimally Invasive Spine Surgery: A Surgeon's Perspective on Technological Convergence and Digital OR Control System CHIU/MAZIAD/RAPPARD/THACKER/LIU/DOCUMET

Figure 5. Different technological equipment in the OR, integrated in the SurgMatix® system.

operative screen to confirm and match prior fingerprint and identity of the patient to avoid operating on the wrong patient. It also contains information from preoperative, Visual Analogue Scale (VAS), and Oswetry disability score/index (ODI) questionnaires, which are provided by the patient using a touch-screen interface before the surgery. All the preoperative information can now be viewed on this large preopera-

tive 52-in. HD LCD monitoring screen, which is easily viewed by all personnel in the OR (Fig. 9a). As required, the fingerprint confirmation and whiteboard “time out” for all surgical staff are conducted by the OR nurse for final preoperative confirmation of the patient identity prior to the actual surgical procedure and the surgical incision. With the patient in position and prepped, the patient is ready for the planned MISS procedure (Figs. 4a, 4b, 9a, & 9b).

Figure 6. SurgMatix® home page of the EMR system showing the three surgical stages: preoperative, intraoperative, and postoperative.

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INTRAOPERATIVE INTRAOPERATIVEPHASE PHASE A second large “Intraoperative 52-in. HD LCD monitoring screen” is located on the wall by the anesthesiologist, which is also easily viewed by all personnel during the entire surgery in the OR. It displays the patient’s vital and operation-related information on a “real-time” basis. It includes intraoperative information on vital signs, pulse oximetry, carbon dioxide partial pressure level, bispectral index (BIS), EMG waveform signal, C-arm fluoroscopic images, endoscopic images, and laser energy (applied). As mentioned previously, MISS involves the use of many advanced surgical devices, such as C-arm fluoroscope, endoscope, EMG monitoring, BIS monitoring, and laser applications that are needed for performing MISS procedures. This SECS system provides the surgical team a great deal of patient-related neurophysiological and vital monitoring information during the surgery. The new SECS system was designed to record all the data collected from all the different machines during the procedure and


Orthopaedic Surgery SURGICAL TECHNOLOGY INTERNATIONAL XIX

record it on a “real-time” and live-data basis, to facilitate the MISS, and to allow it to be performed in a much safer and more precise manner. Live “Real-Time” Inputs Collected During Surgery (Fig. 9a): ‹Digital

C-arm fluoroscopic images (also video for continuous fluoroscopy) . ‹Digital endoscopic still and video images. ‹Waveform signals: EMG, which is crucial to monitor any irritation for nerves during the procedure. ‹BIS, which measures the level of consciousness of the patient and helps to decrease the amount of anesthetic medications used by up to 40%. Bispectral Index™ monitoring system surface EEG (Aspect Medical Systems, Newton, MA). ‹Patient vitals: blood pressure, heart rate, respiratory rate, pulse oximetry, body temperature, and partial pressure of carbon dioxide. Laser machine, used for laser thermodiskoplasty to shrink the disc protrusion, to tighten and harden the annulus and to denervate pain inducing sino-vertebral nerves. The live “real-time” input on laser application includes the level of laser power, its frequency, and the total amount of laser energy utilized during laser thermodiskoplasty. In “real-time,” all intraoperative data is collected, recorded, and simultaneously viewed on a second intraoperative

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Figure 7. The neuro-navigator tool allows cross referencing for correlation of the position of the lesion with the saggital (left) and the axial view (right).

LCD screen—including live endoscopic and live fluoroscopic video with a timeline—and is easily viewed by all surgical team members. For SurgMatix® control pads (Fig. 9b), the surgeon is provided with a sterile control pad used for the control of fluoroscopic and endoscopic video recording (Fig. 9a). A second userfriendly keyboard (Fig. 9b) is available for surgical nursing staff for the SECS (SurgMatix®) system. For added patient safety, the SurgMatix® system includes a biosensor alert feature that provides a visual and auditory alert/alarm—a warning system when the vital signs and vital values significantly deviate from normal (Fig. 14).

Normal values are adjusted by the anesthesiologist for each patient according to age and general health condition. At the conclusion of the MISS procedure, the collected live “real-time” data is stored in a digital database categorized under the patients’ ID and can easily be retrieved for future viewing, reporting, study, and analysis. POSTOPERATIVE POSTOPERATIVEPHASE PHASE All the data collected during the procedure can now be used to help the surgeon create a detailed operative report,

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Figure 8. (a) The preoperative large 52-in. HD LCD monitoring screen, as seen in the OR. Left top: whiteboard information; left bottom: a synopsis of patient history; right: four MRI images with annotation of lesions, selected during preoperative phase. (b) Selected key images and annotations as they appear on the preoperative monitoring screen display.

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Evolving Minimally Invasive Spine Surgery: A Surgeon's Perspective on Technological Convergence and Digital OR Control System CHIU/MAZIAD/RAPPARD/THACKER/LIU/DOCUMET

including selected images and photos for the procedure (Fig. 10). Immediate postoperative VAS and Oswetry data can be filled out by the patient in the recovery area using a portable workstation that is wirelessly connected to the system. Key images from C-arm fluoroscopy and endoscopy along with laser, vital data, and dictated text can be obtained instantly for creating a descriptive operative report. Case Illustrations of SurgMatix® Application in MISS ‹Case

Illustration I (Fig. 11). Endoscopic MISS for large herniated L5–S1 microdecompressive discectomy facilitated with SurgMatix® and grid positional system (GPS) guidance. ‹Case Illustration II (Fig. 12). Endoscopic MISS for severe large herniated L5 microdecompressive discectomy with SurgMatix® and GPS guidance. ‹Case Illustration III (Fig. 13). Endoscopic MISS decompression for morbidly obese patient with right L2, L3, L4 neural foraminal disc herniation and stenosis, with GPS guidance and SurgMatix® system.

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b Figure 9. (a) Intraoperative 52-in. HD LCD monitor screen showing all intraoperative live data. Top row showing vitals and timeline; middle row showing EMG, endoscopic, and C-arm fluoroscopic live images; bottom row showing laser data, alerts panel, and timers. (b) Control pads for OR personnel and surgeon, respectively.

Complication and Risk Avoidance and Management The SurgMatix ® (SECS) system assists in operative and case management and averts critical and severe intraoperative complications and risks. ‹Case

Illustration IV (Fig. 14). Successful endoscopic cervical microdiskectomy on an octogenarian with intraoperative bradycardia treated with SurgMatix® monitoring. CONCLUSIONS CONCLUSION

Figure 10. Postoperative reporting tool demonstrating a second-by-second live real-time corresponding view of intraoperative data as well as C-arm fluoroscopic and endoscopic images.

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Surgery, especially evolving MISS, requires the utilization of sophisticated bio-computer technology, advanced micro-spinal instruments, fluoroscopy, tissue modulation technology, advanced endoscopy, and advanced digital technology integration and OR control. In response the SurgMatix ® system, or simply a “digital surgical technology convergence and OR control system” or an OR “Surgical EMR


Orthopaedic Surgery SURGICAL TECHNOLOGY INTERNATIONAL XIX

Control System” (SECS), was created.1–4,40–45 It provides a complete clinical picture with live “real-time” data of a surgical patient, being “patient-transparent” to facilitate and enhance MISS through technological convergence and OR control. It is a “patient-centric” system and improves the surgical patient care and safety.43–47 SurgMatix® has achieved its goals of facilitating MISS:43–47 b

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1. By providing a complete picture of the patient’s medical history and medical status at all times by consolidating data from multiple IT and OR systems—being “patient-transparent.” 2. By improving patient safety by converging preoperative, intraoperative, and postoperative data and OR control—being “patientcentric.” 3. By offering a complete live “realtime” picture of the patient’s medical status, including vital

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Figure 11. Case Illustration I: Endoscopic MISS for large herniated L5-S1 microdecompressive discectomy facilitated with SurgMatix® and GPS guidance system. A 73-year-old actively practicing neurosurgeon suffering from, rapid, progressive, severe, and intractable back and left leg pain. MRI Scan: (a) saggital T2 Lspine and (b) axial views (on preoperative monitoring screen) revealed a large partially extruded L5-S1 disc at left lateral recess. With GPS and SurgMatix® guidance, an endoscopic microdiskectomy was successfully performed, as pictured in the last row of images on the intraoperative monitoring screen; (c-e) endoscopic view, (f) symptomatic relief after trans-spinal L5-S1 microdecompressive discectomy.

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Figure 12. Case Illustration II: Endoscopic MISS microdecompressive discectomy for severe large herniated L5 disc, as shown on preoperative monitoring screen MRI (b) saggital and (c) axial views, facilitated with GPS guidance and SurgMatix®. (a) Left two photos demonstrate the patient listing to the right. (d,e) On intraoperative monitoring screen, fluoroscopic MISS views and removal of large disc fragments in the right center photos. (f) Right two photos show straightening of her spine immediately postoperatively and on first day postoperatively.

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Evolving Minimally Invasive Spine Surgery: A Surgeon's Perspective on Technological Convergence and Digital OR Control System CHIU/MAZIAD/RAPPARD/THACKER/LIU/DOCUMET

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Figure 13. Case Illustration III: Endoscopic MISS for morbidly obese 48-year-old, 450-lb patient suffering from severe intractable right L2, L3, and L4 neural foraminal disc herniation and stenosis, as shown on (a) MRI scan (saggital T2, lateral view) on preoperative monitoring screen. (b) He underwent successful lumbar endoscopic laser microdecompressive discectomy, precisely guided and facilitated with GPS and SurgMatix速 system, and GPS marking of right flank for SurgMatix速 guidance prior to surgery. He was turned down for herniated lumbar disc surgery by a university spine surgeon due to his morbid obesity before his endoscopic MISS. (c) His postoperative photo.

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Figure 14. Case illustration IV: Successful endoscopic cervical microdiskectomy on an octogenarian with intraoperative bradycardia treated with SurgMatix速 monitoring. An 81-year-old professor underwent endoscopic cervical microdecompressive discectomy, (a,b) C5-C6 per MRI images on preoperative monitoring screen with SurgMatix速 monitoring and GPS guidance. (c,d) He developed transient extreme bradycardia (30), which was detected and monitored closely on the intraoperative 52-in. HD LCD monitoring screen and treated with atropine successfully. (e) The patient did well and was discharged one hour later, as seen in photo.

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signs, waveform, and biosensor data. 4. By promoting workflow efficiency in the OR by reducing personnel and other costs. 5. By enhancing quality of patient care by increasing information to all OR staff and facilitating communication. 6. By facilitating postsurgical care and trend analysis through increased data collection during surgery. 7. Utilizing the SurgMatix®-SECS for MISS is a smart way to perform successful spine surgery, especially endoscopic MISS procedures.2–4,41–44,47 STI ACKNOWLEDGMENTS ACKNOWLEDGEMENTS The authors appreciate Professor H.K. Huang, D.Sc., F.R.C.R. (Hon.), Image Processing and Informatics Lab (IPILAB), Department of Radiology, University of Southern California, for his contribution and guidance in the development and creation of the SurgMatix® System. The support by SurgMatix®, Inc., of Wilmington, Delaware, toward this article is appreciated by the authors. REFERENCES REFERENCES 1. Chiu J. Proceedings, Surgeon's Perspective and Consideration: OR Digital Technology Convergence and Control System for Minimally Invasive Spine Surgery. Presented at Special Session, Minimally Invasive Spine Surgery, CARS 2008. Computer Assisted Radiology and Surgery 22nd International Congress and Exhibition, Barcelona, Spain, June 23-28, 2008, 8. 2. Chiu J. Digital Technology Convergence and Control System: Minimally Invasive Spine Surgeon's (MISS) Perspective and Technological Consideration, "Interdisciplinary PACS." The Second Iranian Imaging Informatics Conference Syllabus, Tehran, Iran, 2008, 30-1. 3. Chiu J. Therapeutic Application of Surgical ePR Control System Beyond Radiology PACS. Presented at the SPIE Medical Imaging Advanced PACS Based Imaging Informatics and Therapeutic Applications, Orlando, FL, February 8-12, 2009. 4. Huang HK. Utilization of medical imaging informatics and biometrics technologies in healthcare delivery. In: Image Processing and Informatics (IPI) Laboratory, University of Southern California, Annual Progress Report, February 2009, 76-88.

5. Chiu J, Savitz MH. Use of laser in minimally invasive spinal surgery and pain management. In: Kambin P (ed.), Arthroscopic and Endoscopic Spinal Surgery - Text and Atlas, 2nd edn. New Jersey: Humana Press, 2005, 259-69. 6. Chiu J. Anterior endoscopic cervical microdiskectomy. In: Kim D, Fessler R, Regan J (eds.), Endoscopic Spine Surgery and Instrumentation. New York: Thieme Medical Publisher, 2004, 48-58. 7. Chiu J. Posterolateral endoscopic thoracic discectomy. In: Kim D, Fessler R, Regan J (eds.), Endoscopic Spine Surgery and Instrumentation. New York: Thieme Medical Publisher, 2004, 125-36. 8. Chiu J, Clifford T, Princenthal R. Junctional disc herniation in post spinal fusion treated with endoscopic spine surgery. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds.), Surgical Technology International XIV. San Francisco: University Medical Press, 2005, 305-15. 9. Chiu J. Endoscopic assisted microdecompression of cervical disc and foramen. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds.), Surgical Technology International XVII. San Francisco: University Medical Press, 2008, 269-79. 10. Chiu J. Endoscopic assisted lumbar microdecompressive spinal surgery with a new smart endoscopic system. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds.), Surgical Technology International XV. San Francisco: University Medical Press, 2006, 265-75. 11. Chiu J. Cervical Endoscopic Microdecompressive Discectomy and Foraminal Decompression. Presented at the Annual Meeting of the Rome Spine Society, Rome, Italy 2009;006:265-75. 12. Savitz MH, Chiu JC, Yeung AT. History of minimalism in spinal medicine and surgery. In: Savitz MH, Chiu JC, Yeung AD (eds.), The Practice of Minimally Invasive Spinal Technique. Richmond, VA: AAMISMS Education, 2000, 1-12. 13. Huang HK. PACS, informatics, and the neurosurgery command module. J Min Invasive Spinal Tech 2001;1:62-7. 14. Huang HK. PACS and Imaging Informatics: Principles and Applications. Hoboken, NJ: John Wiley & Sons, 2004. 15. Chiu JC. The decade of evolving minimally invasive spinal surgery (MISS) and technological considerations. Internet J Min Invasive Spinal Tech 2008;1(2):11-13. 16. Liu BJ, Law YY, Documet J, Gertych A. Image-assisted knowledge discovery and decision support in radiation therapy planning. Comp Med Imaging Graphics 2007;31(45):311-21. 17. Hijikata S. Percutaneous nucleotomy: a new concept technique and 12 years' experience. Clin Orthop 1989;238:9-23. 18. Ascher PW, Choy D. Application of the laser in neurosurgery. Laser Surg Med 1986;2:91-7. 19. Kambin P, Saliffer PL. Percutaneous lumbar discectomy: reviewing 100 patients and current practice. Clin Orthop 1989;238:2434. 20. Schreiber A, Suezawa Y, Leu HJ. Does percutaneous nucleotomy with discoscopy

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replace conventional discectomy? Eight years of experience and results in treatment of herniated lumbar disc. Clin Orthop 1989;238:35-42. 21. Chiu J. Endoscopic assisted lumbar microdecompressive spinal surgery with a new smart endoscopic system. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds.), Surgical Technology International XV. San Francisco: University Medical Press, 2006, 265-75. 22. Destandau J. Endoscopically assisted microdiskectomy. In: Savitz MH, Chiu JC, Yeung AD (eds.), The Practice of Minimally Invasive Spinal Technique. Richmond, VA: AAMISMS Education, 2000, 187-92. 23. Chiu J. Evolving transforaminal endoscopic microdecompression for herniated lumbar discs and spinal stenosis: In: Szabo Z, Coburg AJ, Savalgi R, Reich H (eds.), Surgical Technology International XIII. San Francisco: University Medical Press, 2004, 276-86. 24. Chiu J. Endoscopic lumbar foraminoplasty. In: Kim D, Fessler R, Regan J (eds.), Endoscopic Spine Surgery and Instrumentation. New York: Thieme Medical Publisher, 2004, 212-29. 25. Chiu J, Clifford T, Princenthal R. The new frontier of minimally invasive spine surgery through computer assisted technology. In: Lemke HU, Vannier MN, Invamura RD (eds.), Computer Assisted Radiology and Surgery, CARS 2002. Berlin: Springer-Verlag, 2002, 233-7. 26. Chiu J, Clifford T. Microdecompressive percutaneous discectomy: spinal discectomy with new laser thermodiskoplasty for nonextruded herniated nucleus pulposus. Surgical Technology International VIII. San Francisco: University Medical Press, 1999, 343-51. 27. Chiu J, Stechison M. Percutaneous vertebral augmentation and reconstruction with an intervertebral mesh and morcellized bone graft: In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds.), Surgical Technology International XIV. San Francisco: University Medical Press, 2005, 287-96. 28. Chiu JC, Hansraj K, Akiyama C, et al. Percutaneous (endoscopic) decompressive discectomy for non-extruded cervical herniated nucleus pulposus. Surgical Technology International VI. San Francisco: University Medical Press, 1997, 405-11. 29. Kambin P, Casey K, O'Brien E, et al. Transforaminal arthroscopic decompression of lateral recess stenosis. J Neurosurg 1996;84:462-7. 30. Chiu JC, Clifford T. Multiple herniated discs at single and multiple spinal segments treated with endoscopic microdecompressive surgery. J Min Invasive Spinal Tech 2001;1:15-19. 31. Knight M, Goswami A. Endoscopic laser foraminoplasty. In: Savitz MH, Chiu JC, Yeung AD (eds.), The Practice of Minimally Invasive Spinal Technique. Richmond, VA: AAMISMS Education, 2000, 337-40. 32. Clifford T, Chiu JC, Rogers G. Neurophysiological monitoring of peripheral nerve function during endoscopic laser discectomy. J Min Invasive Spinal Tech 2001;1:54-7. 33. Chiu J. SMART Endolumbar System for Microdecompression of Degenerative Disc


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Disease. Presented at the Practical Course on Minimally Invasive Technique in Spinal Surgery, Russian Spinal Cord Society, Moscow, Russia, April 26-29, 2007. 34. Chiu J. Complications and Avoidance in Endoscopic Spine Surgery. Presented at the North American Spine Society Minimally Invasive Spine Technique: Hands-on Course, Barrow Neurological Institute (BNI), Phoenix, AZ., May 16-17, 2003. 35. Chiu J. Evolving Minimally Invasive Spinal Surgery (MISS) and Future Perspectives. Presented at the Minimal Invasive Spinal Therapy - SPINE Seminar, Session; CARS 2007, Computer Assisted Radiology and Surgery 21st International Congress, Berlin, Germany, June 27-30, 2007. 36. Chiu J. Digital Endoscopic OR Suite. In: Yoshida K (ed.), Views Radiology (Japanese), Tokyo: Medical Tribune, 2007, Vol. 9, No. 3, 20. 37. Chiu J. Interspinous Process Decompression (IPD) System (X-STOP) for the Treatment of Lumbar Spinal Stenosis. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds.), Surgical Technology International XV. San Francisco: University Medical Press, 2006, 265-75. 38. Huang HK. PACS, informatics, and the neurosurgery command module. J Min Inva-

sive Spinal Tech 2001;1(1):62-7. 39. Mogel G. Special Assistant to Director of TATRC, Fort Detrick, MD. Proceedings, The Future of Medical Informatics Technology Implementation and Digital Imaging in Spinal Surgery, 4th Global Congress on Minimally Invasive Spinal Surgery and Medicine, AAMISMS 5th Annual Meeting, Thousand Oaks, CA, November 19-22, 2003, 11. 40. Chiu J. Digital Endoscopic OR Suite. In: Yoshida K (ed.), Views Radiology (Japanese), Tokyo: Medical Tribune, 2007, Vol 9, No. 3, 20. 41. Chiu J. OR Digital Technology Convergence and Control System, Minimally Invasive Spine Surgeon's Perspective and Technological Consideration. Presented at the ISMISS Triennial Scientific Session, integrated into SICOT/SIROT 2008 - XXIV Triennial World Congress, Prince of Wales General Hospital, Chinese University of Hong Kong, August 27, 2008. 42. Chiu J. MISS: A surgeon's perspective and emerging technical considerations (abstract). Internet J Min Invasive Spinal Tech 2008 April;2(3):200. 43. Chiu J. Prototyping an IT Infrastructure in the Digital Operating Room (DOR) - Clinical and Technical Considerations. "Interdiscipli-

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nary PACS," The Second Iranian Imaging Informatics Conference Syllabus, Tehran, Iran, 2008, 28-9. 44. Chiu J. Surgical Informatics for Minimally Invasive Spinal Surgery Practice. "Interdisciplinary PACS," The Second Iranian Imaging Informatics Conference Syllabus, Tehran, Iran, 2008, 32-3. 45. Documet J, Le A, Liu BJ, et al. An imageintensive ePR for image-guided minimally invasive spine surgery applications including real-time intra-operative image acquisition, archival, and display, Proceedings of SPIE Medical Imaging 7264:72640E, 2009. 46. Chiu J. Evolving Minimally Invasive Spinal Surgery (MISS) and Future Perspectives. Presented at the Minimal Invasive Spinal Therapy - SPINE Seminar, Session; CARS 2007 Computer Assisted Radiology and Surgery 21st International Congress, Berlin, Germany, June 27-30, 2007. 47. Chiu J. Evolving Minimally Invasive Spinal Surgery (MISS): A Surgeons Perspective and Technological Considerations. Presented at the Minimal Invasive Spinal Therapy - SPINE Seminar, Session; CARS 2009 Computer Assisted Radiology and Surgery 23rd International Congress, Berlin, Germany, June 2327, 2009.


Evolving Minimally Invasive Spine Surgery: A Surgeon's Perspective on Technological Convergence and