History of endoscopic and keyhole spinal surgery

Development of endoscopic and keyhole surgery is often considered among the greatest scientific advancements in medicine alongside other scientific breakthroughs such as the discovery of antibiotics and the deciphering of DNA structure. The earliest concept of laparoscopy or endoscopy dates back to the use of instruments to visualize various body orifices as recorded in the notes of Hippocrates dating between 460 and 375 B.C. Adequate exposure of the surgical field which is key to safe surgical procedures required large incisions to identify the anatomical structures in the traditional open surgical approaches, and in an attempt to reduce the iatrogenic tissue trauma, smaller corridors were developed to utilize the technological advancements in magnification and illumination, and more recently navigation. As expected, perioperative morbidity is directly proportional to the extent of tissue trauma and surgical dissection, and the shift toward minimizing tissue dissection and prolonged retraction has been generally associated with earlier mobilization, reduced bleeding, and generally reduced morbidity in comparison to traditional open techniques. The advances in surgical technology, particularly in the light source and smaller cameras allowed the use of smaller incisions and adoption of minimal access surgery in the various surgical disciplines, laparoscopic cholecystectomy evolved as a cultural changing procedure and highlighted the focus on minimizing the surgical morbidity experienced by the patient. In spinal surgery, the evolution of surgical loupes, operating microscope, fiber optic light source, and minimal access surgical tools and retractors, allowed for improved surgical field visualization, resulting in smaller incisions and approaches. The initial adoption started with Lumbar discectomy and spinal stenosis decompression and evolved in other aspects of percutaneous fixation and minimal access fusion techniques applicable to trauma, degenerative disease, and tumors. This brief outline of the development of endoscopic and microscopic keyhole techniques in spinal surgery attempts to touch upon the major developments that paved the way for the large plethora of keyhole spinal surgical techniques currently available from the authors’ perspective.