Name: Endoscopic Trans-SAP Approach for Lumbar Spinal Decompression
Uploaded: 2026-07-31T16:38:00Z
Channel: Arthrex
Description: Marc Szadkowski, MD (Lyon, France), demonstrates an endoscopic trans-SAP approach for decompressing the lumbar spine.

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Marc Szadkowski, MD (Lyon, France), demonstrates an endoscopic trans-SAP approach for decompressing the lumbar spine.

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VID1-009597-en-US | A | Endoscopic Trans-SAP Approach for Lumbar Spinal Decompression

Marc Szadkowski

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Endoscopic Trans-SAP Approach for Lumbar Spinal Decompression

Speaker  Hello, I'm Mark Shatkovsky, I'm an orthopedic surgeon in Lyon in France. And today I want to show you a very interesting technique, especially for difficult cases, which is called the trans SAP technique. This technique is really interesting for patients, especially that have a cranial migrated disc herniation because you will have to go cranially. And it's very easy with the trans sap technique. But also if you need to do a transforaminal approach and it can be dangerous if you have a foraminal stenosis. So with this technique, you can remove the bone that is crushing the exiting nerve, and then you can go inside the canal. So this is very interesting in these two cases. So now we'll start with the landmarks. So the patient is in a prone position to know where exactly you are. Here is the cranial side. Here is the caudal side. Here is the left and here is the right. So the first thing is to draw your landmarks. And for that, we'll need the X-ray. So the first step is to draw the horizontal line of the disk you want to target. So for instance here do we do this procedure on L3 L4. Next step the vertical line the midline. And now you want to target the zone. You see this oblique line comes from the upper parts of the ipsilateral pedicle and goes to the lower part of the contralateral pedicle. The other technique, which usually I prefer, is to see exactly where my disc is. Speaker  Then with the probe, you have to see where is this the direction of the disc, and you will draw this new line and you will have the crossing of the AP view line and the lateral view line. And this is exactly where you will do the incision and where you will put your jamshidi needle. You have two possibilities of jamshidi needle. You have diamond tips like today. Or you can also have bevel tipped jamshidi needle. So what is nice with the bevel tip is that you can orientate your jamshidi needle. If you think you are sleeping on the sap, you will follow the way here on this oblique line and you will follow the line here and now you start to push and you start your lateral view. So here I feel bone. Okay, so we have to see where exactly we are. Okay, so here we are too shallow. Okay, so now we have to go ventrally. And cranially on the lateral view. You can see the sap that is here, And I want to go in the middle cranial caudal ventral dorsal. And I want to dog in the middle here. Okay. Something like that. And sometimes with the diamond tip like that you hit and you slip inside the foramen. That's why sometimes a beveled you can turn and you can go doc more on the bone. So now we are docking on the bone and. Speaker  It has to be self holding like that. And then we can do the AP view. So this particular line shows you the limit of the canal. So when you have put your jamshidi needle and after that when you will put the reamers try not to cross this line, especially on the upper levels. The more you go cranially, the more lateral the canal is, I go one millimetre further. Okay, we are stuck in the cortical bone, so it means that we are the right place. And then I will put the wire. Now, I put the wire and try to be cautious because when you remove the jamshidi. Try to have the wire inside and not lose your hole. Because if you lose wire, you have to start again all the procedure. So you put the first dilator and okay, so you see we have the wire inside, we have the dilator. And now we will create the first channel with the small size coronal reamer. So you start by turning counterclockwise in the soft tissue. And when you hit bone. Then you will start to turn clockwise. And be careful with the first because the small diameter. If the patient, especially if the patient has weak bone, poor bone quality, it can go very fast. So just start with an X-ray. Can you see it's quite easy to go quite fast. Here we start to touch the perpendicular line. So it means that you don't have to go deeper. Speaker  Now we have to remove the first reamer. And be careful of one little tip. I tell you with the trans sap approach is that with the first reamer you create a cylinder of bone. And sometimes it's a bit tricky when you remove. So let's see if it's tricky here Always keep in mind that you can lose your key wire. This is the bony cylinder you remove, and this is the shape of your first channel. And we do the same procedure with the second one. We increase the size of the channel counterclockwise. We hit the bone. And then. Clockwise. And always check on the X-ray that you don't go too far. Okay. When you reach the mid particular line you remove this reamer. Always check with the X-ray that you didn't lose your key wire. And then the last one. And you finish by putting the working channel. Then you see that the working channel is beveled like that. And you try always to avoid the exiting nerve roots by opening on the caudal side, and sometimes when it's very tight, you can hammer it. But for instance, in this case we don't have to hammer, I think. And you see that the tip of the working channel touches the mid pedicular line. So it means that we are deep enough. So now we are secured. We can remove all the dilatators and now we can put the scope inside. Another tip to clean your scope is you fill the working channel with water before going inside. Speaker  Now the first step is to clean. You see all you have this fluffy stuff here that you will have to clean. At this time, you don't move the working channel, but you have to find bone. You always know that bone is home, so you need to find the arch of the sap. Okay, so here we can see bony structure here, which is the pedicle here. And here starts the channel you have created with your reamers. And if you don't believe me, we'll push it inside the recess here. Because here you're in the canal and you can push it inside. And X-ray, please. You see, we just came across the pedicle. And here you know that you are in the recess. So now we have first landmark, the pedicle. Okay, so now that you have your first landmark, you can turn your working channel to see The bony channel you have created. Okay? And you can go a bit more cranially. You can clean the soft tissue you have in front of you. So I told you that the first step was to to see the recess and the pedicle. Now the second step is to clean the floor, which is. The disc posterior part of the disc. You see here. The sap and bony channel you have created. And here is the fat tissue surrounding the transversing nerve root. Okay. And now, next step you want to see where is the upper limit of your disc? So what you can do is drink like that X-ray pin and see we are not enough. Speaker  We are not trying enough. So you continue to go cranial. By moving your scope. You see here, this is the end plate. Okay. So with this approach you can go really through cranial. And if needed you can clean the sap. And for instance here this bone you see here is the channel I have created. And if I want to go more cranial I will use the drill. Okay. When you put a drill, you will have it just in the middle, in the center of your circle. So for instance, here it's two ventral. So what you have to do is to place your cannula a bit more. Posterior. And you will hit the bone where you want to drill. And we really can go to the tips of the sap with the drill. Let me show you on the X-ray. You see, I go more and more. Cranially. And caudally. Then you remove the soft tissue. So now you see the limit between the bone and the soft tissue. You can see now here is the beginning of the ligamentum flavum that is here and that is hiding. A bit sticking out. So you can remove it with a kerrison punch if needed for instance here. As you can see when we can, when we go deeper, you see more and more fatty tissue that that is going towards your scope which shows you that you are more you're closer and closer to the spinal canal. Speaker  On a patient with a disc herniation, you will have a huge whitish stuff here, which is the disc herniation that you can that you can see. And what this patient has no discrimination for sure. And you see, what is interesting is that we can go really cranial, but you cannot go with a classical transforaminal approach. That's why this is designed for migrated cranially disc herniations. Which you want to go inside the disc. You can push like that and go inside the disc. Okay, so here is the sap here, the ligamentum flavum. And if I push inside now you can see the transversing nerve root here. And the fact that you remove this ligament of flavum you can reach if needed, the dorsal part of the root here. So here I remove. Some remaining ligamentum flavum. And you see, as I remove ligamentum flavum. Here you have a better view on the dorsal aspect of the transversing nerve root, and you see the fat of the posterior aspect of the spinal canal. That's why we can even use this technique. If you have a recess stenosis and disc herniation that is migrated cranially. It's very effective. You can follow the nerve, the shoulder of the nerve here. And now if we want, we can go finally. Speaker  And you see you turn a little bit your working channel like that, then you can go in the axilla of the exiting nerve roots. Usually you have that in the axilla. I will show you on the X-ray how far we can go. Cranially. And let's see if it's possible to see the exiting nerve root. So your scope is like that. Okay. Neutral position. So you go cranially you turn your scope like that to synchronously with the 30 degrees angle scope. And here you see this fatty tissue. And here you start to see the nerve roots. Now you remove the fat here because this is the fat of the axilla, of the nerve of the exiting. The fat tissue, we say I'm just under the pedicle, which means that my nerve root is here. So with my working channel, you can stick on the bone like that. And that. Okay. And you turn and here. Must be the nerve. But we have to clean a bit. So here. Must be the nerve. Here. Here you can see the nerve. Here. Then. If possible, try to keep all his vein, veins and fat tissue, if possible, not to, in order to keep the vascularization of the dorsal root ganglion. But if you need to see the axilla. Because, for instance, you have foraminal discrimination, you can go and reach this region. And you see that now you can have a very nice view on. The exiting nerve root that reaches the dura here. Speaker  And here. You can follow the nerve root until the recess. There is also one thing you can I can show you is that with this approach, you can really go far to the midline. You can go under. The dura in the anterior epidural space. And you will easily reach the midline. All of the pink stuff you see above you is the dura. Okay, so you can have a vision on the ventral side of the dura if you zoom in. And if you zoom out, you can reach the posterior part of the dura. Here. So for instance, if you have a foraminal stenosis, you can have the tip of the sap that can compress the exiting nerve root. So. You see here it is bone here. And here is soft tissue. So here we are on the tip of the sap. So if you want you can easily drill the tip of the SNP a bit more. And thanks to the bone you have removed, you don't crush the exiting nerve root and you increase the size of the kambin triangle. Let's say that we have a patient with a migrated disc herniation. So now I look. I am here in a neutral position. I go more oblique Towards the cold front. And when you begin, you can't be lost. It's possible. If you're lost, just ask for an X-ray to see where you are. For instance. Here. Speaker  We'll see if we are on the end plate or more code or X-ray. We are on the end plate, so it means that we are code and if needed. We can drill this this aspect here. You see, this piece of bone is moving. It means that it's very thin. So when it's thin thinning out. You have only the soft tissue here. Now we say here you stick on the pedicle. So here is the bone of the pedicle. Here. Here is the recess. Inferior part of the recess here. So for instance, if you have a migrating disc, you can go here. You can even find pieces of migrated herniation this way. For instance. You say you can go until you can reach this level. First thing is you can remove the bone here and decompress the foraminal stenosis by removing the Ligamentum flavum. You can do a recess decompression and see the posterior part of the dura. With this approach, you can travel cranially and you can even see the axilla of the nerve. You can see the exiting nerve, you can see under the dura, and you can even reach the contralateral side. For instance, if you have a central disc herniation. And with this approach you can even go. Caudally and remove Caudally migrated disc Herniations. So this is a very powerful approach. And as you dug more shallow then the transforaminal approach, you are very far away from the exiting nerve roots. Thank you.

Endoskopischer Trans-SAP-Ansatz für die lumbale Diskektomie

Endoscopic Trans-SAP Approach for Lumbar Spinal Decompression

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