NeuroEndospine Surgery Facts

NeuroEndospine surgery is the most minimally invasive effective form of spine surgery currently practiced.  NeuroEndospine surgery originated in the 1990’s. Modern technology has allowed the miniaturization of surgical instruments and lenses connected to high-definition cameras.   Today, surgeons have available to them energy devices safer and more advanced than lasers.   All of these modern-day tools allow images from inside the spine to be projected on the surgeon’s heads up display.  As a result, NeuroEndospine surgery has evolved into the apex of minimally invasive spine surgery.

NeuroEndospine surgery can be used to treat disc herniations.  There are 23 spinal discs.  The disc is located between the spinal vertebrae.  It serves as a cushion and stabilizes the spine.  The center of the disc is called the nucleus and can be jelly like.  It is contained by the annulus, a fibrous band attached to the vertebra.  When the annulus rips or ruptures, nucleus may pass through the rip.  This is called a disc herniation.  This causes neck pain, low back pain, sciatica and other forms of nerve pain.

NeuroEndospine surgery can be used to treat spinal joint injuries.  These joints are called facet joints.  There are two facet joints at each spinal level, located on either side of the disc.   Facet joints can be injured in accidents or can become painful with degeneration.  Facet joint injury causes neck or back pain.

NeuroEndospine surgery can be used to treat spinal stenosis.  Spinal stenosis occurs in older patients.  Repeated stress on the spine causes ligaments and joints to enlarge.  This enlargement can pinch off nerves traveling in the spine.  This causes back pain, nerve pain and pain with walking and standing.

NeuroEndospine surgery can be used to treat pain arising from the sacroiliac joints.  This is the joint between the pelvis and the sacral spine.  Sacroiliac joint pain can occur because of degeneration or injury.  Sacroiliac joint pain is more common after childbirth and spinal fusion.

NeuroEndospine surgery utilizes tiny instruments and miniaturized approaches.  This means less collateral damage to normal structures while performing surgery.   These structures are typically cut or separated in all other forms of minimally invasive spine surgery.  These structures include muscles, joints and ligaments of the spine.  Together, these structures resist abnormal forces and motion of the spine, protecting from injury while performing strenuous tasks.  

The multifidus muscle is one of the “core” muscles of the spine.  These muscles balance the body while allowing movement in any direction.  The multifidus is particularly important in that it provides great strength, especially during postures that tend to injure the back.  Unfortunately, the multifidus is often traversed in spine surgery; it is either cut or separated to allow a 22mm surgical channel into the spine.  NeuroEndospine surgery usually avoids the multifidus completely by passing through the natural nerve openings of the spine.  When the multifidus must be traversed, it is often with a channel one-third the size of standard minimally invasive surgery.

After passing through the multifidus muscle, most minimally invasive surgical approaches require drilling away of a portion of the spinal facet joint.  The facet joint is another key stabilizing structure, preventing abnormal flexion and torsion of the spine.  NeuroEndospine surgery usually avoids the facet joint altogether.  The channels used for NeuroEndospine surgery fit through the normal openings between bones of the spine, usually requiring no drilling. 

After splitting the multifidus muscle and disrupting the facet joint, most minimally invasive surgical approaches to the spine require cutting and removal of the ligamentum flavum.  The ligamentum flavum is a very special and unique ligament; it is the most elastic ligament in the spine and prevents abnormal flexion in the spine.  By using small channels that pass through natural spinal openings, NeuroEndospine surgery usually avoids the ligamentum flavum completely.  When NeuroEndospine surgery requires passage through the ligamentum flavum, it can usually be accomplished by cutting a small window of about 5mm, rather than destroying the ligament in its entirety.

NeuroEndospine surgery is the least invasive form of effective spine surgery.  Small surgical channels result in a preservation of key spinal structures.  As a result, NeuroEndospine surgery patients enjoy a very rapid recovery and return to activity. Patients can take walks and perform light exercise on the day after surgery.

Rhizotomy/radiofrequency ablation is a procedure where a doctor treats spinal joint pain by passing a needle to the pain sensing nerves of the joint and applying enough energy to burn, or coagulate, the nerve.  The coagulated nerve ceases to function and there is joint pain relief.  Unfortunately, since the nerve is not completely cut it regenerates over time and pain comes back.  In the low back, rhizotomy is effective only about 50% of the time.  In the neck the results are better; two-thirds of patients have significant pain relief at 6 months.

NeuroEndospine surgery is a permanent option to rhizotomy/ radiofrequency ablation because the joint pain sensing nerve is cut, not coagulated.  It cannot regenerate, regrow or cause pain again. Because small channels are used to perform surgery the procedure is only marginally more invasive than rhizotomy. 

NeuroEndospine surgery leverages modern technology to perform minimally invasive and minimally disruptive surgery. High-definition cameras and monitors allow crisp and sharp images to be delivered by a tiny lens implanted into the tip of a 6mm endoscope.  The result is never before seen images from the inside of the spine. 

Today’s surgeon performing NeuroEndospine surgery can utilize a high-definition and 3D capable heads up display to be immersed in surgery. Whatever the surgeon’s position, binocular images of surgery are projected millimeters from the surgeon’s eyes.  The heads up display also allows picture in picture capability, meaning that the surgeon can obtain x-ray images to guide surgery and can have the images projected onto the heads up display.   As a result, today’s NeuroEndospine surgeon has a situational awareness of the operating room rivaled only by modern fighter pilots.

State-of-the-art imaging technology has intersected with the development of modern miniaturized surgical instruments to allow NeuroEndospine surgeons to perform procedures not possible through an endoscope just a few short years ago. Chief among these is the creation of miniaturized radiofrequency (RF) probes.  The RF probe is about 2mm in diameter and utilizes high frequency low temperature radiowaves to perform delicate surgery.  Using RF probes, NeuroEndospine surgeons can dissect, cut and coagulate in the spine without endangering normal tissues.  Energy from these probes is absorbed 150X less than laser energy.  This means a NeuroEndospine surgeon can coagulate a bleeding vessel on top of a nerve, without hurting it.  As a result, laser surgery has now become passe.


After a consultation and examination, a careful review of the patient's spine MRI will either pinpoint or suggest the cause of a patient's spinal problems. Dr. Rappard reviews patient MRI scans personally. Dr. Rappard is recognized as an expert in reviewing brain and spine MRI's and has a reputation for seeing what other doctors might miss. This expertise comes from years of training and experience in image guided procedures of the brain and spine.

Precise diagnostic testing is performed to pinpoint the cause of pain. When there is more than one abnormal appearing disc, a disc injection will be performed prior to surgery to target the painful disc. A CT scan of the spine is then taken to precisely display the location of any tears within the disc. In this way, the surgical approach is designed to target the disc tears and spare the normal disc.

When spinal joints are suspected as the cause of pain, a small amount of anesthesia is injected onto the pain sensing nerves of the joint under digital x-ray guidance. The patient is then tested to see if their pain is relieved. A positive test means that a patient can undergo previously painful physical activity without pain. The anesthetic wears off in about 5 hours. Only those joints with positive testing results are targeted for surgery.

NeuroEndospine surgery has a reputation for great precision. NeuroEndospine surgeons carefully correlate a patient's MRI and diagnostic testing of discs and joints to pinpoint the cause of a patient's spinal condition. Once the cause is identified, a directed and precise surgical approach is employed to accurately treat the patient's pain while minimizing or avoiding injury to normal structures.

Fusion is a form of spine surgery where the inside of discs or joints are removed and replaced by bone.  The vertebrae and joints on either side of the fusion are fixed together by screws and rods. 

While fusion can be an effective way to treat back pain, there are significant disadvantages; fusion surgery has a prolonged recovery.  It generally takes almost a year for healing to occur and activity can be limited for quite some time.  Another disadvantage is that fusion results in a loss of motion of the fused disc space or joint. This can be a significant disadvantage for an athlete or highly active person.  Lastly, the loss of motion at the fusion site means that the spine above and below must compensate to maintain motion.  This results in increased stress and can cause disc injuries, herniations, and sciatica at other spinal levels.  This occurs in up to 20% of cases.

NeuroEndospine surgery can be a very effective treatment for back pain without resorting to fusion.  A common cause of back pain is tearing of the inside of the disc, causing a herniation.  Since NeuroEndospine surgery utilizes small surgical channels and an HD camera, the disc itself can be entered and loose disc fragments can be removed. These fragments can cause inflammation and irritation from the inside of the disc.  After removing loose disc fragments from the inside of the disc, residual inflammation is cauterized and removed by using a 2mm diameter energy probe that delivers high frequency radio waves.  This is called thermodiscoplasty.  

Pain emanating from the facet joints is a significant cause of low back pain in older patients and after accidents.   In some cases, facet pain is treated by placing a screw across the joint, fusing it.  NeuroEndospine surgery avoids fusion by removing pain sensation from the joint while maintaining a normal joint structure.  The small surgical channel is passed just to the side of the joint, where a microscopic pain sensing nerve lies.  The nerve is identified with the HD camera and the nerve is cut.  There is no other significant function of this nerve, called the medial branch, other than to sense joint pain.  Core muscle strength is maintained.  Patients can still re-injure themselves and sense pain from muscles, tendons, ligaments, bones and discs.  However, they will never sense pain in the treated facet joint again.

Pain that comes from the sacroiliac joint is being treated with fusion more and more.  Large rods are placed from the pelvis, across the joint and into the sacrum.   The surgery is effective, but the operation is moderate in size and normal pelvic motion is lost.  NeuroEndospine surgery is emerging as one of the most effective ways to treat sacroiliac joint pain.  Using small NeuroEndospine surgery channels, the lens and HD camera are used to identify the pain sensing nerves of the sacroiliac joint and they are cut.  Pelvic muscle strength is maintained and patients can still sense pain from pelvic tendons, muscles, ligaments and bones. However, they will never sense pain from the sacroiliac joint again.

Lastly, NeuroEndospine surgery can avoid fusion in another way.  Some forms of disc herniation treatment require removal of most of the spinal facet joint.  This causes instability.  As a result, fusion becomes manadatory.  By accessing the spine through natural openings and small channels, NeuroEndospine surgery can treat spinal disc problems without having to remove important spinal joints.  Therefore, fusion would not be necessary.

NeuroEndospine surgery is performed utilizing small channels.  This channel is usually 7mm in size.  The small size of NeuroEndospine surgery means that the skin incision is often as small or smaller than a pinky nail. 

Such small incisions are referred to as a “band-aid” incisions because they are small enough to fit under a band-aid.  In common use, a larger dressing is used to ensure that the wound remains clean and water resistant enough for the patient to shower the day after surgery.

A smaller wound allows a faster recovery because it is less painful and heals faster.  A smaller wound also allows showering right after surgery.

In the 1990’s NeuroEndospine surgery was developed by surgeons that already had extensive experience diagnosing and treating joint problems by placing small cameras in the body.    A small number of surgeons developed the field and slowly trained other doctors.  Over time, the procedure spread to other parts of the world.  Unlike other surgeries, the procedure was developed in private surgical practices, outside of hospitals and traditional surgical training programs.  As technology and miniaturization improved the procedure blossomed. 

Today, training of new NeuroEndospine surgeons is taking place at universities, but only a handful of them.  As a result, completion of university training in pain management, neurosurgery or orthopedic spine surgery is no guaranty that a surgeon is experienced or qualified in NeuroEndospine surgery. 

Despite demand for the procedure, there is still a dearth of well trained and experienced NeuroEndospine surgeons.  The experienced NeuroEndospine surgeon has performed hundreds of these procedures, mostly in the out-patient surgical center setting.  These surgeons have spent hundreds of hours training under masters in the field and have become masters themselves, lecturing at recognized scientific/medical conferences and training new NeuroEndospine surgeons.   

A formal certification for NeuroEndospine surgery is in progress.  Meanwhile, these surgeons can make their qualifications known to prospective patients by being transparent about their NeuroEndospine surgery case history, research and teaching experience.

  • Most common spinal conditions can be treated with NeuroEndospine surgery, including disc herniations, spinal joint pain and spinal stenosis.
  • NeuroEndospine surgery allows quick recovery and return to activity by voiding collateral injury to important spinal structures.
  • NeuroEndospine surgery is a permanent alternative to rhizotomy/radiofrequency ablation, while remaining extremely minimally invasive.
  • NeuroEndospine surgery is a state-of-the-art hi-tech procedure that leverages modern high-definition imaging and heads up technology to perform surgery with technology far more advanced than lasers.
  • NeuroEndospine surgery is highly accurate and precise, relying on meticulous planning and diagnostic testing to pinpoint the source of pain.
  • NeuroEndospine surgery is often an alternative to spinal fusion and in many cases is just as effective in treating back pain.
  • NeuroEndospine surgery utilizes the smallest incision of any effective spinal surgery.
  • Only doctors with specialized training and experience are qualified to perform NeuroEndospine surgery.



The guy really knows his stuff - after reviewing my imaging, we discussed possible procedures. I have done a lot of research online, and had a lot of questions. Dr. Rappard explained the different options, reviewed the pros and cons and offered me a really competitive price. Much better than flying to Arizona for some laser procedure!!

Jacob G.

I am 6 months removed from a couple of branch blocks and then 2 follow up neck procedures. I feel fine, everything is working perfectly. I was willing to accept that Dr. Rappard was a credible, and honest person from meeting with him, and thankfully I can confirm that he is a great doctor, that I recommend to anyone. To be honest, I thought the operating experience was surreal, and I was comfortable. There was a great team, that do their jobs very well, from the anesthesiologist, to the nurse.

Shari A

You saved me from a life of opiates and/or pain so strong that I couldn't perform adequately in my daily activities. After this Rhizotomy procedure, I walked off the table, and except for not drinking the chardonnay, ate dinner with my family. The anesthesiologist, Dr. Paul Rodrick was excellent as well.

Anonymous Patient

I was in a car accident and my lawyer set me up with Dr. Rappard. He is a real straight shooter who wants the best for his patients. He took care of me and totally fixed my back problem. I would highly recommend him.

Anonymous Patient

Dr. George Rappard was very professional and I felt he sincerely cared about my well being. I was injured in a slip and fall and my treatment lasted almost 3 years. I never felt rushed while in his office and received a high level of care. Dr. Rappard kept me appraised of my progress and my experience with his treatment was positive. He did an excellent job with my spinal cord stimulator implant and discectomy. I was very nervous but Dr. Rappard was reassuring. It takes a lot to allow someone to work in your spine, and it is scary, but I trusted Dr. Rappard and he didn't let me down. His office staff are caring, friendly, and terrific! I highly recommend him.

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