Bounce Back
Minimally Invasive Spine Surgery Speeds Recovery
By Eric Wieser, M.D.
Minimally invasive spine surgery refers to an exciting and rapidly expanding set of surgical techniques that are becoming available to spine surgeons. The goal of these procedures is to use technologies that minimize tissue trauma, reduce blood loss, lessen post-operative pain, shorten hospital stays, and achieve results that are equal to or superior to conventional techniques.
With technological advances in the equipment available to spine surgeons, the ability to perform many surgical procedures through a minimally invasive approach is becoming more viable. In this article I will discuss a few of the procedures in which minimally invasive techniques are now often used in order to enhance patient outcomes.
Techniques Gaining Popularity
Minimally invasive techniques in spine surgery originally gained popularity with the advent of percutaneous endoscopic discectomy. Using a small stab incision on the skin, an endoscopic camera can be introduced into the spinal canal in order to accurately visualize the neural structures. Another small incision allows the introduction of instruments in order to excise the herniated disc material and free the nerve within the spinal canal.
In addition to removing herniated disc material, surgeons can perform bony spinal decompression using this same approach. Although initially described using endoscopic visualization, a surgeon can perform the technique using an operating microscope and a tubular retractor system.
The use of these techniques has shown a shorter patient recovery time, lower morbidity, and better cosmetic results. The use of minimally invasive techniques has expanded to the cervical spine, in which anterior cervical discectomy and fusions are performed with a microscope and tubular retractor system. In addition, posterior cervical discectomies and foraminotomies are sometimes performed in a similar fashion.
Endoscopic Techniques
Endoscopic techniques are also used today in combination with percutaneous pedicle screw fixation in order to perform minimally invasive lumbar interbody fusions. Studies suggest that a minimally invasive approach can achieve the same goals as a standard open procedure with less tissue trauma and less blood loss, less post-operative pain, and a shorter hospital stay. The potential drawbacks of the technique include the learning curve, the initial cost of equipment, and the risks associated with percutaneous pedicle screw placement.
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Other Approaches
Transabdominal and retroperitoneal approaches for anterior lumbar interbody fusions are widely accepted and effective tools for managing painful degenerative disc disease that is unresponsive to non-operative measures. Recent advances in interbody cage technology have generated a great deal of interest in their application by minimally invasive techniques.
There are several potential advantages of using a spinal fusion system inserted through a laparoscopic technique. This approach avoids posterior incisions with the associated trauma to the paraspinal musculature. Also epidural scarring, nerve root traction injuries, and dural lacerations that are associated with posterior lumbar interbody fusions are avoided. Early trends suggest a reduced length of hospitalization and a faster return to work with fusion rates equivalent to open techniques.
Kyphoplasty
Approximately 700,000 osteoporotic compression fractures occur yearly, and nearly one-third of them become painful.
Kyphoplasty was recently introduced. A balloon catheter is inserted into the vertebral body through a percutaneous incision. The balloons are inflated and a restoration of vertebral body height is achievable. The balloons are then removed and cement is used to fill the void created. This technique provides a restoration of vertebral body height with excellent pain relief.
Not for Everyone
With the availability of minimally invasive techniques, one must bear in mind that there are situations in which a minimally invasive approach may not be feasible. There are situations in which a procedure may begin through a minimally invasive approach, but because of difficult anatomy or complications encountered, that the minimal approach is abandoned in order to safely complete the procedure. Also, the degree of pathology, the patient’s unique anatomy, and the patient’s particular body habitus may influence the surgeon’s choice of whether to use a minimally invasive approach.
Improving Results
Recent advances in the field of minimally invasive spine surgery are helping to improve patient outcomes and decrease surgical morbidity. It is clear that the future of spine surgery is moving toward minimizing the approach related trauma while treating primarily painful conditions.
Minimally invasive technology will also complement the developing technologies of computer image-guidance systems and disc replacement devices, as well as future gene manipulation therapies.