Minimally invasive spine surgery

By Dr Ezriel E. Kornel, MD


The history of spine surgery

For over forty years, lumbar spine (back) surgery was destructive to structures of the spine while at the same time attempting to rectify disorders of the spine.

In order to gain entry into the spine to decompress nerves and remove herniated discs, bone spurs, thickened ligaments and cysts that compress the nerves, muscle were extensively dissected off of the vertebrae.  This caused disruption to tendons and damage and scarring to the muscles, at times extensive.

Additionally, ligaments holding the vertebrae together had to be removed, weakening the spine. Sizable portions of the vertebral bone, including portions of the joints, were removed to gain access into the spine. This can weaken the spine and expose the nerves to scar tissue that could result in further irritation and compression of nerves.  In order to stabilize the spine when necessary, these disruptive techniques were also utilized.

There are still occasions when these previously standard techniques need to be utilized.  However, over the past ten years new techniques have been developed that are far less destructive and traumatic to the tissues of the spine.

Minimally invasive spine surgery

Minimally invasive spine surgery s for less trauma and damage to muscles, tendons, ligaments and joints as well as the bones of the spine. It also allows for less damage to any other surrounding tissues.

The spine is able to be entered through incisions via tubular channels and endoscopes by a camera placed in the tube or with a high-power microscope visualizing directly through the tube. Endoscopes are thin tubular devices connected to cameras. These enable the surgeon to visualize the procedure. In addition, some surgeons may use CT or MRI data to view 3D computer models of their patient’s spine.

Furthermore, conditions that cannot always be managed with minimally invasive technique include some cases of severe degenerative facet disease with severe stenosis and scoliosis and the resection of intraspinal tumors.

The necessary incisions tend to be small. For example, one type of minimally invasive spine surgery called balloon kyphoplasty requires only two needle-size incisions. Furthermore, spinal fusion, a condition that previously required 4-6 inch incisions to be made during traditional open spine surgery, can now be treated using ½-1 inch incisions.

Muscle fibers are separated rather than cut and can resume their normal position after the instruments have been removed. This means that the patient experiences less pain and scarring following minimally invasive spine surgery.

A very limited amount of ligament and bone is resected and at times none needs to be removed. The nerves are exposed to very little scarring.

Screws, rods and clamps that require implantation to stabilize and realign the spine can now be inserted through very small incisions via what are referred to as percutaneous approaches.

Damaged discs can be removed through very small openings into the disc, at times percutaneously as well.

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  • Working through these small incisions endoscopes and microscopes can be utilized allowing excellent visualization of nerves, limiting the risk of damage. Interbody devices can then be placed into the disc spaces to maintain the disc space height through these very small openings and can then be expanded within the disc to the desired size.

    Artificial discs can be inserted to replace damaged discs via small abdominal incisions precluding any damage to the bones, muscles, tendons and ligaments of the spine.

    It is also now possible to remove a damaged disc and replace it with an interbody device through a small incision in the flank, again avoiding any significant damage to the muscles, ligaments and bone of the spine. New intraoperative x-ray imaging can allow for highly precise computer-guided placement of hardware such as pedicle screws into the spine.

    These techniques are continuously being refined and new techniques developed.

    Specialists involved in minimally invasive spine surgery

    Many specialists are involved in treating patients that require minimally invasive spinal surgery. These include:

    • Neurosurgeons
    • Orthopedic surgeons
    • Diagnostic imaging staff
    • Pain management physicians
    • Nurses
    • Physical therapists

    What spinal disorders is minimally invasive spine surgery available for?

    There are a number of spinal disorders for which minimally invasive surgery is available. These include:

    • Herniated discs
    • Degenerative spinal disease
    • Fractures
    • Tumors
    • Spondylosis
    • Scoliosis
    • Stenosis
    • Pseudoarthrosis
    • Kyphosis
    • Spinal instability
    • Osteomyelitis /discitis
    • Post-laminectomy syndrome
    • Injuries to the spinal column

    What problems cannot be treated using minimally invasive spine surgery?

    Some conditions cannot currently be treated using minimally invasive spinal surgery. This may be due to a number of reasons including the complexity of the condition and the time taken to carry out the surgical procedure.

    For example, patients with severe stenosis secondary to facet hypertrophy may not be able to be treated using minimally invasive spinal surgery as surgeons may require posterior access.

    Types of minimally invasive spine surgery

    The following procedures may be performed using minimally invasive spinal surgery:-

    • Fusion including Transforaminal Lumbar Interbody Fusion (TLIF), Posterior Lumbar Interbody Fusion (PLIF), Anterior lumbar interbody fusion (ALIF), Transforaminal lumbar interbody fusion (TLIF), Posterolateral fusion and Revision fusion
    • Discectomy
    • Foraminotomy including Posterior cervical Foraminotomy and Lamino-foraminotomy
    • Costotransversectomy
    • Spinal fusion with Bone Morphogenetic Protein
    • Anterior thoracoscopic correction
    • Vertebroplasty
    • Kyphoplasty
    • Disk electrocauterization

    Benefits of minimally invasive spine surgery

    Minimally invasive spine surgery allows for faster recovery and often patients can now go home the same day of surgery. Previously, patients had to remain in the hospital four to five days following open spine surgery.

    Blood loss is generally greatly reduced and the overall stress on the body is less pronounced. In addition, the risk of infection is lower. There are also less visible scars.

    Most importantly, with less damage to tissues of the spine the potential deleterious effects of spine surgery are minimized and the likelihood of injury to nerves both in the short term as well as long term is reduced.

    Another benefit of minimally invasive spine surgery is that it may be performed on patients that were formerly considered poor candidates for open spine surgery.

    Complications of minimally invasive spine surgery

    Minimally invasive spine surgery is technically complex and according to Kim, Siemionow et al. “a significant complication rate has been reported during a surgeon’s initial learning curve for the procedures.”

    Sources

  • https://www.uchospitals.edu/specialties/minisurgery/spine/
  • neurosurgery.ucsf.edu/.../...disorders_minimally_invasive_surgery.html
  • health.ucsd.edu/.../minimally-invasive-spine-surgery-types.aspx
  • neurosurgery.med.miami.edu/.../
  • www.cedars-sinai.edu/.../Minimally-Invasive-Spine-Surgery.aspx
  • www.medicine.virginia.edu/.../minimallyinvasive
  • https://medicine.yale.edu/neurosurgery/clinical/spine/surgeries.aspx
  • https://www.neurosurgery.pitt.edu/spine/minimal/lateral.html
  • gsm.utmck.edu/.../...rticles%20-%20Minimmally%20Invasive%20Surgery.pdf
  • https://www.ncbi.nlm.nih.gov/pubmed/21553786
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