Minimally invasive spine surgery

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Minimally invasive spine surgery
Specialty orthopedic surgeon, neurosurgeon

Minimally invasive spine surgery, also known as MISS, has no specific meaning or definition. It implies a lack of severe surgical invasion. The older style of open-spine surgery for a relatively small disc problem used to require a 5-6 inch incision and a month in the hospital. MISS techniques utilize more modern technology, advanced imaging techniques and special medical equipment to reduce tissue trauma, bleeding, radiation exposure, infection risk, and decreased hospital stays by minimizing the size of the incision. Modern endoscopic procedures (see below) can be done through a 2 to 5 mm skin opening. By contrast, procedures done with a microscope require skin openings of approximately one inch, or more.[ citation needed ]

Contents

MISS can be used to treat a number of spinal conditions such as degenerative disc disease, disc herniation, fractures, tumors, infections, instability, and deformity. [1] It also makes spine surgery possible for patients who were previously considered too high-risk for traditional surgery due to previous medical history or the complexity of the condition.

Methods

Traditionally, spine surgery has required surgeons to create a 5-6 inch incision down the affected portion of the spine and to pull back the tissue and muscle using retractors in order to reveal the bone. The wound itself takes a long time to heal; the aim of minimally invasive surgery is reduce tissue trauma and the associated bleeding and risk of infection by minimizing the size of the incision. [2] [3]

Some minimally invasive spine surgery may be performed by a spinal neurosurgeon or an orthopedic surgeon and a trained medical team. Typically, they will begin the operation by delivering a type of anesthesia that numbs a particular part of the body in conjunction with sedation or simply give a general anesthesia that prevents pain and allows the patient to sleep throughout the surgery. [2] [3]

Next, the surgeon may begin taking continuous X-ray images in real time, a process called fluoroscopy, of the affected portion of the spine. This allows them to see what they're operating on, in real-time, throughout the surgery without creating a large incision. [3]

At this point, the surgeon may begin performing the operation, by creating an incision in the skin above the affected portion of the spine and then using a device called an obturator to push the underlying tissue apart; the obturator is inside a tube, which is left behind after the obturator is removed, leaving a channel down to the spine. Small operating tools as well as cameras and a light are used through this tube. In other surgeries this is called a trocar; in spine surgery it is called a "tubular retractor." [2] [3] [4]

The surgeon makes the necessary repairs to the spine, extracting affected disc material out through the tubular retractor and inserting medical devices, such as intervertebral spacers, rods, pedicle screws, facet screws, nucleus replacement devices, and artificial discs, through the retractor. [2] [3] [5]

Robot-assisted surgery is another technique that is used occasionally in minimally invasive spine surgery. [6]

When the procedure is done the tube is removed, and the wound is stitched, stapled, or glued shut. [2] [3]

Specific procedures

There are many spinal procedures that make use of minimally invasive techniques. They can involve cutting away tissue (discectomy), fixing adjacent vertebrae to one another (spinal fusion), and replacing bone or other tissue.The main philosophy is least bloods, tissue damage, and keep bone/tissue architecture The name of the procedure often includes the region of the spine that is operated on, including cervical spine, thoracic spine, lumbar spine. [7] These procedures include: [2] [3]

Small or ultra-small endoscopic discectomy (called Nano Endoscopic Discectomy or Endoscopic Transforaminal Lumbar Discectomy and Reconfiguration) does not have bone removal, like laminectomy or laminotomy. These procedures do not cause post-laminectomy syndrome (Failed back syndrome). [10] [11]

Risks and benefits

Risks include damage to nerves or muscles, a cerebrospinal fluid leak, and typical surgical risks, such as infection or a failure to resolve the condition that prompted the surgery. [12]

Claims are made that the larger style of MISS has better outcomes than open surgery with respect to fewer complications and shorter hospital stays, but data supporting those claims is non-conclusive. [13] [14]

History

Humans have been trying to treat spinal pain for at least 5,000 years. The first evidence of spine surgery appeared in Egyptian mummies buried in 3,000 BC. [15] However, Hippocrates is often credited with being the father of spine surgery due to the extensive amount of writing and proposed treatments he produced on the topic. [16] The first operative spine surgery is credited to Paul of Aegina who lived during the 7th century. [17]

However, only within the last 50 years have advances in digital fluoroscopy, image guidance, endoscopy and minimally invasive surgical tools allowed minimally invasive spine surgery to rise to the forefront of spinal procedures. [18] [19]

Related Research Articles

<span class="mw-page-title-main">Neurosurgery</span> Medical specialty of disorders which affect any portion of the nervous system

Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and peripheral nervous system.

<span class="mw-page-title-main">Discectomy</span> Surgical removal of an intervertebral disc

A discectomy is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an intervertebral disc, which causes pain, weakness or numbness by stressing the spinal cord or radiating nerves. The traditional open discectomy, or Love's technique, was published by Ross and Love in 1971. Advances have produced visualization improvements to traditional discectomy procedures, or endoscopic discectomy. In conjunction with the traditional discectomy or microdiscectomy, a laminotomy is often involved to permit access to the intervertebral disc. Laminotomy means a significant amount of typically normal bone is removed from the vertebra, allowing the surgeon to better see and access the area of disc herniation.

<span class="mw-page-title-main">Laminectomy</span> Surgical removal of a lamina

A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending on the problem, more conservative treatments may be viable.

<span class="mw-page-title-main">Back injury</span> Damage or wear to bones, muscles or other tissues of the back

Back injuries result from damage, wear, or trauma to the bones, muscles, or other tissues of the back. Common back injuries include sprains and strains, herniated discs, and fractured vertebrae. The lumbar spine is often the site of back pain. The area is susceptible because of its flexibility and the amount of body weight it regularly bears. It is estimated that low-back pain may affect as much as 80 to 90 percent of the general population in the United States.

<span class="mw-page-title-main">Minimally invasive procedure</span> Surgical technique that limits size of surgical incisions needed

Minimally invasive procedures encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definition is invasive and many operations requiring incisions of some size are referred to as open surgery. Incisions made during open surgery can sometimes leave large wounds that may be painful and take a long time to heal. Advancements in medical technologies have enabled the development and regular use of minimally invasive procedures. For example, endovascular aneurysm repair, a minimally invasive surgery, has become the most common method of repairing abdominal aortic aneurysms in the US as of 2003. The procedure involves much smaller incisions than the corresponding open surgery procedure of open aortic surgery.

<span class="mw-page-title-main">Degenerative disc disease</span> Medical condition

Degenerative disc disease (DDD) is a medical condition typically brought on by the normal aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with or without symptoms, but is typically identified once symptoms arise. The root cause is thought to be loss of soluble proteins within the fluid contained in the disc with resultant reduction of the oncotic pressure, which in turn causes loss of fluid volume. Normal downward forces cause the affected disc to lose height, and the distance between vertebrae is reduced. The anulus fibrosus, the tough outer layers of a disc, also weakens. This loss of height causes laxity of the longitudinal ligaments, which may allow anterior, posterior, or lateral shifting of the vertebral bodies, causing facet joint malalignment and arthritis; scoliosis; cervical hyperlordosis; thoracic hyperkyphosis; lumbar hyperlordosis; narrowing of the space available for the spinal tract within the vertebra ; or narrowing of the space through which a spinal nerve exits with resultant inflammation and impingement of a spinal nerve, causing a radiculopathy.

Ralph Bingham Cloward was an American neurosurgeon, best known for his innovations in spinal neurosurgery. Cloward is known for the development of the Posterior Lumbar Interbody Fusion and Anterior Cervical Discectomy and Fusion. Cloward moved from Chicago to Hawaii in 1938, becoming the state's lone neurosurgeon. He is well known for his work treating victims of brain injuries after the Pearl Harbour attack in 1941.

<span class="mw-page-title-main">Spinal fusion</span> Immobilization or ankylosis of two or more vertebrae by fusion of the vertebral bodies

Spinal fusion, also called spondylodesis or spondylosyndesis, is a surgery performed by orthopaedic surgeons or neurosurgeons that joins two or more vertebrae. This procedure can be performed at any level in the spine and prevents any movement between the fused vertebrae. There are many types of spinal fusion and each technique involves using bone grafting—either from the patient (autograft), donor (allograft), or artificial bone substitutes—to help the bones heal together. Additional hardware is often used to hold the bones in place while the graft fuses the two vertebrae together. The placement of hardware can be guided by fluoroscopy, navigation systems, or robotics.

Failed back syndrome or post-laminectomy syndrome is a condition characterized by chronic pain following back surgeries. Many factors can contribute to the onset or development of FBS, including residual or recurrent spinal disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness, spinal muscular deconditioning and even Cutibacterium acnes infection. An individual may be predisposed to the development of FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral blood vessels (vascular) disease.

Microsurgical lumbar laminoplasty is a minimally invasive technique for decompressing pinched nerves in the lumbar spine. Pinched or compressed nerves may result from herniated discs, lumbar spinal stenosis, or spondylolisthesis.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including posture.

<span class="mw-page-title-main">Anterior cervical discectomy and fusion</span> Surgical procedure

Anterior cervical discectomy and fusion (ACDF) is a surgical procedure to treat nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy, followed by inter-vertebral fusion to stabilize the corresponding vertebrae. This procedure is used when other non-surgical treatments have failed.

<span class="mw-page-title-main">Laminotomy</span> Surgical procedure

A laminotomy is an orthopaedic neurosurgical procedure that removes part of the lamina of a vertebral arch in order to relieve pressure in the vertebral canal. A laminotomy is less invasive than conventional vertebral column surgery techniques, such as laminectomy because it leaves more ligaments and muscles attached to the spinous process intact and it requires removing less bone from the vertebra. As a result, laminotomies typically have a faster recovery time and result in fewer postoperative complications. Nevertheless, possible risks can occur during or after the procedure like infection, hematomas, and dural tears. Laminotomies are commonly performed as treatment for lumbar spinal stenosis and herniated disks. MRI and CT scans are often used pre- and post surgery to determine if the procedure was successful.

<span class="mw-page-title-main">Laminoplasty</span>

Laminoplasty is an orthopaedic/neurosurgical surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The main purpose of this procedure is to provide relief to patients who may have symptoms of numbness, pain, or weakness in arm movement. The procedure involves cutting the lamina on both sides of the affected vertebrae and then "swinging" the freed flap of bone open thus relieving the pressure on the spinal cord. The spinous process may be removed to allow the lamina bone flap to be swung open. The bone flap is then propped open using small wedges or pieces of bone such that the enlarged spinal canal will remain in place.

The TESSYS method is a minimally-invasive, endoscopic spinal procedure for the treatment of a herniated disc. It was a further development of the YESS method by the Dutch Dr Thomas Hoogland in the Alpha Klinik in Munich in 1989 and was first called THESSYS. The procedure involves performing a small foramenotomy and removal of soft tissue compressing the nerve root.

Curtis Dickman is an American researcher, author, and retired Neurosurgeon. He is recognized internationally for his pioneering work in the fields of Spinal Surgery, Surgery of the Craniocervical Junction, Spinal Biomechanics, and Thoracoscopic Neurosurgery.

<span class="mw-page-title-main">Parviz Kambin</span> American-Iranian medical doctor and orthopaedic surgeon (1931–2020)

Parviz Kambin was an American-Iranian medical doctor and orthopaedic surgeon. He was a Professor of Orthopaedic Surgery and has established an Endowed Chair of Spinal Surgery Research at Drexel University College of Medicine. He published more than 55 articles in peer-reviewed journals, edited two textbooks and contributed chapters in spinal surgery textbooks. He lectured worldwide in the field of minimally invasive spinal surgery. His research and development in this specialty began in 1970.

Joseph Maroon is an American neurosurgeon, author, and triathlon athlete. He is the professor and vice chairman of the Department of Neurological Surgery at the University of Pittsburgh Medical Center and is the current medical director of WWE. He is particularly known for his work studying concussions and concussion prevention as well as his hypothesis on the development of chronic traumatic encephalopathy (CTE).

The Philadelphia Surgery Center is a medical facility in Narberth, Pennsylvania, that specializes in small-scale endoscopic spine surgery for the treatment of spinal stenosis and herniated or fragmented spinal discs.

Pohang Wooridul Hospital is a medical institution designated by North Gyeongsang Province, South Korea, in 2016 and the first hospital in Pohang to been certified as a medical institution by the Ministry of Health and Welfare in 2013. It specialises in spinal therapy and research.

References

  1. ↑ Kanter AS, Mummaneni PV (2008-08-01). "Minimally invasive spine surgery". Neurosurgical Focus. 25 (2): E1. doi:10.3171/FOC/2008/25/8/E1. PMC   4473410 . PMID   18673038.
  2. 1 2 3 4 5 6 "Minimally Invasive Spine Surgery". American Academy of Orthopaedic Surgeons. Retrieved 2016-12-15.
  3. 1 2 3 4 5 6 7 "Minimally Invasive Spine Surgery". American Association of Neurological Surgeons. Retrieved 14 June 2017.
  4. ↑ Kim YB, Hyun SJ (October 2007). "Clinical applications of the tubular retractor on spinal disorders". Journal of Korean Neurosurgical Society. 42 (4): 245–250. doi:10.3340/jkns.2007.42.4.245. PMC   2588212 . PMID   19096551.
  5. ↑ Oppenheimer JH, DeCastro I, McDonnell DE (September 2009). "Minimally invasive spine technology and minimally invasive spine surgery: a historical review". Neurosurgical Focus. 27 (3): E9. doi: 10.3171/2009.7.FOCUS09121 . PMID   19722824.
  6. ↑ Shweikeh F, Amadio JP, Arnell M, Barnard ZR, Kim TT, Johnson JP, Drazin D (March 2014). "Robotics and the spine: a review of current and ongoing applications". Neurosurgical Focus. 36 (3): E10. doi: 10.3171/2014.1.focus13526 . PMID   24580002.
  7. ↑ Banczerowski P, Czigléczki G, Papp Z, Veres R, Rappaport HZ, Vajda J (January 2015). "Minimally invasive spine surgery: systematic review". Neurosurgical Review. 38 (1): 11–26, discussion 26. doi:10.1007/s10143-014-0565-3. PMID   25199809. S2CID   12358669.
  8. ↑ Abbasi H, Abbasi A (October 2015). "Oblique Lateral Lumbar Interbody Fusion (OLLIF): Technical Notes and Early Results of a Single Surgeon Comparative Study". Cureus. 7 (10): e351. doi: 10.7759/cureus.351 . PMC   4652919 . PMID   26623206.
  9. ↑ Nam HG, Kim HS, Lee DK, Park CK, Lim KT (August 2019). "Percutaneous Stenoscopic Lumbar Decompression with Paramedian Approach for Foraminal/Extraforaminal Lesions". Asian Spine Journal. 13 (4): 672–681. doi:10.31616/asj.2018.0269. PMC   6680032 . PMID   30909675.
  10. ↑ Book Chapter - Decision Making in Spinal Care - Chapter 61; Copyright 2013 by Thieme
  11. ↑ "ISASS17 - Regular Poster Presentation Abstracts - Endoscopic Surgery - 455 - Nano Endoscopic Approach for Central Lumbar Disc Herniations".
  12. ↑ Ghobrial GM, Theofanis T, Darden BV, Arnold P, Fehlings MG, Harrop JS (October 2015). "Unintended durotomy in lumbar degenerative spinal surgery: a 10-year systematic review of the literature". Neurosurgical Focus. 39 (4): E8. doi: 10.3171/2015.7.FOCUS15266 . PMID   26424348.
  13. ↑ Goldstein CL, Macwan K, Sundararajan K, Rampersaud YR (March 2016). "Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review". Journal of Neurosurgery. Spine. 24 (3): 416–427. doi: 10.3171/2015.2.SPINE14973 . PMID   26565767.
  14. ↑ Quirno M, Vira S, Errico TJ (March 2016). "Current Evidence of Minimally Invasive Spine Surgery in the Treatment of Lumbar Disc Herniations". Bulletin of the Hospital for Joint Disease. 74 (1): 88–97. PMID   26977554.
  15. ↑ Perez-Cruet MJ, Balabhadra R, Samartzis D, Kim DH (2004). "Historical background of minimally invasive spine surgery". In Kim DH, Fessler RG, Regan JJ (eds.). Endoscopic spine surgery and instrumentation. New York: Thieme. pp. 3–18. ISBN   978-1588902252.
  16. ↑ Marketos SG, Skiadas P (July 1999). "Hippocrates. The father of spine surgery". Spine. 24 (13): 1381–1387. doi:10.1097/00007632-199907010-00018. PMID   10404583.
  17. ↑ Knoeller SM, Seifried C (November 2000). "Historical perspective: history of spinal surgery". Spine. 25 (21): 2838–2843. doi:10.1097/00007632-200011010-00020. PMID   11064533.
  18. ↑ Snyder LA, O'Toole J, Eichholz KM, Perez-Cruet MJ, Fessler R (2014). "The technological development of minimally invasive spine surgery". BioMed Research International. 2014: 293582. doi: 10.1155/2014/293582 . PMC   4055392 . PMID   24967347.
  19. ↑ Jaikumar S, Kim DH, Kam AC (November 2002). "History of minimally invasive spine surgery". Neurosurgery. 51 (5 Suppl): S1-14. doi:10.1097/00006123-200211002-00003. PMID   12234425. S2CID   33816323.
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