SIGNIFICANT ADVANCEMENTS have been made in the area of orthopaedic surgery, specifically in developing minimally invasive procedures. In the past, the standard approach to the spine has been through incisions made on the back, retracting the musculature attached to the spinal bones in order to have direct access to the spine. With minimally invasive surgery, small incisions are used minimizing the damaging effects of large muscle retraction and leaving the body as naturally intact as it was prior to surgery. The benefits of this type of procedure are rapid recovery, less post-operative pain, and a more cosmetic approach to incisional scars.
What are Minimally Invasive and Microsurgery?
Minimally Invasive Surgery is a surgical procedure that is performed through several small incisions (usually less than 1 inch in diameter), or puncture sites, with the least amount of disruption to the body’s natural structure. Using an endoscope, a thin, lighted tube with an attached camera, a surgeon is able to view the problem area and operate without making a large incision. By performing the operation through a series of small incisions, the surgeon can work on the spine without disturbing normal tissue and can maintain proper body function. As a result, patients recover sooner and are less likely to develop complications. Many of these procedures can be performed as outpatient surgery allowing a more expedient return to normal activity.
Microsurgery is a type of minimally invasive surgery using an operating microscope and specially designed surgical instruments. The microscope enables surgeons to perform delicate operations through an incision as small as 1 to 1.5 inches in length. Traditionally, the same procedure for a delicate operation would require an incision from 6 to 10 inches in length.
The new advances using an endoscope or operating microscope for smaller incisions have enabled anterior (frontal) approaches to thoracic and lumbar spine surgery. Anterior exposure of the lumbar spine can be very effective in biopsy and fusion procedures. In the anterior approach, the lumbar spine may be exposed through a 2-4 inch incision in the abdomen allowing the surgeon to pass through the abdomen or shift the abdomen structure, to expose the spine. These approaches are called Transabdominal and Retroperitoneal respectively. Another less invasive procedure involves using a laparoscope (a type of endoscope) to visualize the abdomen and reposition the anatomy from in front of the spine. This requires special skills in using an endoscope and being able to visualize the exposed spine. The laparoscopic procedure usually requires 3-5 small (less than 1.5 inch) incisions in the abdomen.
Anterior fusion consists of placing bone between two or more vertebrae to promote the growth of bone between the vertebrae. In time, the vertebrae fuse together and can no longer move, relieving spine instability. Anterior fusion eliminates painful, abnormal motion that can cause nerve irritation, and provides increased function in most patients. With this type of procedure, hospitalization may not be required or may be minimized to less than 2 days compared to the standard posterior (through the back) fusion usually requiring 3-5 days. The decrease in wound size and smaller amount of disruption to the muscular structure significantly impact the retention of body function and increase recovery time, making the procedure less painful and more tolerable.
The endoscope is also used in treatment of the thoracic spine (thoracoscopy) for biopsy, bone removal, disc removal, and for placement of hardware.
Microsurgery using an operating microscope is strategic in the case of a herniated disc where the ruptured disc material (nucleus pulposus) in the spine can be responsible for pinched nerves. Through microsurgery the surgeon can remove the ruptured disc material from the spinal canal using a microscope along with special small instruments. The surgery can be performed under local anesthesia and most patients leave the hospital within an 8-12 hour period with significant reduction of pain once the disc material is removed.
With the condition of spinal stenosis resulting from degeneration and arthritis of the spine, microsurgery can remove bone or tissue that has thickened, narrowing the spinal canal and impacting nerve function. By relieving the pressure on the spinal nerves through microscopic removal of the damaging bone or tissue, severe pain, numbness, weakness, bowel and bladder problems, and in severe cases, partial paralysis can be eliminated or improved. Most patients leave the hospital within a 24 hour period and start physical therapy shortly thereafter.
New techniques in posterior spinal surgery using the endoscopic approach have led to smaller incisions making it possible to provide spine surgery as an outpatient procedure, with minimal amount of muscular disruption, and faster recovery times. Additionally, the use of minimally invasive surgery techniques have allowed conditions such as scoliosis (curvature of the spine), kyphosis (hump back), fractures, and tumors which may require major surgical procedures from two approaches: anterior and posterior to occur simultaneously. Today, surgeons can use minimally invasive surgery techniques to work on the front and back, in many cases eliminating the need for two separate surgeries. This approach has proven to be safer, to have fewer complications, to allow quicker recovery, and to be more cost effective than traditional surgical approaches.
Not all procedures are amenable to minimally invasive techniques and your orthopaedic surgeon can advise you of the most effective surgical procedure in regard to your medical condition. These new advances have provided a greater range of options for the patient in need of spinal surgery.