Minimally Invasive Spine Surgery

Has minimally invasive spinal surgery been recommended by your doctor? In this article, resident orthopaedic consultant Dr. Lim Heng Hing from Gleneagles Hospital Kuala Lumpur discusses all you need to know about this procedure. 

What is Minimally Invasive Spinal Surgery?

Minimally Invasive Spinal Surgery a type of surgery that achieves the surgical objective with minimal destruction of normal functioning tissue.

The trend of surgery toward minimally invasive is not new. It is an attractive concept to both patients and doctors alike. The benefits include:

1. Smaller incisions
2. Fast
3. Less painful recovery
4. Lesser tissue damage

The concept of minimally invasive spine surgery is the targeted treatment of surgical pathologies and has been widely practised for many years. Targeted treatment aims to limit the dissection of normal tissue and rectify the pathological processes.

Types of Minimally Invasive Spine Surgery (MISS)

1. Endoscopy

   This involves a fibreoptic endoscopic tube to visualise the surgical field. We can divide this type into 2 subcategories: 

   • True endoscopic procedures
     • This is a surgery through a lumen of the endoscopy like posterolateral endoscopic lumbar discectomy (PELD)
   • Endoscope-assisted spinal surgery
     • The endoscope lighting and visualisation are used to conduct surgery in the traditional surgical method. Examples of this include thoracoscopic assisted discectomy and release in scoliosis surgery.
2. Tubular retractors

These are specially designed soft tissue retraction devices to allow surgery to be conducted. This is combined with the use of a microscope to allow adequate lighting and visualization of the surgical field. For example, minimally access transforaminal Interbody fusion (MASTLIF).

Indications for MISS

Almost all spinal conditions except severe deformity correction and cancer ablation surgery are done with minimally invasive techniques. There is a wide spectrum of spinal conditions treatable by minimally invasive procedures. This includes:

• Spinal Fractures

Minimally invasive pedicle screws stabilise the fracture through multiple small holes. This reduces the amount of bleeding expected in traditional open surgery.

• Spinal Tumour and Metastases

Stabilisation and decompression by spinal fractures can be done together with intraoperative radiotherapy (IORT) through the pedicle of the spine at the time of operation. The IORT method reduces the amount of radiation that is required as the radiation is delivered within the bone.

• Disc Excision 

A variety of minimally invasive spinal procedures (PELD, unilateral biportal endoscopy (UBE), and microscopic endo tubular discectomy (MED)) can be performed on the cervical, thoracic and lumbar spine. 

• Spinal Canal and Foraminal Stenosis 

This can be enlarged by using a myriad of endoscopic tools like in the Biportal Endoscopic Spinal Surgery (BESS) method.

• Post-open Spine Surgery 

Complications like epidural fibrosis can be removed by an epiduroscopic procedure. This is not previously achievable by traditional open surgery.

Surgeries where major deformity correction and tumour excision for cure is currently not advocated for minimally invasive spinal surgery. Remember, a prerequisite for minimally invasive spine surgery is the ability to achieve optimal results equivalent to traditional open surgery.

Advantages & Disadvantages of MISS

The main advantage of MISS is the preserving the function of spinal structures along with a hastened recovery period. The disadvantage is the cost of additional equipment.

Additional Advantages:

Some procedures like PELD can be done under local anaesthesia. This is very important for the elderly and those severely sick patients with contraindication to General Anaesthesia.

Special long retractors allow for deep assessment often required of obese and muscular patients.

Disadvantages:

It is a fallacy to deny the potential of poor results and complications that can occur with minimally invasive spine surgery. This would include:

• Inadequate surgery
• Dural tears
• Neuropathic pain from radiofrequency or laser energy damage

These potential problems are lessened with the extensive use of image guidance and Intraoperative neuromonitoring.

• Nerve monitoring is an important safety feature of MISS and MASTLIF

The cost of minimally invasive spine surgery is generally higher due to the additional equipment like the video camera setup and special instruments like nerve monitoring required.

What is Expected During Recovery & Rehabilitation?

You can expect recovery to be hastened and reduced physiotherapy needs with the initial focus on postoperative pain control followed by long-term restoration of spinal column stability.

Rehabilitation, recovery, and return to work periods are generally shortened compared to traditional open spine surgery. The emphasis is on preserving normal functioning muscle and restraining ligaments rather than the size of the wound.

The application of physiotherapy post operation is individualised to the needs of the individuals and the procedures. The initial phase of physiotherapy is to provide pain control and the later phases of physiotherapy are to restore the stability and function of the spinal column through core muscle exercises.

Closing Thoughts

Minimally invasive surgery of the spine has been a beneficial trend replacing much traditional open surgery and achieving the equivalent or better patient outcome in terms of lesser intraoperative morbidity and patient recovery.

Written by

Dr Lim Heng Hing

Consultant Orthopaedic

Gleneagles Hospital Kuala Lumpur