Minimally Invasive Spine Surgery

Minimally Invasive Spine Surgery Kasra Ahmadinia MD Spine Center at Eastern Oklahoma Orthopedics Center Why Minimally Invasive Surgery (MIS)? MIS Go...
Author: Alexander Ward
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Minimally Invasive Spine Surgery Kasra Ahmadinia MD Spine Center at Eastern Oklahoma Orthopedics Center

Why Minimally Invasive Surgery (MIS)? MIS Goal: Minimize the surgical assault, post-operative pain, morbidity and expedite recovery, while not compromising the surgical goals

Open Spinal Surgery • Much of the morbidity of traditional spinal procedures is related to accessing the spine – Delicate work on the spinal structures – Extensive muscle dissection and retraction with large open incision • damages the muscle’s blood and nerve supply and causes acute pain and chronic dysfunction

Why MIS? Open posterior spine surgery consequences • Muscle retraction duration corresponded with MRI muscle damage and post-op low back pain • Gejo R Spine 1999 • Intra-operative muscle retraction may cause muscle pressure to point of ischemia (permanent damage) • Styf JR Spine 1998

MIS: RULES • Should not compromise established principles to perform surgery through a small incision • Should not let thrust towards minimallyinvasive procedures, generate “fringe” technologies • Unless procedure can be done in an efficient, cost-effective fashion, with documented outcome advantages it becomes questionable

Why MIS? • Patients – – – – –

Smaller incisions Less need for blood transfusions Less post-operative use of narcotics Shorter length of hospital stay More rapid resumption of activities and employment

• Payers

– Less expensive (days in hospital strongest driver of costs) – Lower risk of infection (often leads to multiple additional surgeries and prolonged treatment)

MIS surgical skills • Different surgical skills – Visualize only a small area of anatomy, not entire spine • higher level of anatomic appreciation – Complications more difficult to treat

deal with

– Rely heavily on radiographs – Convert 1-D fluoro image into appreciation

3-D anatomic

– Rely on tactile feedback

MIS Evolution • Minimally invasive spine since 90’s • Early experience, MIS was limited by technology • Over past decades enabling technologies have been developed allowing for safe and reproducible minimally invasive spine surgery

– – – – –

Microscopes and endoscopes Specially designed retractor systems Real time imaging Real time nerve monitoring Specialized tools and implants

Minimally invasive spinal surgery • Goal is to perform established surgeries that are validated as effective in a less invasive fashion – Avoid “minimally-invasive, minimally effective” procedures

• Spinal Procedures (MIS or Open) – Decompress nerves (bone spurs/ discs) – Restore spinal alignment with deformity (scoliosis) – Prevent abnormal motion with fusion

Minimally Invasive Nerve Decompression “muscle-sparring” using tubular retractors

Minimally Invasive Decompression “muscle-sparring” using tubular retractors

• MIS discectomy or laminectomy • Usually + 1 hr • No blood loss • Home 2 hrs after surgery

Decompressiom Pre-op


SPORT STUDY • Largest NIH sponsored study on Spine Surgery • Rush participated Surgical versus nonoperative treatment for lumbar disc herniation and spinal stenosis: four-year results. Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, Herkowitz H, Hilibrand A, Albert T, Fischgrund J. • In the 4-year combined as-treated analysis, those receiving surgery demonstrated significantly greater improvement in all the primary outcome measures (95% CI): BP (45.6 vs. 30.7; 15.0; 11.8 to 18.1), PF (44.6 vs. 29.7; 14.9;12.0 to 17.8) and ODI (-38.1 vs. -24.9; -13.2; -15.6 to -10.9).

Minimally Invasive Posterior Lumbar Fusion (TLIF) • Pedicle screws-rod and cage in the disc space through 1.5 inch incision • Length of stay 1-2 days • Lower hospital costs in both WC and noncomp patients with MIS vs open TLIF (Singh K, Phillips FM. Spine 2012)

Disc Preparation

Implant Insertion

Why MIS TLIF? • Patients recover faster • Rapid, reproducible (2hrs every time) – improves my OR efficiency

– Pt size doesn’t matter, musculature not an issue – Step-by-step procedure – No wound opening and closing

• Faster discharge, less rounding

– 80% pts discharged POD 1

• Less expensive for hospital

– Lesser use of resources (OR time, LOS, blood transfusions etc,,,,) Singh, Phillips Spine 2012 – BUT, DIFFICULT INITIAL LEARNING CURVE!!!!!!!

eXtreme Lateral Interbody Fusion (XLIF) Surgical Goals Minimally-invasive, retroperitoneal trans-psoas lateral interbody fusion

Provide indirect neural decompression

Restore proper coronal and sagittal alignment

Promote fusion

Minimize soft tissue disruption

Surgical Benefits • • • • • • •

Conventional surgery through small incisions Minimal soft tissue/muscle damage Reduced post-operative morbidity Outpatient or 23 hr procedure Adequate exposure Safe and reproducible Meet or exceed traditional results


Direct Lateral Access

Position Confirmation

Trans-psoas dissection requires real time neuro-monitoring


Distraction and Sizing

Implant Insertion


68 yo male with scoliosis L2-5 XLIF, Percutaneous screws 3.5 hrs; EBL < 50cc

Where is MIS? • Minimally-invasive spine surgery is safe and reliable but requires advanced training • Data confirming benefits over open surgery is compelling (“I don’t believe in it”) • Can now do majority of cases with minimally invasive techniques (“I do minimally invasive, but you’re not the right patient”) • Can customize operation to patients pathology and expectations