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Minimally invasive spine surgery

Minimally invasive spine surgery (MISS) has been developed within the last 20 years in an effort to treat pathologies of the spine, causing only minimal tissue trauma.
In general, each minimally invasive spinal procedure originates from a traditional – “open” procedure with well-established efficacy. The aim of a MISS procedure is to achieve the same anatomical result as its open equivalent, with much less tissue trauma, and accordingly less tissue trauma – related complications.

For example, narrow spinal canal causing leg pain with walking (neurogenic claudication) can be treated by the traditional open laminectomy or by its minimally invasive equivalent technique (Figure).

There are minimally invasive alternatives for most of the spinal surgery techniques: herniated disc removal, vertebral osteosynthesis for unstable fractures, spinal fusion, narrow canal decompression, even for complex surgery as scoliosis correction.

However, there are some MISS procedures that stand alone, without an “open” alternative. Vertebral kyphoplasty (cement injection in a cavity formed by a small balloon inside the vertebral body) for traumatic or osteoporotic fractures is an example.

From a technical point of view, the aimed result of minimal trauma is achieved by the use of a tubular retractor in a way that pushes away muscle fibres instead of cutting them, for the surgical instruments to pass through (Figure, D). The use of a surgical microscope is imperative. Endoscopic spinal surgery is a variation of decompressive MISS, which uses an endoscope instead of the microscope and can be performed by even less traumatic “paths”.

Besides the fact that there are minimally invasive equivalents for practically every spinal pathology that needs surgery, the indications may vary and often the use of the traditional techniques is preferred, as being more relevant and expected to be more efficient for a specific patient’s pathology.

The main advantage of MISS is less post-operative pain and more rapid recovery. Every MISS technique that has been established in clinical practice has been proved to offer at least an equivalent clinical result comparing to its open alternative. In many cases, minimally invasive techniques have been proved to be superior to their alternatives concerning post-operative pain, hospitalization duration, blood loss during surgery and infection rates. Moreover, within some patient groups, these advantages become even more prominent: for elderly patients, obese patients and patients suffering from malignant diseases, the MISS benefits from less tissue trauma are more important.

The main disadvantage of MISS is its relatively higher cost, related to the need for special equipment (microscope / endoscope and adapted instruments which are often unique for each technique). However, it is still considered as cost-effective in most cases, as a result of the lower complication rate, shorter hospitalization and faster recovery. Another disadvantage is the relatively long surgeon’s learning curve, which still prevents MISS from being available to patients in many cases.

Finally, each patient should trust a spinal specialist, who will decide mainly if a surgical treatment is an appropriate option for his problem. Next, if surgery is necessary, follows the method’s choice, with MISS being relatively advantageous when performed by an experienced surgeon and when there is no specific reason to choose an open technique.

Triantafyllos Bouras

Figure
Schematic illustration of various conditions of a lumbar canal (a single vertebra is presented in each one of the pictures, with the patient lying in prone position, his back being on the top of each picture):

A: normal canal
B: narrow lumbar canal
C: standard “open” laminectomy with bilateral muscle dissection, and
D: unilateral minimally invasive decompression with smaller skin incision, minimal muscle dissection and less bone resection
Copyright: R. Mobbs, published in August 2014, in “Mobbs R, Li J, Sivabalan P, Raley D, Rao P. Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy.
J Neurosurg Spine 2014 Aug;21(2):179-86

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