The trend in spine surgery has moved toward minimally invasive procedures. Minimally invasive spine surgery (MIS) involves surgical treatment of the spine through small incisions with minimal disruption of the surrounding muscle tissue.

The benefits of minimally invasive spine surgery include:

●    Small incisions and minimal scar tissue formation

●    Less damage to surrounding muscle and soft tissues

●    Decreased blood loss

●    Decreased pain and reduced need for pain medication

●    Quicker recovery and faster return to regular activities

●    Shorter hospital stays

●    Many procedures can be performed as outpatient surgery

●    Decreased risk of postoperative infection

“Open” Surgery and Minimally Invasive Surgery

Surgical procedures of the spine are often referred to as either an “open” procedure or minimally invasive.

An open procedure involves making a skin incision and retracting (moving aside) any tissues overlying the anatomy that is to be worked on so that the surgeon can directly view the desired anatomy. The surgeon will view the anatomy either with the naked eye, magnifying telescopic eyeglasses called loupes, or a magnifying microscope. Traditionally, open procedures have required larger incisions and more muscle tissue distraction than minimally invasive surgery.

Minimally invasive surgical techniques utilize specialized instruments, which allow a surgical procedure to be done through smaller incisions with much less tissue disruption. It includes

1.    Endoscopic spine surgery

2.    Tubular assisted Microscopic surgery

One of these specialized instruments is called a tubular retractor, which is a series of gradually expanding tubes that gently and progressively dilate and separate muscles and soft tissues to expose the desired anatomy. Using specialized tools, surgery is performed through the tube.

Endoscopic and Endoscopically-Assisted Spine Surgery

An endoscope is a very thin fiber-optic video camera, which can be used to see internal portions of the body. The camera sends the images to a monitor similar to a television. The endoscope is made with built-in magnification and a light source. Surgery is performed by passing instruments through the endoscope to remove disc material or bone spurs. The major advantage of the endoscope is that it allows for the procedure to be done through a very small incision with minimal tissue damage, while allowing direct visualization of the desired anatomy via the camera.

Endoscopes used for spine surgery are typically the diameter of a standard pencil (5-7mm). The endoscope is inserted into the body through a small “keyhole” incision, just large enough for the endoscope to fit through. When this technique is used, the procedure is considered to be true endoscopic surgery.

The endoscope can also be inserted through an open incision or through a tubular retractor in order to improve visualization with greater magnification of anatomic structures. This technique is called “endoscopically- assisted” surgery and is often done through slightly larger incisions (14-18mm) than true endoscopic surgery.

Laser Spine Surgery

A laser is a device that produces a form of light energy. Surgical lasers are typically used to remove (ablate) unwanted or abnormal tissue. As the affected tissues absorb the laser, light is converted to heat. As the tissue is heated, it vaporizes, a process known as ablation.

The term “Laser Spine Surgery” has become very popular on the internet and in magazine ads in recent years. The idea of having a surgeon “zap” you with a laser to cure your back pain sounds great. You may have had back pain for many years and tried many treatment options that have failed, so when an advertisement in a magazine or on the internet promotes that they can cure your pain with laser surgery, and have you back to playing golf the next day, it is tempting to want to believe it.

Many people buy into the marketing hype offered by many laser spine centers because of what I consider the “LASIK surgery effect.” There’s a good chance that you know at least one person who has gone from having terrible vision and being totally dependent on glasses or contacts to having perfect vision after having their eyes treated with a quick, outpatient laser procedure called LASIK surgery. If it works so well for the eyes, why can’t it cure back pain and sciatica too, right?

Unfortunately, it’s not that simple. The spine is a complex structure consisting of bones, discs, joints, nerves and muscles. Often, for patients with chronic back pain, it is very difficult to determine which of theses structures is the cause of pain, and in many cases, the pain is caused by multiple structures.The laser is not a “magic wand” that can reverse arthritis, heal degenerated discs, or cure all back pain. The laser is merely a tool that can be used to perform specific surgical techniques (listed below) that may (or may not) help with back and leg pain. Like any other tool, the laser has its benefits and its limitations.

Laser Spine Surgery Myths and Facts:

Myth: Laser spine surgery means that I don’t have to have an incision.

Fact: A laser is like any other surgical tool. In order for it to be used, it has to be placed into the appropriate area of the body through an incision. The laser instrument can be inserted through a very large open incision (3- inches or more), through a minimally invasive tubular retractor (14-18mm), through an endoscope (8mm), or percutaneously (3mm) with x-ray guidance, and in all of these cases the surgeon may call this “laser spine surgery.”

Myth: Laser surgery can cure spine arthritis and remove bone spurs causing stenosis.

Fact: Spinal arthritis is a condition that cannot be cured and it cannot be “lasered away”. Spinal arthritis is the wearing away of the cartilage surface that lines the facet joints, and once the cartilage wears away it will not grow back. These arthritic changes can lead to inflammation and back pain. Arthritis also causes thickening of the facet joints and ligaments and the formation of bone spurs, all of which result in stenosis (narrowing of the spinal canal) and pressure on the spinal nerves, leading to leg pain. One goal of spine surgery is not to cure the arthritis, but to remove the overgrown tissues causing the pressure on the spinal nerves. The laser that is used in spine surgery cannot cut bone. The bone spurs that cause spinal stenosis must be removed with small drills and/or cutting instruments.

When a laser is used in spine surgery it is used to perform facet joint nerve ablation in an attempt to reduce back pain from arthritic facet joints. This technique involves using the energy from the laser to vaporize (ablate) the small nerve endings that supply the facet joints, essentially disrupting the pathway the pain signals use to get to the brain. Facet joint nerve ablation can also be performed without a laser with a technique called radiofrequency nerve ablation (RFNA).

Myth: Laser surgery is always better than surgery without a laser.

Fact: Although it is advantageous to use the most minimally-invasive techniques when possible, not all spinal conditions can be safely or appropriately treated with a laser, and using a laser does not always provide advantages. Disc material can be ablated with a laser, however it is often easier and quicker to remove the disc material with other tools, which can often be placed into the disc through just as small of an incision as a laser.

As with all types of surgery, success should never be guaranteed, and there are always risks. If a surgeon is making a technique sound too good to be true, you should be cautious. Some laser spine centers have received negative press recently regarding patient outcomes.

Summary

Minimally invasive surgery is emerging as an alternative, reliable method of treatment for a variety of spinal disorders. Like “building a ship in a bottle”, there is a steep learning curve for surgeons learning to do these procedures. Although the recovery is often faster, the complication rate during surgery can be greater and the results not as predictable when the surgery is performed by surgeons who have not become totally skilled at these newer techniques. Minimally invasive surgery is certainly “the wave of the future” for many spinal procedures and will continue to develop as new, safe techniques continue to evolve. Not every patient, however, is a candidate for minimally invasive spinal surgery. To see if you are a candidate for this type of surgery contact our office for a second opinion

• Hardik Pandya undergoes ‘successful’ back surgery

  Hardik has been hampered by lower back issues since the Test series in England in 2018