Minimally Invasive Spine Surgery

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Dr. Amit Kapoor

Posted By : Dr. Amit Kapoor - DNB Orthopaedics, Clinical Hands on Fellowship at Singapore General Hospital

Posted On : Dec 16, 2012 (Views : 1177)

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The problem of back and neck pain is quite common. Studies estimate that up to ninety percent of the people will have back or neck pain at least once in their life time. There are many types of back pain with several contributing factors. It could be due to overactivity, chronic overuse, poor posture or due to pathologies like disc herniation, disc degeneration, spinal stenosis or spondylolisthesis leading to compression on the nerves. Most can be managed conservatively using medication, physical therapy and injections. And you will be surprised to know that only 5% of these are likely to require surgery. This means 95% can be managed conservatively. There is a common myth among the masses that spine surgery is dangerous and requires prolonged periods in bed. This no longer holds true in the present scenario.

Over the recent years, the Spine Surgery has emerged as a separate specialty and has undergone tremendous advancements. These developments have taken place due to synergistic improvements in the modern imaging techniques(e.g. MRI, digitalized Xrays, intraoperative imaging with C arm, intraoperative CT and navigation systems), advances in the surgical instrumentation and implant technology, improvements in the optical visualization systems(e.g. microscopes). These advancements have revolutionized the techniques of spine surgery. Conventionally the surgery of the spine is done using open techniques. The most common posterior midline approach involves a big midline incision over the back with dissection and stripping of the muscles from its spinal bony attachments and there retraction laterally. This muscle cutting and forceful retraction leads to injury to the nerve and blood supply of the muscle. This leads to atrophy and scarring of the muscle and subsequent loss of its function post surgery.

The goal of minimally invasive spine surgery, despite the type and location, is to correct the underlying spine pathology while avoiding the excessive damage to the paraspinal soft tissue envelope. The MIS(Minimally invasive surgery) technique involves minimizing muscle injury. The muscles are dilated using sequential dilators with minimal dissection. This causes little retraction force on the muscles. Furthermore the operative corridor is focused on the target site and the muscle stripping is minimized. This prevents extensive muscle damage which occurs with open approach. The surgery is performed with the help of microscope which helps magnify and illuminate the surgical field. So using MIS technique, the procedure is done with smaller incision, less tissue damage, less blood loss and early rehabilitation. The patient starts walking on the first postoperative day and can be discharged in 2-4 days. There is a word of caution. MIS procedure cannot be done in all cases. Each case is to be seen individually and then assessed about the feasibly of use of this technique. Like any other surgical procedure, it involves risk of complications like infection, dural tears, deep vein thrombosis, implant failure, nerve or vascular injury which should be discussed with the surgeon.

The various types of procedures can be done using MIS technique. To name a few, these include:

1. Microdiscectomy

2. Microlumbar decompression

3. Transforaminal Lumbar Interbody Fusion(TLIF)

4. Mini ALIF


Microdiscectomy: This is a procedure done to remove the prolapsed disc fragment that is compressing on the nerves(Sciatica). The surgery is done through a small incision using operating microscope and microsurgical techniques. The patient starts walking on the first day after surgery.

Who require this: The operation is required in those having

a) disabling pain going down the legs that is not relieved despite adequate period of conservative treatment,

b) having weakness in the legs or foot,

c) persistent numbness in lower extremities d) having problems with urination or massing motion.

Microlumbar Decompression: This is done in cases of spinal stenosis and involves the small incision and use of microscope. The thickened lamina with ligamentum flavum is removed to decompress the spinal cord and the nerve roots. This allows early recovery with walking allowed on the first day after surgery.

Who require this: The procedure is done in patients who have back pain with pain or numbness in their legs on walking. These patients can walk for only short distances at a time and start feeling pain or heaviness in their legs.

MIS-TLIF(Transforaminal Lumbar Interbody Fusion): This is a form of spinal fusion procedure done to fuse the two vertebral bodies. This is done in cases of Spondylolisthesis, degenerative disc disease or spinal stenosis with instability. Spondylolisthesis is a condition where one vertebral bone slips over the other. There is usually associated nerve root compression. The goal of surgery is decompression, achieve stability and realignment.

Who require this: The patients with spondylolisthesis can have back pain, pain in the buttocks, pain or numbness in the legs. This surgery is required in those in whom the symptoms persist despite conservative treatment; or who develop weakness in the leg or foot; or who have bladder or bowel involvement. What is done: The technique of MIS TLIF involves reaching the target area using dilators and then positioning a hollow tube. Through this tube of 26mm diameter, using specialized instruments and microscope, the decompression is done and the degenerated disc is removed and replaced with cage and bone graft. Then pedicle screws are inserted percutaneously. The whole surgery is done through two small paraspinal incisions with minimal blood loss or tissue damage. This reads to faster recovery and patient can be discharged walking by day four after surgery.

Mini ALIF(Anterior Lumbar Interbody Fusion): This is a form of surgery of the back where the spine is approached through an anterior abdominal incision. The procedure is done for painful degenerated discs. In this the painful degenerated disc is removed and a cage with bone graft is placed to achieve fusion.

XLIF/DLIF(Extreme/Direct Lateral Interbody Fusion): This is a form of spinal fusion in which spine is approached through the lateral abdominal wall. This is done for degenerative scoliosis, degenerated discs, or spondylolisthesis. The above contains general information and is not a substitute for professional medical evaluation and management. Always consult your doctor for any health problem.

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