The basic tenet of minimally invasive or least invasive spine surgery is to effectively treat patients with the most reliable technique while minimizing tissue trauma. Least invasive spine surgery has become more available over the past 10 years, paralleling the remarkable advancements in surgical visualization technologies coupled with the emergence of the internet as a patient-driven education tool. Patients are seeking smaller incision options and the surgical industry is responding.
My article — a 2.4MB PDF reprinted with permission from the Journal of The Spinal Research Foundation, Spring 2010 — offers a brief review of the evolution of spinal surgery with a focus on minimally invasive techniques. Please take a moment to read it, or continue reading below.
There has been a huge push over the past 10 years to improve our surgery outcomes by making smaller incisions. This Minimal Access Surgery is sometimes more technically demanding for the surgeons. The benefits to patients are smaller incisions, less collateral damage to the muscles and usually faster recovery times.
Outpatient Spine Surgery
Yes, you are reading correctly.
I am now performing an increasing number of our minimally invasive spinal surgeries at the Presidio Surgery Center. Years ago, the sports medicine doctors pioneered the outpatient surgery trend and I am proud to say that spine surgery is finally catching up.
As our technologies continue to improve I am certain the numbers of spine surgeries that I will perform as an outpatient will continue to grow. The key element in any surgery, especially outpatient surgery, is attention to detail. The two key elements for successful outpatient surgery are pain control and small incisions. Small incision surgery means less tissue damage and this seems to directly improve my patients’ pain levels.
I use long-lasting local anesthetics to numb up the skin and muscles during the operations and then make sure my patients have the best pain medications available to use for the short recovery time. Additionally, if the patient requests (or I feel it is in their best interest medically) we can always admit the patient the hospital overnight for observation. My patients have however been overwhelmingly positive about their outpatient surgery experiences and seem to feel more comfortable recovering in the familiar setting of their homes.
Microdiscectomy
The "Micro" has been an important part of my practice over my whole career and continues to improve with modern technology. It is one of my most successful operations because it offers patients with sciatica due to a herniated disc (pinched nerve/ slipped disc) a great chance for full recovery. The microdiscectomy is a surgery with typically a very short recovery times (2-8 weeks on average). The operation begins with a small incision surgery (usually 1-2 inches) performed without cutting any muscles. In order to remove the disc I must create a laminotomy.
Just like a dentist uses a small drill to open a tooth to treat a cavity, I make a small opening in the bone (lamina= spine bone; laminotomy= small opening) to see the disc and nerve safely. This small opening does not cause any problem to the spine itself if done properly. I use a microscope (hence the name “micro”) and remove the piece of disc material that has torn free from the main part of the disc and is compressing the nerve. Given the advances in modern spine surgery techniques, the microdiscectomy is a surgery I now perform almost exclusively as an outpatient.
Cervical Discectomy/Fusion
(ACDF: Anterior Cervical Discectomy Fusion)
When a patient injures a single (1 level) disc in their neck and surgery has been recommended, I can now perform the case as an outpatient. If a patient needs a more extensive surgery (2 or more disc levels) then I usually prefer to do those cases in the hospital.
In Patient Spine Surgery
Mini-open ALIF
As our lumbar discs are actually located in the front half of our spines we often use an anterior (through the abdomen) approach. Although this may sound like a peculiar way to reach your “back” it is actually an easier recovery for patients than a traditional posterior (through the back) surgery. I always use a vascular surgeon to guide me safely to the anterior spine as they are experienced in the important anatomy here. The key is to use a small, otherwise known as the “mini-open”, incision which decreases the trauma to the surrounding structures. The ALIF part of the surgery is the actual spine fusion: Anterior Lumbar Interbody Fusion.
