Minimally Invasive Spine Surgery, Dr. John Small

Someone talk a little bit about minimally invasive spine surgery and we all hear a lot of buzz about minimally invasive spine surgery. And we see all these horror stories of patients who had huge operations and sometimes not having the greatest outcome. So what are the chances spine surgery. Steve just talked about the motion preservation biologics and biomaterials. A lot of things now we’re using that have special surfaces that actually bone grows into that can increase our chance of fusion.
So if we do fusions, we want one bone to knit to another. That’s our goal. There’s pluses and minuses for that but sometimes that’s a necessary thing. And then less or minimally invasive type surgeries we’ll talk about it in robotics.
The one thing that I think that sometimes gets missed in the minimally invasive spying world is what is your goal for surgery. And we have very specific goals for surgery and even tighter now with the insurance companies who now deny a lot of our requests for surgery because they didn’t feel quote unquote that they fit into the category or they have perfect indications. But we want to adequately decompress take the pressure off the nerves. That’s a primary reason that we do surgery.
Secondarily to stabilize the spine we want to improve sagittal balance or patient’s uprightness.
We’ve all seen patients who are bent over who can’t stand up straight. And so we we can help them in ways to improve that. And then as far as traditional spinal approaches you can look in the textbooks and you can see the types of approaches you can see it’s a pretty good incision posteriorly to do a posterior lumbar antibody fusion and a TLIF and ALF and a thoracotomy. What we want to avoid is this where you actually do a very large incision that picture on the upper left is in the thoracic cavity. That’s a diaphragm and you can see the length of that incision. Then we turn that patient over and did it about the similar length.
And you can see it’s a very invasive surgery. Now sometimes that’s necessary.
And even today in this day and age of mentally invasive type surgery it’s getting less and less but sometimes it’s necessary to accomplish your goals.
The other question is what’s the laminectomy. And I think that the laminectomy And you can see on the picture to the right that you’re removing a good portion or most of the lamana. We used to do very destabilizing laminectomy where we take out the joint which is right next door a hemilaminectomy is just on one side and that’s what we tend to operate through now. And the minimally invasive world where you open up a one area in the spine on one side you do it you need to do and then you go over to the other side and do it and frame anatomy even a smaller area opened up in the spine to maintain that integrity of the bone and also the ligaments.
This is an open laminectomy. It’s you see the stenosis on the left and you can see the bone has been removed and that’s what it looks like on a drawing. So you can see that we’ve taken away a good portion of that anatomy. And again, and a lot of situations that’s going to create some instability and create other potentially create other problems down the road I think depending upon your activity level and again what your goals are in elderly people especially you can do a very nice laminectomy very limited. You can see the joints are still intact and have a good outcome. What about fusions post your lateral fusions antibody fusions all that kind of stuff. We’ve been doing these for many years started with posterior post your lateral fusion then started with the instrumentation and then doing transfer handling antibody fusion that lower picture on the left that those two markers that’s a cage within the disc base a lot of these are pink or plastic that you can’t see him on x rays so they put markers and then the right on the right and the lower that patient at an anterior fusion and know that because that screw is the interference screw to keep it from backing out and then had it backed up with instrumentation.
So those are the basic type of fusions that we do. The purpose of the Fusion is a stabilizer correct deformity we want to stop motion at times we’re still in that then that age where we stop motion to to take away pain we’re getting heavily into the arthroplasty that that Steve just talked about maintaining motion but it’s still one of the main ways that we take away pain or help improve pain is by doing a fusion. We want to protect the nerves in the spinal cord and sometimes in the instability situation that’s very important to do that. And then also at the Inter body implants more and more were able to restore the height of the disk. Sometimes you have this bone on bone situation you can indirectly decompress the nerves and open up the frame and open up the spinal canal just by jacking that space opening and putting a cage in again another example of a very invasive type of surgery.
This is a young lady who had a grade three spondylolisthesis removed the gill body typically that’s this is all five of us. Once you take that bone away that that’s the dura the shiny area in the middle. And the nerves that are coming off. And then you we got into the disc base put in a cage and then the instrumentation post yearly. The lower right-hand corner is actually a tumor operation where the spinal cord is in the middle this is up in the thoracic area where you actually went around. You can’t see it but you can see there’s a small area right along the side where you can actually see the cage and then put a cage in the front and back to but the instruments are very these are very big open operations again with the minimally invasive is we want to try to tried to prevent some of that. This is another open deformity where you can see that patient is very sadly imbalanced meaning they’re bent forward and they’ve got scoliosis and then this is the type of correction that you can obtain with open surgery but also now we’re starting to see this amount of correction with minimally invasive type surgery.
So what is minimally invasive type surgery this is a definition I can tell you that if you asked five different people you would probably get five different answers but basically you’re trying to decrease the collateral damage to the tissue you want to live in with smaller incisions and smaller incisions that necessarily mean a a smaller operation. The saying is as a small incision with maximal damage underneath can happen. So you really have to not only look at the skin incision but examine what you’re doing underneath that all these conditions can be treated with MISS techniques. Some of them we kind of think that at least historically that they need to be big open procedures but more and more you’re seeing minimally invasive type techniques even for tumors. And this is a tumor on the lower right-hand corner.
That’s. This was a a benign tumor that was done with mentally removed as mentally invasive techniques probably about an inch incision. And so the advantages again of MIS is smaller incisions less tissue dissection theoretically less damage to the surrounding muscles potential for less blood loss quicker return to daily activity. That’s what we all want and I think in a lot of elderly people the longer they’re down the longer they’re going to be downs kind of thing and the less oftentimes the less function they’ll actually recover.
So you want to get him up get a move him to a minimally invasive type surgery and again that’s the driving thing then the marketing we see every day there’s we’re just inundated with marketing about minimally invasive all types of surgery. But in particular with spine surgery the laser spine all that kind of stuff you know. But really there really isn’t anything new. I think that if you want to find a minimally invasive spine surgeon that’s great but it may they may not be accomplishing what needs to be accomplished. You have to look out for that marketing is a great thing. What are the disadvantages inadequate treatment or decompression prolonged operative time some of these they have a very steep learning curve where if I do a lamb anatomy disc to me it takes me about 30 to 45 minutes to do that. Now I’m doing an MRI as it takes me two to three hours plus I have a neural tear you know so on and so forth. So there’s a pretty steep learning curve. So we have to take that into consideration because not every surgeon is going to be or can be a minimally invasive spine surgeon radiation exposure is huge. And I think that with my techniques there’s been a lot written on that. There’s been a lot of surgeons who have died you know with different types of cancer. There has been some association with that and radiation exposure. Is
that something we all need to take not only for the surgeon but also for the patient and really is not appropriate for every case that the case on the bottom. I just didn’t feel there is any way we can do that minimally invasive where you have to restore the balance down lower at the bottom where you don’t see the instrumentation that was cut off that patient had surgery there got infected and that again that’s just not a an operation you want to do minimally invasive.
So on the timeline the minimally invasive surgery has been ongoing since the 50s and with per cutaneous screws and all kinds of different things the latest at least in my opinion at least where it started for me kind of plastic which Steve talked about and to the retractor is to me were the things that kind of pushed us into a different era. I think of the types of surgery where we we could figure out where we can actually go into the vertebral body through the pentacle which is the round area that on the left you see that truck are going into then on the right in this situation this is a compression fracture and then with the kind of plastic insert the balloons blow up and braise the the fracture back up reduce the fracture and then put the cement in the microscopic tubular retractor were developed in the mid 90s when I was a fellow we actually wrote one of the test sites and I think again the whole idea was to reduce the amount of collateral damage that these tubes actually became very popular. Medtronic is the company who originally developed it come in different sizes different widths again depending upon what you want to accomplish. In general, the heavier the person the thicker the tissue the longer the tube the harder it is to do so. We’d like skinny people with small incision because the tubes on the left are much more easy to operate through than the tubes on the right.
Typical setup is at least for me and a microscope or I use loops but magnification is very important. There’s a series you take an x ray. Try to figure out where the incision goes and then you dilate the soft tissue. You dock right onto the inner laminar space you open up the in a laminar space and then you remove the disc and then that lower left.
That’s a plastic tube. Now one of the companies has developed and which is disposable but very effective way I think of axis in the spine.
This is the typical example disc herniation left side. You make an incision dilate the tissue put in the tube on the upper right and that’s a marker just showing that you’re at this base and this is a direct look down the tube where that’s the dura.
The nerves are in it’s more towards the midline towards the bottom or what would be in this case to the left side. But the bottom is where you actually move the nerve over and then a disc to me was performed in this bilaterally you can actually do this on both sides to do a minimally invasive fusion.
And again this is where I think a lot of traction back in the mid and later 90’s up into the early 2000 where we started doing this type of surgery instead of a big midline incision two small incisions where you can go and take out the Disc Decompression but in the cage in the stepwise diagram putting screws this was the first I would say system Medtronic sort of passing a rod where this this gadget is connected to the particle screws those tubes coming up out of the patient are connected to two screws and you can pass that has an arc and you can pass it right into the screws looking down on it that’s what it looks like looking down on it. So this is a four or five fusion two small incisions an inch maybe an inch and a half incision. So again there’s that’s where that really becomes attractive you know not only for surgeons but also patients in you know in recovery and then putting in screws and we started out putting in two possibly three screws on one side but we developed now a system where we can put in many screws go from the thoracic upper thoracic to the lumbar spine with minimally invasive techniques.
This is probably one of the biggest I think developments over the over the last several years is extreme lateral approach. When I first started in spine surgery we did not go from the side because the psoas was there so psoas muscle lays right along the spine and even more importantly the nerves the lumbar in the end the sacral plexus or within the.
So we didn’t really know where they were. Nuvasive Developed a monitoring system to be able to find the nerves with the probe and that way you know where you’re at and you don’t have to see him and you can go through this so as muscle and you can get into the disc space take out the disc put in a cage.
This is a a Idiopathic Scoliosis case where you can see a significant curvature there where the patient is on the table put on their side lateral approach you dilate use it the dilate was you look for the nerves and if it’s safe and you and the nerves are out of the way then you perform the operation you go into the disc base the lower left that said dial later and then those are the cages on the lower right from the side view in front view and this is the result of just the first step of the cage or the excuse me the case that was presented you can see significant improvement just in indirectly by putting those spacers of those cages in and then the second part turned the patient over and using this this device called Jamb Chaney needle right here actually steer that with using fluoroscopy. Now you can use robotics and you can use nav navigation to do that but you can also do it with radio with x ray. And then you pass the K wire you dilate this up tissue, and then you can stimulate you know to try to see if and there are any nerves nearby. But then you put the screws in and looks like this, and so that’s the hardest part of this operation. Steve will tell you his passing that rod when the longer it gets and the more you make an incision on top and you’re passing it underneath the skin through the muscle.
These can be technically very demanding also done a significant amount of radiation to you and the patient. And sometimes you don’t have a lot of the feel that you get with the open procedure. But again it’s common. I think this sets the definitely the wave of the future. What about robotic guidance we’ve all heard a lot about robots. I’m going to spend a lot of time but really the indication is pretty much from the top to the bottom and more and more they’re the developments and it’s getting better and I think you’ve heard a lot about robotics and Arthur plastic and other and other arenas. But I think for us it’s a little bit slower to come. But again, it’s going to be very helpful. This is one of the older systems that we started with. And this is called The mazor. It has a workstation.
You do preoperative planning and then it has a device that actually attaches to the patient so that you maintain that relationship. The thing about difference when you know doing a spine and doing a total knee for instance is that you’ve got two bones with a total knee or three but basically you’ve got pretty good control those with this you’ve got multiple bones that are moving as far as the vertebra. You have disk and if something shifts then you could easily be putting screws in places where they don’t belong. So it’s very important to do the preoperative planning and this is what the model looks like after you’ve selected the angle and the length of your screws and then you attach this to the patient. Use those k wires that actually attaches it solidly. You hope so. This system this type of system is is going away.
There are other systems now that are actually on the floor that are grounded much better than you actually take some x rays and then that merges whatever preoperative scan like a C.T. scan and this scan and that actually is what gives you your navigation ability and then you put the screws in and this thing this little robot. Remember the first time I saw that and so there’s this like is this like it you know so much beefier there much more I would say a much more developed. Now this again was the original one that’s probably about now seven eight years old and this is the result as far as when. On the right where you’re putting in the wire very similar to what I had talked about which is doing the minimally invasive techniques. These are other innovations for MIS. We are up on the left-hand corner that round thing that’s interoperative C.T. scan.
Oftentimes we have one of those and we can do a C.T. on the tables and then you’re getting real time information whether you want to whether you’ve already put in screws and rods and you want to check to make sure they’re in the right place or you want to feed that information into the computer and do the navigation techniques that we talked about. There are other expandable cages that you put them in small and you expand them which can make a big difference in in your quest for minimally invasive type techniques. The artificial dis I’m not going to really spend much time Steve did but there’s seven of them that are approved by the FDA and that list keeps growing. A lot of them have different designs and they just keep evolving and getting better and better. Probably the most recent I would say went for the spine surgery world is with Tiger Woods.
He’s just signed a 10 million dollar contract with Sentinel spine to to kind of be there. Their advocate or they’re their spokesperson. He actually had had that we all know he had issues with his back for several years and had to drop out of golf altogether. He was operated in April in 2017 at Texas back who we actually know very well and see him in a lot of meetings and but he did a minimally invasive anterior approach did not put in posterior screws and that’s pretty much the result that the implant. You can see it’s got pretty beefy screws it has a surface of treated titanium that has some in growth and that’s plastic in the middle of the peak and so it’s a very sophisticated type of implants and these implants are getting very sophisticated and very expensive. So include conclusion and my guess is here to stay.
It’s the future. Again, the techniques continue to improve. I think biologics have a lot to do with that. We use bone more for genetic protein and other things which also are very expensive to help improve our fusion rate even though we may not be as good at carpenters and things that all the principles that we learned many years ago because we aren’t doing these big open cases than biologics are going to become more and more important. And then when you look at robotics this is some numbers that I saw they were projected by 120 million spent probably this year it’s going to be about 22 billion on robotics by 2023. So again, you can see where the wave is going. You know in our quest to be better minimally invasive surgeons and that’s it.