Lumbar Spinal Fusion
Minimally invasive spine surgery (MIS) was first performed in the 1980s, but has recently seen rapid advances. Technological advances have enabled spine surgeons to expand patient selection and treat an evolving array of spinal disorders, such as degenerative disc disease, herniated disc, fractures, tumors, infections, instability, and deformity.
Minimally invasive spine surgery (MIS) was developed to treat disorders of the spine with less disruption to the muscles. This can result in quicker recovery, decrease operative blood loss, and speed patient return to normal function. In some MIS approaches, also called "keyhole surgeries," surgeons use a tiny endoscope with a camera on the end, which is inserted through a small incision in the skin. The camera provides surgeons with an inside view, enabling surgical access to the affected area of the spine.
Not all patients are appropriate candidates for MIS procedures. It is important to keep in mind that there needs to be certainty that the same or better results can be achieved through MIS techniques as with the respective open procedure.
As with all non-emergency spinal surgeries, the patient should undergo an appropriate period of conservative treatment, such as physical therapy, pain medication, or bracing, without showing improvement, before surgery is considered. The time period of this varies depending on the specific condition and procedure, but is generally six weeks to six months. The benefits of surgery should always be weighed carefully against its risks. Although a large percentage of patients report significant symptom and pain relief, there is no guarantee that surgery will help every individual.
Many MIS procedures can be performed on an outpatient basis. In some cases, the surgeon may require a hospital stay, typically less than 24 hours to 2 days, depending on the procedure.
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Thoracic spinal fusion may be indicated for the surgical treatment of a wide range of conditions, including trauma, deformity, tumor, and infection. Conventional open surgical procedures for treatment of thoracic spine disease can be associated with significant approach-related morbidity. Recent advances in technology have led to the development of posterior MIS approaches for thoracic fusion. In a posterior thoracic fusion, the surgical approach to the spine is from the back through a midline incision. Special retractors are utilized, in addition to fluoroscopy, which provides intraoperative x-ray images of the spine. Monitoring equipment is used to determine the placement of the instruments in relationship to the spinal nerves. At present, thoracic MIS techniques are primarily used for stabilizing traumatic injuries, although some surgeons may use these techniques for treatment of tumors, infections, or degenerative disc disease. These procedures typically take about 3 to 3 1/2 hours to perform, although with more complex spinal disorders, longer procedures may be necessary.
Outcome
A large study of 104 spine trauma patients who underwent MIS transmuscular pedicle screw fixation of the thoracic and lumbar spine yielded the following results. Overall, 87 percent of screws were judged to be good, 10 percent were judged to be acceptable, and 3 percent were judged to be unacceptable. Immediate surgical revision, which was always performed through MIS techniques, was necessary in nine patients for pedicle screw repositioning and in two patients for incomplete tightening of anchor bolts. In the entire patient group, two patients with an unacceptable screw position had new radicular pain that resolved completely after screw repositioning, and two patients had delayed wound healing. No patients experienced new neurological deficits.
This is a MIS technique that is performed in patients with refractory mechanical low back and radicular pain associated with spondylolisthesis, degenerative disc disease, and recurrent disc herniation. The procedure is performed from the back (posterior) with the patient on his or her stomach.
Using x-ray guidance, two 2.5-cm incisions are made on either side of the lower back. The muscles are gradually dilated and tubular retractors inserted to allow access to the affected area of the lumbar spine. The lamina is removed to allow visualization of the nerve roots. The disc material is removed from the spine and replaced with a bone graft and structural support from a cage made of bone, titanium, carbon-fiber, or a polymer, followed by rod and screw placement. The tubular retractors are removed, allowing the dilated muscles to come back together, and the incisions are closed. This procedure typically takes about 3 to 3 1/2 hours to perform.
Outcome
In a study of 31 patients who underwent the MIS PLIF surgery, there was less blood loss, tissue trauma and operative time, quick recovery and bony fusion. In two patients, the pedicle screws were not ideally positioned, but there was no nerve root irritation or fixation failure and thus no revision was required. The overall short-term outcomes were excellent.
