When patients experience back pain, there are multiple options available to them to make it more manageable, depending on the source of the pain. Spine surgery is one of these options, but this is often a daunting one because of the complications and lengthy recovery that are associated with it. It is also not recommended unless the patient has exhausted every non-invasive option first without experiencing any relief. In recent years, medical and technological innovations have enabled surgeons to perform minimally invasive surgeries. These options represent the best of both worlds, as they can relieve back pain permanently while also not disrupting the patient’s life in the way open surgery can.
WHAT IS MINIMALLY INVASIVE SPINE SURGERY (MISS)?
Traditionally, spine surgery was “open”, meaning the surgeon performing it would open the back with a large incision to be able to access the areas that needed to be surgically repaired. When these incisions are made, the muscles and surrounding tissues are cut in such a way that makes recovery a longer, more difficult process. Open surgery is still used for patients who do not have conditions eligible for less invasive approaches. In contrast, minimally invasive spine surgery is performed using an endoscope, which is a flexible tube with a small camera on the end of it. This camera then displays what is happening inside the body on large display screens in the operating room. The surgeon inserts the endoscope through small, half-inch incisions in the back, preventing the need for larger, more invasive incisions.
BENEFITS OF MINIMALLY INVASIVE SPINE SURGERY:
There are many benefits of minimally invasive surgery. When fewer areas of the body are disrupted, the healing process is expedited. When there is a large incision during surgery, there is an increased risk for infection, as well as more blood lost during the operation. The procedure itself is shorter than open surgery. Both of these factors lead to weakness during recovery time, delaying when you can begin a rehabilitation program. The faster you can start rehabilitating, the faster you will be back to feeling pain free and optimally healthy. In summary, the benefits of this approach include:
- Less pain, especially in recovery
- A faster recovery period
- A shorter hospital stay
- Less visible scarring, making it more aesthetically pleasing
WHO IS ELIGIBLE FOR MINIMALLY INVASIVE SPINE SURGERY?
MISS can be used to treat a variety of conditions, depending on the severity. Each patient is unique and having one of these conditions does not guarantee eligibility, but it decreases your chances of needing open surgery. Some of the conditions that can be treated with this approach include:
- Herniated discs: In spinal anatomy, there are discs between vertebrae that serve as cushions to protect the vertebrae. The inside of these discs is composed of a jelly-like material. With age, discs can degenerate and become more prone to leaking the jelly out onto other areas of the spine. When this happens, the pressure of the material on sensitive areas can cause inflammation or pinched nerves. The pain can become increasingly debilitating, leading patients to MISS as a solution.
- Spinal Stenosis: Another side effect of disc degeneration is this condition, which also impacts the facet joints. Facet joints are small joints located between adjacent vertebrae that function to stabilize the area. When the facet joints become arthritic, they grow in size, which decreases the space available for nerve roots. This increases the pressure on the nerves, and in turn creates the pain symptomatic of stenosis.
- Spondylolisthesis: There are many different types of this condition, mostly relating to the different reasons for getting it. It occurs when one vertebra slips forward on the adjacent vertebrae. It can either be passed on genetically, or as a result of physical stresses on the spine or spinal degeneration. Degenerative spondylolisthesis is one of the most common conditions that surgery is indicated for. It is more common in women, and especially common in patients with arthritis.
- Scoliosis: This is a condition where the spine is curved sideways instead of appearing in a straight line. Surgery is recommended for this condition if the curve is over 40 degrees, and is worsening. Surgery is able to correct, stabilize, and fuse the curve. It occurs most often during the growth spurt right before puberty. When children get the condition at this age, the progress of the growth of their spine is closely monitored. If the curve continues to worsen with time, surgery is an option.
- Spondylosis: This term refers to degeneration of the spine, most often in relation to osteoarthritis of the spine. Patients often report pain, associated with the deterioration of the facet joints, and the narrowing of space between vertebrae. The narrowing of space puts pressure on the surrounding nerve roots. When there are times of physical activity or long periods of inactivity, the pain worsens. Arthritis is just one of the conditions that causes this pain. Others include spinal stenosis and degenerative disc disease.
- Neck Pain: Neck pain is most often caused by muscle strain, but can also be a result of an injury or whiplash. If the condition does not improve on its own, it is likely that it is a more serious condition. Some of these include cervical degenerative disc disease, cervical herniated disc, cervical stenosis, and cervical arthritis. These conditions are similar to those of the lower back, but impact the discs and vertebrae of the neck.
- Degenerative Disc Disease: This is one of the most common causes of both neck and back pain. With age, the discs become more prone to inflammation and instability. This is a normal part of the aging process, though patients do vary in how the discs present at different ages. For those with this condition, the instability of the lower back or neck causes muscle spasms. These spasms are the body’s attempt to stabilize the area, but result in being very painful.
- Bulging Disc: These are similar to herniated discs, in that both involve the disc moving outside of its allotted space between vertebrae. While a herniated disc results when a crack in the outer layer enables some of the inner cartilage to leak out, a bulging disc simply refers to the disc looking swollen and extending out of the space. Bulging discs are very common, and are less likely to cause the pain of herniated discs, though it is possible when they put pressure on surrounding nerves.
VARIATIONS OF MINIMALLY INVASIVE SPINE SURGERY
Minimally invasive surgery can be performed in many ways, depending on the condition and symptoms. Some of the different options include:
- Endoscopic Lumbar Fusion: This minimally invasive surgery is used to treat spinal instability caused by a number of degenerative conditions including recurrent disc herniation, scoliosis, and spinal stenosis. The lower back is approached to remove all or part of a herniated disc from in-between adjacent vertebrae, followed by a fusion of vertebrae on either side of the remaining disc space using bone grafts. Bone grafts are pieces of bone, usually harvested from other parts of the patient, which are used to replace pieces of missing bone.
- Cervical Disc Surgery: This approach is used less often than the lumbar fusion because of the location on the spine (near the neck) and elevated risk level this poses to the patient. The disc is removed with the same endoscopic approach as the lower back, with the hope that the pain level will be reduced because of the decrease in pressure in the area.
- Laminectomy: This surgery’s goal is to decompress the spinal cord and relieve pressure on nerves that are inflamed or compressed. For patients who have bony overgrowths, or bone spurs, on their spines, commonly seen in arthritis patients, this surgical option can help to widen the space these overgrowths are taking. These overgrowths narrow the space available for nerves and can cause pain, weakness, or numbness. This surgical solution is effective in relieving the associated symptoms of the spinal pressure.
- Discectomy: For patients with herniated discs, this procedure removes the part of the disc that is pressing on a nerve. When performed minimally invasively, the procedure is performed endoscopically, using an endoscope to display the image of which part of the disc needs to be removed. For patients who have tried other conservative approaches with little benefit, a discectomy is a surgical option that removes the problem area.
- Kyphoplasty: When patients have compression fractures, the vertebrae lose height because they are pressed together. This surgery is designed to get the vertebrae back to their former height. During the surgery, the surgeon makes a small incision and then inserts a narrow tube. While using x-ray images, the surgeon guides a balloon through the tube into the affected vertebrae, and inflates it. When the balloon is inflated, the vertebrae are no longer compressed. Next, the balloon is removed and the doctor fills the cavity with a cement-like material, which stabilizes the bone in that position.
- Scoliosis Surgery: For scoliosis patients, the traditional approach involved making a large incision along the length of the spine. Now the surgery can be performed minimally invasively, with surgeons using small incisions that spare muscles and make recovery easier.
- Spinal Decompression: This is a general term for some of the other procedures referenced, like a discectomy or laminectomy. In decompression procedures, the surgeon removes the disc or bone material that is causing the nerve to be compressed. It is typically performed for patients with spinal stenosis, sciatica, and herniated discs.
- Plateless Cervical Technology: Discectomy and fusion surgeries involve using a bone graft combined with plates and screws. In discectomy surgeries specifically, the entire disc is removed and replaced. Though patients have good results with these surgeries in terms of stability and reduction of pain, there can be issues, especially when they involve the cervical vertebrae. The location of the esophagus and trachea can cause difficulty swallowing after the procedure. With this information in mind, plateless technology was developed to allow for cervical discectomy and fusion without the need for plates or screws. In one of the plateless approaches, surgeons place an intravertebral cage within the intravertebral space, followed by self-deploying anchors that promote stability. This technology, which our surgeons have used with great success, enables smaller incisions and reduces swallowing difficulties. Though not everyone is a candidate, we are a national leader in this procedure and can identify if your case qualifies.
These are just some of the MISS options available. Your surgeon will decide which approach is best for you after evaluating your symptoms and diagnosing your condition. The Center for Spinal Disorders has an experienced team equipped to answer any question you may have about minimally invasive surgery. To schedule an appointment to talk to one of our surgeons, please call (718) 759-6100.