The goal of all surgery is to provide the maximum amount of clinical improvement in pain relief and function with the minimal amount of risk and collateral tissue injury. Surgical techniques all trend toward these goals. There may be some short term benefit to minimally invasive spine surgery but there are also trade-offs with regards to certain complications and long-term results. I trained in minimally invasive spine surgery (MISS) performing laparoscopic anterior interbody lumbar fusions and balloon assisted retroperitoneal lumbar dissections, MIS TLIF’s and discectomies. I am fully aware of the purported benefits. However, I am also aware of the limitations, pitfalls, complications and the long-term outcomes of even well performed MISS procedures. I have links to several clinical studies comparing the two techniques if the reader is interested. My opinion is not based upon these published studies but they do confirm my own observations.
There is nothing wrong with the concept of minimally invasive surgery. I applaud the ideal. It is the practical application of some minimally invasive spinal surgeries that I have trouble with. It is certainly a popular concept that has plenty of marketing potential. Who wouldn’t rather have a surgery that was minimally invasive when compared to any other, what, maximally invasive surgery? It is true that arthroscopic knee reconstruction is much better than open knee reconstruction and with laparoscopy, there is limited necessity to make large incisions in the abdominal wall any longer. This has led to much faster recovery times, less recovery pain and shorter hospitalization times. The benefits in spine surgery are a lot less clear cut.
Here’s the thing. If you and your surgeon are both convinced that you need to have a spinal surgery then the thing that both of you should be concentrating upon is what is method is “Maximally Effective” in relieving your symptoms and not how “Minimally Invasive” the procedure can be performed. To focus exclusively on the latter can be very short-sighted. Besides the published articles sited below I would like to provide a personal observation.
A transforaminal lumbar interbody fusion (TLIF) is a commonly performed spinal fusion operation done both minimally invasive and open. I have performed both. I abandoned the MIS TLIF because I could not achieve all the goals of the surgery as I could with the open technique. I could not provide as complete of a disc space clean out. I could not place the screws in exactly the best position or use the best sized screw with the same safety margin. I could not compress the screw/rod construct to impart the appropriate amount of rigidity to the fusion procedure as I could with open techniques. I did not observe any significant clinical benefit that could justify the limitations inherent in MISS. These short-falls persist today and likely represent the increase in cage migration seen in MISS and the requirement to use expensive biologicals to achieve a bony fusion.
In addition, I believe that any fusion procedure should restore disc height and re-align the spine to its original position relative to the other vertebra as closely as possible. The newest trend in spinal surgery is to treat every fusion as if you are treating a spinal deformity. This concept does not translate easily into slick marketing memes but I have seen the clinical benefit of this concept play out over my career and I believe that if every spine surgeon understood the benefit of this credo that society would see a sharp decrease in the number of revision spine surgery. Although these goals – complete disc clean out to make room for abundant bone graft, restoration of disc height and normal spinal alignment and controlled compression of the cage – can at times be achieved with MIS techniques I have found that in order to achieve all these stated goals of surgery in nearly every patient every time that open techniques are frequently needed. Many other spine surgeons that I know and respect are returning to open techniques for similar reasons.
One more thing about minimally invasive spinal surgery. I don’t like the cosmesis. If you stay in the midline then the incisional scar is generally thin and fades to a thin line. Incisions in the paraspinal region tend to stretch and multiple small scars just don’t look as aesthetic as a central midline scar. I swear that I have seen some patient’s backs scars who have had minimally invasive spine surgery appear like Norman Bates got to them in the shower scene of the movie “Psycho”. A clean, midline incision is very cosmetic and heals with minimal scarring.
Maximally effective surgery provides the ability to obtain all the goals of surgery with minimal variation from patient to patient, providing consistent results and outcomes for as many patients as possible. Blood loss is rarely if ever enough to require a blood transfusion and recovery and return to activities benefitted by the optimal mechanical stability provided by open surgical techniques.
Open techniques are generally hours faster than MISS which means less time under general anesthesia. The duration of general anesthesia has been shown to have a correlation with diminished mental acuity long-term. Click here to view the PDF for Postoperative Cognitive Dysfunction.
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Texas Spine Consultants Addison
Legacy Orthopedics & Sports Medicine
Texas Spine Consultants
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Addison, Texas 75001
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Legacy Orthopedics & Sports Medicine
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Plano, Texas 75024
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