By Jed S. Vanichkachorn, MD, MBA, MSHA
Many of my patients are beginning to ask me about minimally invasive surgery. In fact, approximately 40% of the surgeries that I perform are minimally invasive. I believe it is important to clarify exactly what MISS means and who is a candidate for this type of surgery. Minimally invasive surgery does not just mean “small incision”. MIS is a concept that uses advanced technology and innovative techniques based on a thorough understanding of the anatomy to treat back pain and neck pain caused by various spinal disorders.
Minimally invasive SPINAL surgery (MISS) is any spinal surgery that specifically attempts to minimize tissue damage caused by surgical trauma. The goal of MISS is to accomplish the same results you would get with standard open surgery with less tissue damage.
There are many benefits of minimally invasive spinal surgery, but the main benefits are:
- Less soft tissue dissection
- Maintenance of soft tissue envelope
- Less blood loss
- Maintenance of normal physiologic motion
- Limit adjacent level disease
- Quicker return to activities of daily living (i.e. work)
There is always a downside to any surgery and the downsides of MISS are:
- Technically more demanding than open procedures
- Much more technology dependent
- Limited surgical fields
- Increased surgical times
- Increased radiation exposure
- Steep learning curve – not the same for everyone
Fortunately, a variety of spinal disorders of the cervical and lumbar spine can be corrected with MISS. A few of the conditions that can be treated are:
- Herniated Discs
- Degenerative Disc Disease
- Spinal Stenosis
- Degenerative Deformity
Various techniques can be used in MISS. One of those techniques is decompression (discectomy, foraminotomy, laminectomy and laminotomy) which is used to take pressure off (to decompress) the spinal cord or nerve roots. The goal of this procedure is to relieve the pressure and reduce pain. The other technique is fusion (spinal stabilization and fixation) that is used to secure a mobile segment of the spine that may be causing pain due to the mobility.
The three main minimally invasive spine surgery techniques are:
- Tubular Access: This surgery involves a tubular retractor, which acts as a tunnel that passes through the back muscles to access the spine. MISS with a tubular retractor is a muscle sparing procedure because the retractor separates the muscle along the fibers. Compared to open spine surgery, there is less muscle damage and less blood loss when using a tubular retractor.
- Mini-open: This is similar to an open procedure, but has fewer risks, such as less blood loss during surgery and less risk of infection because the incision is much smaller. Visualization is also improved with intra-operative imaging (x-rays) called fluoroscopy that helps guide the surgeon during the procedure.
- Endoscopic: This spine surgery uses a tiny video camera called an endoscope that guides the surgeon by giving them an internal view of the spine on screens throughout the operating room. The American Association of Neurological Surgeons states this procedure is commonly referred to as a “keyhole surgery”. I will be attending training on this procedure very soon and hope to utilize this technique in 2014.
The ideal patient for MISS has moderate joint disease, single level fusion, L3-4 or L4-5, normal BMI, grade I spondylolisthesis, no secondary gains, normal psych profile and is a non-smoker.