HOW DOES MINIMALLY INVASIVE SPINE SURGERY WORK?
Over a million people each year will hear the dreaded words: “spine surgery” from their doctor. For many, the prospect of having a surgeon operate on one of the most essential parts of your body is terrifying and can feel somewhat ambiguous.
Though spine surgery has evolved and improved dramatically over the last several decades, it doesn’t make the idea of it any less scary.
For many, the next natural step is to try and understand what spine surgery even means. Where do you begin? What is the surgery actually like? What is happening to you during the surgery?
These are the right questions to ask, but information online can so often be vague, misleading, or focused on trying to sell you a surgery – which is far from helpful. In this piece, we will walk you through minimally invasive spine surgery and try to cast some objective light on a procedure that doesn’t always feed straightforward.
Taking the time to educate yourself on minimally invasive spine surgery will help you not only be better equipped to talk with your doctor but also to advocate for your own health.
So, let’s start at the beginning…
“MEET SALLY
Sally, our fictitious example patient, is in her mid-fifties and begins to find that she cannot ignore her persistent back pain.
She maintains an active lifestyle, has no family history of spinal trouble, and has not experienced any injuries that would explain her pain. However, her pain is constant and keeps her from doing the daily activities that she enjoys.
Sally starts where many people start when dealing with back pain: the Internet.
She tries the quick at-home remedies recommended online, the weighted neck pillows, widely available pain creams, anti-inflammatory foods, and more, but none are able to put a meaningful dent in her pain. Like something stuck between her teeth, the spinal pain reminds Sally it’s there throughout each day.
The constant pain continues and determines that she should consult a spinal professional.”
WHAT IS MINIMALLY INVASIVE SPINE SURGERY?
MISS is not a single procedure, but rather an overall approach to spinal surgery that aims to reduce the amount of incisions and overall intrusion into the body performed by a surgeon during the course of an operation.
“Minimally invasive” describes a broad medical philosophy that includes operations across numerous medical disciplines. Though minimally invasive procedures have blossomed with the advent of 21st century technologies, the minimally invasive approach in medicine dates back to at least the 19th century. The key discoveries in minimally invasive spine procedures, however, emerged a century later.
GUIDING PHILOSOPHY:
Every surgery, even those done with expert precision and no complications, necessarily involves trauma to the body. For surgery to happen, a doctor must make incisions, probe those incisions to access the site of the surgery, and potentially move internal organs around from their natural resting places to complete the operation. Surgery heals, but it also disturbs.
Therefore, the guiding philosophy behind minimally invasive spine surgery hinges on a basic premise: treat the physical issue in the body with as little damage to surrounding muscles and tissues as possible.
Traditionally, spine surgeons used what is called an “open” or “traditional” approach to operating on the spine.
In open spine surgery, the surgeon will need to make a 5-6 inch incision through the skin of the back and physically move the muscles to the side in order to properly see and operate on the spine.
As time progressed, however, surgeons realized that this traditional technique uses more anatomy than is actually required and can have some serious drawbacks. One of the biggest issues is that the pulling back, or retraction, of the muscles can damage the soft tissue and lead to longer recovery times for patients.
Spinal surgeons have made considerable headway in the latter half of the 20th century in making the minimally invasive philosophy a familiar practice. Although some more advanced MISS techniques require more data to ensure their long-term sustainability, the general consensus now is that many of the most common types of spinal surgery can be handled through minimally invasive applications.
This can include conditions like:
Spinal deformities
Spinal instability
Spondylolysis
Removal of a tumor in the spine
Infection in the spine
Minimally invasive spine surgery has gained wider acceptance over the years because, primarily, it reduces surgical disturbance, meaning that there are fewer incisions and more precise surgical movements, which subsequently means briefer recovery time for patients. MISS claims other benefits, too: shorter hospital stays, lowered rates of post-operative infections, higher degrees of surgical precision, and less bleeding during the procedure.
Most important for patients like Sally, though, is the reduced amount of pain after the surgery. With the spine serving as an integral part of the body’s nervous system, pain reduction is an especially important area of emphasis for spinal surgeons.
“SALLY’S CONSULTATION
Sally schedules a consultation with a spine doctor to try and determine what’s going on.
In this consultation, she’ll be asked about her family history, when the pain started, what the pain feels like, if she’s able to pinpoint the location of the pain and similar questions. These questions help her doctor make some assumptions about what’s going on inside of her back.
From there, Sally’s doctor orders a scan of her spine, likely an X-ray or an MRI, which will allow them to identify any structural reasons why there might be consistent pain in the spine.
Sally’s results show that her pain stems from a collapsed disc, a condition caused by a weakening of the outer layer of the spinal disc (called the annulus fibrosis) that results in the disc no longer being able to serve its cushioning function between the vertebrae.
After reviewing the scans, Sally’s doctor recommends surgery as the best course of action to address the failed disc.”
WHAT HAPPENS IN MINIMALLY INVASIVE SPINE SURGERY?
The primary emphasis of a neurosurgeon employing a MISS approach will be to utilize small incisions to access the affected area of the spine. The incisions in MISS procedures are quite small, as tiny as four to five centimeters, compared to open spinal surgery’s five inches to over half a foot.
A typical surgery will begin with an anesthesiologist administering anesthesia. The anesthesia will be either regional (you’ll be somewhat awake but numb from the waist down) or general (you’ll be totally asleep). The type of anesthesia depends on multiple factors, including:
The specific spinal condition being corrected by minimally invasive spine surgery
The part of the spine needing surgery
How extensive the spinal disease is
How extensive the surgery needs to be
Where the surgeon needs to make the incisions (Sometimes, incisions must be made through the throat, chest or abdomen to reach the diseased spine instead of in the back.)
Other medical conditions you have
After anesthesia, the operation will begin. Typically the surgeon will begin by making an incision over the operating site. With the incisions achieved, the surgeon then has a few possible options for surgical devices.
One camera known to medical practitioners of all persuasions also serves a useful role for MISS: the endoscope. In an endoscopic spinal surgery, the spinal specialist makes very small incisions at the site of the affected area, and guides in the endoscope – which, like a laparoscope, sits at the end of a long skinny tube that can be guided inside the human body – to identify the surgical site and perform the procedure.
Where in an endoscopic surgery it is the surgeons alone operating the camera and the tools needed for the procedure, in robotic spine surgery, surgeons utilize hyper-precise robotic tools to guide their instruments in the course of a procedure. “Guide” is the key word there; the surgery being “robotic” does not mean a robot performs the surgery itself, but rather the surgeon has additional robotic tools at her disposal to ensure more accurate deployment of the surgical plan. The robotic implements come into play following a three-dimensional blueprint of the patient’s spinal CT scan, which is then utilized once the robotic tools are mounted for the procedure. Robotic spinal surgery proves especially helpful when the surgeon needs to place screws in the spine; one study found that in contrast to 92 screw placement percent accuracy when performed by traditional surgery, robotic MISS results in 98 percent accuracy.
“SALLY’S SURGERY
The day of Sally’s surgery arrives and she is taken to the outpatient wing of a hospital in her insurance network. Once she arrives everything begins to happen in an orderly whirl.
She meets the nurses and doctor performing the surgery and is able to ask any last-minute questions that she has before going into surgery.
Soon enough, she’s in the operating room, and the general anesthesia begins to kick in. Depending on the circumstances of a given patient, the anesthesia could be either general, meaning the patient is completely sedated, or regional, in which the patient is partially awake but numb from the site down.
The next time she wakes up, her journey to spinal healing will have already begun.
Once asleep, Sally’s neurosurgeon begins the work of performing the minimally invasive spine surgery.
He makes a small incision over the affected area of her spine and inserts what is known as an endoscope, a tool that allows him to see where he is working. This ensures that the surgery affects as little of the rest of the body as possible.
During the operation, the surgeon will excise the failed disc and pull it out piece by piece. He will then prepare the surrounding vertebrae to be able to accept an artificial disc.
Finally, he will insert the new disc, assess that it fits the intervertebral space well, and then close up the incision made in the back.”
WHAT HAPPENS AFTER SURGERY?
Assuming no complications during the procedure, a patient undergoing MISS may not need to stay long at the hospital at all. Some may even be able to go home the same day. Most likely, however, the MISS patient would spend one to four days onsite to ensure that no issues stemming from the surgery emerge, and to provide uninterrupted rest time.
Upon being discharged, patients taking an Enhanced Recovery After Surgery (ERAS) approach will receive a customized recovery plan from an ERAS-certified nurse practitioner.
Every patient is different and every patient experiences surgery differently. Their bodies may require more time to recover, they may be more sensitive to pain than they originally imagined, they may feel absolutely fine and able to function normally. It’s difficult to say for sure until the surgery has actually been completed.
At this point, nurse practitioners are able to make educated decisions about the patient’s recovery plan and tailor the regimen to each individual person.
With rest at home of between one and a half to three months – versus up to a year for open surgery – those who elect an MISS procedure will very likely be able to greet normal life in a surprisingly quick amount of time.
This recovery period requires maintaining good posture, ample rest, and refraining from burdensome physical activity or exercise, particularly anything that requires lifting heavy weight.
“SALLY’S RECOVERY
Following an uneventful overnight stay in the hospital, Sally returns home, sore but already feeling a change in her spine. The nagging pain of her old native disc, spent after many years of use, is now replaced by a spinal disc that’s going to be better suited to keep her upright and mobile in the years of her life to come.
When being discharged from the hospital, a nurse practitioner helped create a customized recovery plan for her along with instructions on how to handle any pain-management drugs safely and effectively.
Weeks later, following carefully managed recuperation planned with assistance from her spinal surgeon, Sally returns for a post-operation consult to give a report on her progress.
In this follow-up appointment, she sits down with her nurse practitioner and analyzes how recovery is going in terms of pain and compliance with the steps laid out after surgery. From there, her NP tailors her treatment plan to make sure it’s still right for where she is in the recovery process.”
CONCLUSION
As is the case with any surgical approach for any condition, MISS might not be the best option for everyone. Patients may need to use a particular type of MISS, given the range of operations available, contingent on their body chemistry and the nature of their ailment. The best course of action will be determined through discussions with the patient and their doctor.