MINIMALLY INVASIVE SPINE SURGERY (MISS)
(MISS) simply describes our innovative surgical techniques that minimize tissue trauma during a spinal surgery.
WHAT IS MINIMALLY INVASIVE SPINE SURGERY?
Minimally invasive spine surgery is not necessarily a specific procedure but a surgical technique that seeks to minimize tissue trauma during back surgery by accessing the spine through a small incision.
Traditional spine surgery is “open” surgery. This means that the surgeon makes a large incision and has to cut through a lot of tissues to see the spine and surrounding areas directly.
In traditional open spine surgery, the surgeon will make a 5-6 inch incision down the back and physically move the muscles to the side in order to properly see and operate on the spine. However, this technique uses more anatomy than the surgeon actually requires 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.
With MISS, your neurosurgeon uses special surgical instruments and specialized techniques to reduce the amount of tissue required in the surgery. The incision will be much smaller, often less than an inch. MISS also involves much less pulling on back muscles and other tissues resulting in much less surrounding damage.
Minimally invasive spine surgery is a highly technical procedure and only trained and knowledgeable neurosurgeons are capable of using the tools necessary to complete it effectively. The tissues, nerves and bone structure of the backbone are very detailed and complicated, as are the tools needed to perform microsurgery, so it takes many years of training and experience before a neurosurgeon can operate on this area. Even after your surgeon learns standard ways of doing spine surgery, they go through more training and experience to learn the very specialized techniques of MISS. In total, neurosurgeons spend between 6-9 years training to operate on the spine.
The technique that is used for minimally invasive spine surgery will depend on your particular spinal condition and the tools that are available at your local hospital. There are many different techniques for MISS.
The most common procedure is known as endoscopic spine surgery and involves the neurosurgeon inserting an endoscope into your spine through a small opening in your back, usually about an inch. An endoscope is a small, narrow, flexible tube-shaped camera. The surgeon can see the details of the affected spinal area and perform the needed surgery with small tools.
Another form of minimally invasive spine surgery uses robotic guidance to help guide the neurosurgeon with levels of precision and accuracy that are impossible with the human hand. This helps reduce the amount of time in surgery and increases the level of safety around the procedure.
In the end, your neurosurgeon will talk you through the specific minimally invasive procedure that is right for you and your spine.
WHAT ARE THE BENEFITS OF MINIMALLY INVASIVE SPINE SURGERY?
There are many potential benefits to MISS versus traditional spine surgery. Among these potential benefits are:
Smaller surgical incisions (which means smaller scars).
Higher level of accuracy.
Less damage to tissues around the surgical site, including the back muscles.
Less bleeding during the procedure.
Less anesthesia.
Reduced risk of infection.
Less pain after the operation.
Shorter stay in the hospital (which can mean lower costs to you).
Faster recovery time.
Faster return to normal daily activities.
In addition, MISS prevents damage to the spine’s structure and stability.
WHAT ARE THE LATEST ADVANCES IN MINIMALLY INVASIVE SPINE SURGERY? WHAT TO ASK FOR, WHAT TO AVOID
Given the numerous benefits of minimally invasive spinal surgery detailed above, surgeons, doctors, and medical professionals are currently developing new and cutting-edge ways to improve the procedure and provide patients with a range of options that best suit their particular medical situation.
We have already mentioned endoscopic spine surgery and robotic guidance as two techniques that apply the MISS philosophy. Along with those patients also have the option to explore procedures that use:
New robotic tools are being developed to assist doctors in the previously mentioned robotics-guided surgeries. At certain specialty spine hospitals around the United States, surgeons have access to robotics-controlled microscopes that can be used to help surgeons execute each step of a spinal procedure with greater precision, including screw placement and discectomies (removal of degenerated native discs). These microscopes feature superior image resolution and allow for more angled views of the spine.
One of the most exciting trends for spinal surgery as a whole, including MISS, is the use of something similar to what many people have for entertainment in their homes: virtual reality. In contrast to robotics-assisted procedures, or traditional non-MISS procedures where a doctor has to expose more of a patient’s spine, an “augmented reality” approach requires the surgeon to wear a headset that gives them real-time images of the patient’s spine. Combined with MISS techniques such as smaller and fewer incisions, this virtual reality approach facilitates a patient experience that involves fewer surgical intrusions.
Due to effective marketing and snazzy scientific language, certain spinal procedures claiming to use the MISS ethos have gained attention nationally. However, not every procedure with the MISS name attached to it actually lives up to the goals of surgeons that specialize in MISS. Two prominent examples include:
For much of the 2010s, there was extensive marketing about the use of lasers in spinal surgery. Several “laser spine centers” even cropped up throughout the United States as the notion of laser-centric spine surgery gained traction. However, these efforts would ultimately be short-lived. Apart from legal controversies that mired the Laser Spine Institute of Tampa, Florida – including a lawsuit directed at the company by former wrestler Hulk Hogan following what he deemed ineffective procedures – the goals of these laser spine centers run against the grain of what surgeons already know about the use of lasers for spinal operations.
Because of the intense, focused energy of lasers, it is generally advised that they not be used on the spine. The spine protects valuable neurological structures that are less strong than the individual vertebrae of the spine, so it is not worth the risk of using something as powerful as a laser when numerous other MISS alternatives exist. Lasers have been used in some narrow applications for spinal issues, but in the vast majority of cases they would not be a leading option, if an option at all.
ULTRASONIC SPINE SURGERY
Like lasers, ultrasonic surgical tools already exist and are used by hospitals around the United States. Some have suggested that these could be applied to spinal procedures. For the time being, there is no substantial body of evidence to suggest that these sonic tools offer patients any more efficacy than other existing MISS options.
Both of the procedures above, it should also be noted, are not inherently minimally invasive in their application, meaning that ultrasonic and laser-based procedures exist that do not conform to the methods of MISS. In general, be wary of anyone who tries to hook you on a surgical option whose primary appeal is its scientific novelty, or the flashiness of its accompanying technology. A true MISS practitioner’s primary aim should be, above all else, to perform the necessary surgery with a few incisions and interventions as possible, not just to use the flashiest tech.
WHO NEEDS MINIMALLY INVASIVE SPINE SURGERY?
Your neurosurgeon will generally recommend spine surgery if you have ongoing pain or other ongoing spinal problems, and all of these apply to you:
Non-surgical treatment has not been successful. Non-surgical (aka medical) treatment can consist of physical therapy, exercises, oral medications, topical medications, or back injections.
Your doctor can trace the cause of your pain or other severe symptoms to an abnormality in a specific area of the spine. Besides pain, severe problems can include arm or leg weakness (even paralysis) or stool and urine incontinence.
· Continued pain or other problems caused by the spinal condition are severe enough to warrant risks of surgery.
If you need spine surgery, you can likely have a minimally invasive procedure. The reasons that justify traditional spine surgery are generally the same reasons that justify MISS. In certain situations, you may need traditional spine surgery. Your spine surgeon will determine which type of spinal surgery is most appropriate for you.
There are many reasons someone might need to undergo minimally invasive spine surgery. Some of the common ones are:
Ruptured or bulging spinal discs that are pressing on nerves.
Spinal stenosis (where something inside the spinal canal presses on the spinal cord itself).
Spinal bones that are pressing on nerves.
Spinal bones that are not stable.
Spinal deformities.
Spinal arthritis.
Spinal tumors.
Certain spinal infections.
QUICK TAKEAWAYS
Minimally invasive spine surgery (MISS) is an attractive option if you need spinal surgery.
MISS has many advantages over traditional spinal surgery.
MISS is a set of newer techniques for spine surgery that are far less invasive and cause far less tissue damage than traditional spinal surgery.
You’ll usually be a candidate for MISS if you need spine surgery.
You can decrease your costs for MISS by taking specific steps before the surgery.
INTRODUCTION
Back pain and other back problems are very common. In many cases, back pain will respond to rest, stretching, anti-inflammatory medication and minor medical treatment alone. However, in certain situations, surgery may be recommended by your doctor depending on your specific spinal condition. Bulging or ruptured discs in the back are a frequent cause of severe back pain that may eventually require surgery.
The application of minimally invasive spine surgery (MISS) has continued to evolve and improve as the technology around the procedure has developed. Over time, neurosurgeons and researchers have improved on the available MISS techniques and procedures while, simultaneously, the surgical equipment for MISS has become more advanced.
Minimally invasive spine surgery has multiple potential advantages over traditional spine surgery if back surgery is needed. So, MISS is an option to consider if you need back surgery and if your specific situation qualifies for MISS.
WHAT HAPPENS DURING MINIMALLY INVASIVE SPINE SURGERY?
The anesthesiologist will administer 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.
Which part of the spine needs 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. There are many different specific procedures for minimally invasive. One of the most common procedures involves a “tubular retractor.” This is a small tube-like device that’s inserted from the skin down to the spine. The tubular retractor will keep the back muscles apart without cutting them, unlike traditional surgery where the back muscles are cut open. The surgeon will place the operating instruments through the tubular retractor to perform the MISS. Sometimes the surgeon will place the surgical instruments through an endoscope (a small tubular camera) instead of a tubular retractor.
Under many circumstances, you can go home either the same day or in 1-2 days. The exact amount of time before you can go home depends on the specific spinal procedure, your overall health, and how you tolerate the surgery.
WHICH TYPES OF MEDICAL FACILITIES DO MINIMALLY INVASIVE SPINE SURGERY?
Surgeons can perform MISS while you’re an outpatient and at any facility that has the tools and neurosurgeons available to perform the surgery. This means the surgeon can often do minimally invasive spine surgery in either a hospital outpatient department or an ambulatory surgery center. “Hospital outpatient” means the doctor won’t formally admit you to the hospital, although you’ll still stay at the hospital. You might wind up staying at the hospital for up to two nights if your surgeon does the MISS in a hospital outpatient department. Your surgeon usually expects you’ll go home the same day when they do the operation at an ambulatory surgery center.
Sometimes when you have a MISS, your doctor will admit you to the hospital as an inpatient. Your doctor might plan all along to admit you as an inpatient due to complicated medical or surgical situations. You could also be changed from a hospital outpatient to a hospital inpatient if you develop complications that require a stay at the hospital for longer than two nights.
Your neurosurgeon will talk you through the specifics of your surgery based on your specific condition and tolerance for surgery.
HOW MUCH DOES MINIMALLY INVASIVE SPINE SURGERY COST? HOW CAN I CUT DOWN ON MY COSTS FOR MINIMALLY INVASIVE SPINE SURGERY?
Publicly posted hospital and ambulatory surgery center MISS prices can vary dramatically. However, your cost will usually be far less than these posted prices with insurance and by using in-network doctors and surgery facilities. Insurers usually negotiate special pricing with in-network doctors, hospitals, and ambulatory surgery facilities. These prices are generally only a small fraction of the publicly posted prices.
As Medicare explains, hospital inpatient care is more expensive than hospital outpatient care. This is generally true for all insurance, not just for Medicare. Also, ambulatory surgery centers usually cost less than an outpatient hospital.
Make sure you get your health insurance to approve the minimally invasive spine surgery before you have the procedure done. This is often called “pre-approval” or “prior authorization.” If you don’t do this, you could be liable for a lot of money. If you have MISS done before getting it approved, your insurer may decide it wasn’t medically necessary. They might not pay anything, and you could be liable for the total cost.
As another example, let’s say you have MISS done in a hospital outpatient department without pre-approval. Your insurance might only pay lower rates charged by an ambulatory surgery center, leaving you on the hook for the balance due.
If the surgery is a true medical emergency, your insurance will generally cover their share of the costs. However, be aware that what you or your doctor consider a medical emergency might not be regarded as a medical emergency by your insurance.
Remember that in addition to the hospital or ambulatory surgery center charges, you’ll usually be responsible for your share of the following costs:
Surgeon charges.
Anesthesiologist charges.
Charges from any additional or consulting doctors who take care of you.
Any x-ray or laboratory services billed separately from the hospital charges.
Emergency room charges (if you decide to go to the emergency room due to pain or other symptoms).
Also, remember that in general, how much you have to pay will depend on:
Your specific health insurance policy benefits and exclusions.
Any deductibles.
Any copays.
Any coinsurance amounts.
Your out-of-pocket maximum.
Whether the hospital and doctors are in-network.
Always confirm directly with your insurance what your expected costs will be, so there aren’t any cost surprises.
If you have questions about minimally invasive spine surgery, do not hesitate to reach out to our office and our staff would be glad to assist you and help answer any questions you have about insurance, surgery or recovery.
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Prior to coming to Dr. Lim, I tried acupuncture, physical therapy, and everything else I could on my own. I decided it was time to see a surgeon. When we saw Dr. Lim, I got MRIs done and he said that it would require major surgery. Soon after surgery I began to feel tremendously better.
— BARRY WILLIAMS, CENTREVILLE VA