9 Surgeons on Adopting Minimally Invasive Spine Techniques

Spine

Nine spine surgeons discuss minimally invasive spine techniques and which they have or will be adding into their surgical repertoires. Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses. Next week's question: How can spine surgeons partner with surgeons of other specialties to benefit patient care?

Please send responses to Heather Linder at hlinder@beckershealthcare.com by Wednesday, April 17, at 5 p.m. CST.


Neel Anand, MD, Director of Spine Trauma and Minimally Invasive Surgery, Cedars-Sinai Spine Center, Los Angeles: For the past 12 years my practice has been dedicated to performing minimally invasive surgery. Among the most promising surgical advances to effectively treat many cases of spinal trauma is the minimally invasive approach. This approach allows surgeons to effectively treat spinal trauma by accessing the affected part of the spine utilizing small skin incisions, avoiding the need to cut through large muscles in the back and thereby minimizing additional and unnecessary damage. Regardless of the procedure used to correction the condition, a minimally invasive approach has a common goal: to keep the body as naturally intact as it was prior to surgery. When performed by a skilled, highly-trained and experienced surgeon, this goal is achieved with faster recovery than traditional open procedures, less pain after surgery and a generally speedier recovery time. Minimally invasive spine surgery has also been proven to decrease the risk of infection, bleeding and scarring post-surgery.

W. Daniel Bradley, MD, Orthopedic Spine Surgeon, Texas Back Institute, Plano: Minimally invasive spine surgery has been a foundation of my practice for more than 10 years. As more innovative instrumentation and refined MIS techniques prove themselves not only in clinical outcomes but in cost savings, I will absolutely continue to incorporate minimally invasive procedures into my practice. The caution, however, should always be with procedures that minimize the clinical benefit for the sake of incision size.

Walter Eckman, MD, Owner of Aurora Spine Center, Tupelo, Miss.: In spite of my age of 69, I realized the coming importance of minimally invasive spine surgery about 16 to 17 years ago. As soon as I learned to perform surgery through small, closed working channels, I made a commitment to never go back to open surgery. Since then I have done over 1,150 minimally invasive decompressions and discectomies with all of them going home within hours, with the exception of three cases. In 2003 I began to do minimally invasive TLIFs and have now done a little over 1,100 with over 800 going home the day of surgery. I have done no open discectomy, decompression or fusion procedures since starting these minimally invasive series.

In presenting this information, I am trying to emphasize that nearly all spine surgery for one and two level degenerative conditions can culminate in same-day discharge. I believe this is vitally important for young American surgeons because of the challenges we face due to high costs, low reimbursement and regulatory problems (government, third party payors, hospitals). My vision for the future is that young surgeons will have to move to ASCs with same-day discharge for almost all spine patients and they may have to move to private contracting for companies and individuals.

J. Brian Gill, MD, Orthopedic Spine Surgeon, Nebraska Spine Center, Omaha: At this time I do not see myself adopting any new minimally invasive techniques, as I do not think the current evidence demonstrates superior outcomes over the traditional procedures. I am refining how I do my procedures, including smaller incisions with less dissection. I am also considering the costs of the implants which are typically higher with minimally invasive procedures.

Jeffrey Goldstein, MD, Director of Spine Service, NYU Langone Medical Center's Hospital for Joint Diseases: We were early adopters of minimally invasive spine surgical techniques at NYU Langone Medical Center Hospital for Joint Diseases, and our experience is increasing. Minimally invasive surgery must be maximally effective in order to obtain the best results for our patients. MIS techniques mean different things to different people. Generally, there is less soft tissue dissection and subsequently lower risks of bleeding and soft tissue injury. This leads to potentially faster recovery. It makes sense to do the least surgery possible to achieve the most favorable surgical result as long as the results are equivalent.

As a group, we are now providing outcome studies to support our theories. Societies representing spine surgeons, such as the International Society for the Advancement of Spine Surgery, are providing forums for the teaching of MIS surgery, sharing outcomes and enhancing surgical techniques. Patients are seeking out surgeons who provide good outcomes and incorporate MIS when appropriate.

Hooman Melamed, MD, Orthopedic Spine Surgeon, DISC Sports & Spine Center, Marina Del Rey, Calif.: I think there is definitely a potential to do minimally invasive scoliosis correction surgery in the future. It is currently being done by some surgeons but has not had five-to-10-year outcome studies. Moreover, the main issue is correcting sagittal balance which, with the current minimally invasive technique, has not always been ideal. I can definitely see this becoming more practical down the line with newer instrumentation techniques.

Also, the use of navigation and robotic screw placements can make minimally invasive scoliosis correction much easier, safer and faster. This can ultimately result in a much more optimum patient outcome. I already do minimally invasive lumbar and cervical microdecompression, one-two level ACDF surgery, and even one-two lumbar fusions all as minimally invasive procedures in an outpatient setting. I don't see myself changing these techniques, since they are already minimally invasive.

Kern Singh, MD, Rush University Medical Center, Chicago: My practice is exclusively MIS and has been so for the past seven years.

Jeffrey Wang, MD, UCLA Spine Center: We already try to do our surgeries with smaller incisions, less soft tissue disruption and faster recovery. I have been doing microsurgery for years. I really do not see any really innovative and new minimally invasive instruments, but I am seeing an ongoing philosophy of smaller surgeries and smaller incisions. I do think minimally invasive cervical surgery has a lot of potential and foresee that this may become more popular in the upcoming years.

Robert Watkins, Jr., MD, Co-Director of Marina Spine Center, Marina Del Rey (Calif.) Hospital: Currently, we perform the full spectrum of spine surgery, from minimally invasive microscopic decompressions to multi-level open spinal fusions. The patient's pathology determines the surgery to be performed. There is a constant desire and evolution to perform surgeries as minimally invasive as possible. However, the surgery still needs to accomplish certain goals in order to correct the patient's pathology. A small scar doesn't do anyone good if the problem is not corrected without complications. The continued evolution of computer spine surgery and minimally invasive technology will allow us to perform fusions in a less invasive but still safe method in the future.

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