Minimally invasive spine surgery has been available for several years, but the trend has just begun picking up steam across the country. Many surgeons who learned traditional open surgery are content with those procedures, but more spine fellows are seeking to learn minimally invasive techniques and will begin incorporating them into their practices at a faster rate than ever before.
"Minimally invasive techniques were historically used for diagnosis only. But technology advances have allowed us to improve the treatment of spine disorders using the same techniques for surgery," says Nimesh H. Patel, MD, a neurosurgeon at the Methodist Moody Brain and Spine Institute in Dallas. "It's one of the biggest advantages for patients because we are able to do spinal procedures with smaller incisions, which means less pain and blood loss. Hospital stays are also shorter."
Shorter hospital stays and reduced risk of infection have a huge economic impact on the cost of care for people with spine issues, which is one of the biggest costs to our system today. Device companies and insurance providers are slowly coming on board with these new techniques as they are proven safe and effective in the literature.
"There is some data that shows less cost associated with minimally invasive procedures and patients are able to return to work more quickly as well," says Dr. Patel. "However, there is a cost associated with purchasing the equipment, so it can be a double-edged sword. However, data has shown there are more benefits and less cost overall to perform minimally invasive procedures on the appropriately selected patients."
Here, spine surgeons who are experienced with minimally invasive procedures discuss their evolution and where we are likely to see this trend headed in the future.
1. Complex procedures are now minimally invasive. Simple procedures, such as discectomies, were among the first to transition into a minimally invasive approach, and now surgeons are performing minimally invasive fusion procedures on a regular basis. However, more recent technological development has allowed even more complex procedures, such as scoliosis correction, to fall under the minimally invasive umbrella.
"Traditionally scoliosis is known as a very difficult surgery on the physician and the patient," says Dr. Patel. "Now we are able to access the spine from a lateral approach and perform scoliosis surgery with significantly less blood loss and pain. Patients can mobilize the next day and their hospital stays have decreased."
While the more complex minimally invasive procedures are still relatively new, they could become more popular on the horizon if quality and cost can stand the test of time. However, the minimally invasive approach isn't right for all patients and there will likely be a subset that will still need the traditional open procedures going forward.
"Every patient is unique, and minimally invasive surgery can help some patients but not all," says Dr. Patel. "For some patients, the more traditional procedures may yield the best results. The key is finding a surgeon who is experienced in minimally invasive techniques and who relies on proven medical data to support the surgical reliability and safety of the techniques."
2. Outpatient spinal fusions are more common. As more surgeons are learning minimally invasive techniques and the technology develops for fusion procedures, more of those cases could be performed in the ambulatory surgery center setting. Anterior cervical discectomies and fusions are performed regularly in some ASCs, and additional procedures could make the transition in the future.
"Where we are trying to push the envelope a little more is in fusions," says Paul Nottingham, MD, a spine surgeon in Walnut Creek, Calif. "We can do some lumbar fusions in the outpatient setting. Single level transforaminal lumbar interbody fusions have also worked well in the ASC for painful degenerative discs. I think we are going to try to gain better constructs on a single-level lumbar fusion and a better alignment for TLIFs in the outpatient setting."
Insurance companies reimburse outpatient facilities at a lower rate than hospitals, in most cases, and ASCs generally have a lower infection rate than inpatient facilities.
3. Artificial disc technology in limbo. Motion preservation has been a trend in orthopedics for years, and disc replacement technology was designed as a step up from fusions in the field. However, attempts at lumbar disc replacements are largely considered failures and recent studies question whether cervical disc replacements reduce the risk of adjacent segment disease.
"This goes back to an overall healthcare question: how do we obtain the fountain of youth and stop ourselves from aging?" says Dr. Patel. "One of the things we are looking toward in spine surgery is motion preservation. Currently the dogma is too much motion creates too much pain and is unstable, so a fusion is required. However, fusion is the opposite of what the body wants to do — it wants to preserve motion."
In orthopedics, knee and hip surgery has evolved from early fusion techniques to joint replacements, which are now the standard of care.
"We have some development in implant technology that allows us to perform motion restoration procedures like artificial disc replacement or even instrumented fusion or arthrodesis procedures," says Hieu Ball, MD, an orthopedic spine surgeon in Walnut Creek, Calif. "We are looking to do things in a less traumatic way than in the past."
However there are other treatment options beyond disc replacement that may develop further in the future. "Artificial disc surgery may have reached its zenith as newer and better treatments are evolving and becoming available," says Ara Deukmedjian, MD, founder and medical director at Deuk Spine Institute in Melbourne, Fla. "Endoscopic spine surgery combined with a multidisciplinary approach to treatment of common spinal disorders will likely take center stage in treating degenerative spinal conditions. The next 10 years will be very exciting for surgeons with the skills to successfully cure back and neck pain. This is a $100 billion-plus market."
4. Biologics and disc regeneration. Moving forward with motion preservation, surgeons and scientists have set their sights on biological solutions and disc regeneration. Early technologies are still in the beginning stages and clinical trials, but this area shows the most promise in combating some of the highest pain and cost generators in the country.
"Disc regeneration seeks to bring the cushion of the spine back to its normal state," says Dr. Patel. "These techniques are being researched and there have been some attempts at performing them, but we don't have any solid clinical evidence that will promote the idea we should change the way we treat spinal surgery at this point in time."
Biologics has permeated the market with bone morphogenic proteins and other similar synthetic fusion materials. Device companies are working on creating a material that allows bone graft substitutes to achieve fusion without harvesting bone from the patient's iliac crest.
"I have actually converted the majority of our procedures where we had used BMP to using some of the ceramic based substitutes," says Dr. Ball. "Some are usable by themselves and others are used in conjunction with a demineralized bone matrix. I think that is really where people are going; going back to using allograft or autograft because there has been evidence in the literature of the potential complications and side effects of BMP."
BMP has also been very expensive in the past and surgeons are now encouraged to use other options in the future.
5. Lateral approach is gaining steam. More procedures are looking for a lateral approach to the spine, and device companies are developing new lat
eral systems to meet these needs. Initial minimally invasive procedures approached the spine anteriorally or posteriorally, but there have been some proven benefits to the lateral approach when possible.
"The biggest trend in minimally invasive surgery right now is the lateral approach," says Jennifer Sohal, MD, a spine surgeon with St. Vincent Spine Institute in Los Angeles. "It has been very effective in decreasing postoperative pain and allowing surgeons to perform more complex procedures with less morbidity."
Even high acuity procedures such as scoliosis repair are now accessible through a lateral approach. However, the technique has not become a standard of care yet.
"It's still in the early stages, but I think more people are increasing their skill level in these techniques," says Dr. Sohal. "We'll see more training opportunities available and surgeons will become more comfortable selecting the right patients for the procedure. Minimally invasive techniques are not replacing all open techniques; it's just another tool in the toolbox."
6. Intraoperative neuromonitoring and neurophysiology. Along with minimally invasive instrumentation and implants, a new need for advances in neuromonitoring and neurophysiology has emerged. Surgeons want to perform these procedures safely for their patients, and an extra person gauging the quality of the procedure can really make a difference.
"An area of advancement in the future is going to be neuromonitoring so surgeons can make sure they aren't doing any nerve damage during these procedures," says Dr. Nottingham. "We'll also need a way to package this technology so it can come at a reasonable cost to the ASC or hospital. It will be in the interest of companies to develop models for leasing and temporary rental programs so that these technologies can be used in a more economical manner."
Lawrence Dickinson, MD, a spine surgeon with Pacific Brain and Spine Medical Group in Castro Valley, Calif., has added a neurophysiologist to his practice, which he has found improved the quality of his procedures. He uses the Baxano system to perform minimally invasive spine surgeries and has see the advantage of using a neurophysiologist in the operating room, even if it adds expense to the case.
"I think adding a neurophysiologist is an advantage and the patient will never complain about someone guarding the nervous system," he says. "This person is in the room telling the surgeon if he is irritating the nerve root. Addition safety is helpful in the long run because it prevents complications, whether you are using a device or not. I started using electrophysiology and improved my practice."
7. Computer navigation could have a place going forward. Computer assistance and robotic guidance for orthopedics and spine have been a contentious issue for the past few years; the equipment is expensive and surgeons question whether it actually improves the procedure enough to warrant that cost. However, there is a market for this technology and future iterations could make an impact on spine care.
"Surgeons are able to use navigation to assist in surgery, decreasing operative time and need for revision surgery," says Dr. Sohal. "It involves obtaining an intraoperative CT scan to create a model of the spine on which we can project our operative plan."
Mazor, a robotic spine technology company, has published results from individual surgeons on their accuracy placing pedicle screws.
"I think we have navigational systems working now, but there will be a continued improvement there," says Dr. Nottingham. "The technology continues to reduce our element of error and the amount of radiation used to produce images."
8. Physician-owned ambulatory surgery centers are more common in spine. There is an opportunity for more spine surgeons to become investors in ambulatory surgery centers if they can move their cases into the outpatient setting. Spine practices in unsaturated markets are able to open their centers and have more control over their cases.
"Our ASC is really staying on the forefront of minimally invasive spine technology," says Dr. Nottingham. “There is a keep interest of the management and ownership to really develop quality outpatient spine surgery services, so it's been a real pleasure working with them. Some ASCs don’t show that level of interest because it really takes commitment to develop an outpatient spine service."
Spine surgeons must partner in outpatient surgery center endeavors and commit to performing cases there to make the investment successful.
"If there is teamwork amongst the surgeons and administration, the program will come into existence and become one of quality service," says Dr. Nottingham. "If you bring in the appropriately selected cases, you will have the monies to purchase the navigational, neuromonitoring and anesthesia systems along with any other instrumentation needed. The critical element is getting interested parties together."
"Minimally invasive techniques were historically used for diagnosis only. But technology advances have allowed us to improve the treatment of spine disorders using the same techniques for surgery," says Nimesh H. Patel, MD, a neurosurgeon at the Methodist Moody Brain and Spine Institute in Dallas. "It's one of the biggest advantages for patients because we are able to do spinal procedures with smaller incisions, which means less pain and blood loss. Hospital stays are also shorter."Shorter hospital stays and reduced risk of infection have a huge economic impact on the cost of care for people with spine issues, which is one of the biggest costs to our system today. Device companies and insurance providers are slowly coming on board with these new techniques as they are proven safe and effective in the literature.
"There is some data that shows less cost associated with minimally invasive procedures and patients are able to return to work more quickly as well," says Dr. Patel. "However, there is a cost associated with purchasing the equipment, so it can be a double-edged sword. However, data has shown there are more benefits and less cost overall to perform minimally invasive procedures on the appropriately selected patients."
Here, spine surgeons who are experienced with minimally invasive procedures discuss their evolution and where we are likely to see this trend headed in the future.
1. Complex procedures are now minimally invasive. Simple procedures, such as discectomies, were among the first to transition into a minimally invasive approach, and now surgeons are performing minimally invasive fusion procedures on a regular basis. However, more recent technological development has allowed even more complex procedures, such as scoliosis correction, to fall under the minimally invasive umbrella.
"Traditionally scoliosis is known as a very difficult surgery on the physician and the patient," says Dr. Patel. "Now we are able to access the spine from a lateral approach and perform scoliosis surgery with significantly less blood loss and pain. Patients can mobilize the next day and their hospital stays have decreased."
While the more complex minimally invasive procedures are still relatively new, they could become more popular on the horizon if quality and cost can stand the test of time. However, the minimally invasive approach isn't right for all patients and there will likely be a subset that will still need the traditional open procedures going forward.
"Every patient is unique, and minimally invasive surgery can help some patients but not all," says Dr. Patel. "For some patients, the more traditional procedures may yield the best results. The key is finding a surgeon who is experienced in minimally invasive techniques and who relies on proven medical data to support the surgical reliability and safety of the techniques."
2. Outpatient spinal fusions are more common. As more surgeons are learning minimally invasive techniques and the technology develops for fusion procedures, more of those cases could be performed in the ambulatory surgery center setting. Anterior cervical discectomies and fusions are performed regularly in some ASCs, and additional procedures could make the transition in the future.
"Where we are trying to push the envelope a little more is in fusions," says Paul Nottingham, MD, a spine surgeon in Walnut Creek, Calif. "We can do some lumbar fusions in the outpatient setting. Single level transforaminal lumbar interbody fusions have also worked well in the ASC for painful degenerative discs. I think we are going to try to gain better constructs on a single-level lumbar fusion and a better alignment for TLIFs in the outpatient setting."Insurance companies reimburse outpatient facilities at a lower rate than hospitals, in most cases, and ASCs generally have a lower infection rate than inpatient facilities.
3. Artificial disc technology in limbo. Motion preservation has been a trend in orthopedics for years, and disc replacement technology was designed as a step up from fusions in the field. However, attempts at lumbar disc replacements are largely considered failures and recent studies question whether cervical disc replacements reduce the risk of adjacent segment disease.
"This goes back to an overall healthcare question: how do we obtain the fountain of youth and stop ourselves from aging?" says Dr. Patel. "One of the things we are looking toward in spine surgery is motion preservation. Currently the dogma is too much motion creates too much pain and is unstable, so a fusion is required. However, fusion is the opposite of what the body wants to do — it wants to preserve motion."
In orthopedics, knee and hip surgery has evolved from early fusion techniques to joint replacements, which are now the standard of care.
"We have some development in implant technology that allows us to perform motion restoration procedures like artificial disc replacement or even instrumented fusion or arthrodesis procedures," says Hieu Ball, MD, an orthopedic spine surgeon in Walnut Creek, Calif. "We are looking to do things in a less traumatic way than in the past."
However there are other treatment options beyond disc replacement that may develop further in the future. "Artificial disc surgery may have reached its zenith as newer and better treatments are evolving and becoming available," says Ara Deukmedjian, MD, founder and medical director at Deuk Spine Institute in Melbourne, Fla. "Endoscopic spine surgery combined with a multidisciplinary approach to treatment of common spinal disorders will likely take center stage in treating degenerative spinal conditions. The next 10 years will be very exciting for surgeons with the skills to successfully cure back and neck pain. This is a $100 billion-plus market."4. Biologics and disc regeneration. Moving forward with motion preservation, surgeons and scientists have set their sights on biological solutions and disc regeneration. Early technologies are still in the beginning stages and clinical trials, but this area shows the most promise in combating some of the highest pain and cost generators in the country.
"Disc regeneration seeks to bring the cushion of the spine back to its normal state," says Dr. Patel. "These techniques are being researched and there have been some attempts at performing them, but we don't have any solid clinical evidence that will promote the idea we should change the way we treat spinal surgery at this point in time."
Biologics has permeated the market with bone morphogenic proteins and other similar synthetic fusion materials. Device companies are working on creating a material that allows bone graft substitutes to achieve fusion without harvesting bone from the patient's iliac crest.
"I have actually converted the majority of our procedures where we had used BMP to using some of the ceramic based substitutes," says Dr. Ball. "Some are usable by themselves and others are used in conjunction with a demineralized bone matrix. I think that is really where people are going; going back to using allograft or autograft because there has been evidence in the literature of the potential complications and side effects of BMP."
BMP has also been very expensive in the past and surgeons are now encouraged to use other options in the future.
5. Lateral approach is gaining steam. More procedures are looking for a lateral approach to the spine, and device companies are developing new lat
eral systems to meet these needs. Initial minimally invasive procedures approached the spine anteriorally or posteriorally, but there have been some proven benefits to the lateral approach when possible."The biggest trend in minimally invasive surgery right now is the lateral approach," says Jennifer Sohal, MD, a spine surgeon with St. Vincent Spine Institute in Los Angeles. "It has been very effective in decreasing postoperative pain and allowing surgeons to perform more complex procedures with less morbidity."
Even high acuity procedures such as scoliosis repair are now accessible through a lateral approach. However, the technique has not become a standard of care yet.
"It's still in the early stages, but I think more people are increasing their skill level in these techniques," says Dr. Sohal. "We'll see more training opportunities available and surgeons will become more comfortable selecting the right patients for the procedure. Minimally invasive techniques are not replacing all open techniques; it's just another tool in the toolbox."
6. Intraoperative neuromonitoring and neurophysiology. Along with minimally invasive instrumentation and implants, a new need for advances in neuromonitoring and neurophysiology has emerged. Surgeons want to perform these procedures safely for their patients, and an extra person gauging the quality of the procedure can really make a difference.
"An area of advancement in the future is going to be neuromonitoring so surgeons can make sure they aren't doing any nerve damage during these procedures," says Dr. Nottingham. "We'll also need a way to package this technology so it can come at a reasonable cost to the ASC or hospital. It will be in the interest of companies to develop models for leasing and temporary rental programs so that these technologies can be used in a more economical manner."
Lawrence Dickinson, MD, a spine surgeon with Pacific Brain and Spine Medical Group in Castro Valley, Calif., has added a neurophysiologist to his practice, which he has found improved the quality of his procedures. He uses the Baxano system to perform minimally invasive spine surgeries and has see the advantage of using a neurophysiologist in the operating room, even if it adds expense to the case.
"I think adding a neurophysiologist is an advantage and the patient will never complain about someone guarding the nervous system," he says. "This person is in the room telling the surgeon if he is irritating the nerve root. Addition safety is helpful in the long run because it prevents complications, whether you are using a device or not. I started using electrophysiology and improved my practice."
7. Computer navigation could have a place going forward. Computer assistance and robotic guidance for orthopedics and spine have been a contentious issue for the past few years; the equipment is expensive and surgeons question whether it actually improves the procedure enough to warrant that cost. However, there is a market for this technology and future iterations could make an impact on spine care.
"Surgeons are able to use navigation to assist in surgery, decreasing operative time and need for revision surgery," says Dr. Sohal. "It involves obtaining an intraoperative CT scan to create a model of the spine on which we can project our operative plan."
Mazor, a robotic spine technology company, has published results from individual surgeons on their accuracy placing pedicle screws.
"I think we have navigational systems working now, but there will be a continued improvement there," says Dr. Nottingham. "The technology continues to reduce our element of error and the amount of radiation used to produce images."
8. Physician-owned ambulatory surgery centers are more common in spine. There is an opportunity for more spine surgeons to become investors in ambulatory surgery centers if they can move their cases into the outpatient setting. Spine practices in unsaturated markets are able to open their centers and have more control over their cases.
"Our ASC is really staying on the forefront of minimally invasive spine technology," says Dr. Nottingham. “There is a keep interest of the management and ownership to really develop quality outpatient spine surgery services, so it's been a real pleasure working with them. Some ASCs don’t show that level of interest because it really takes commitment to develop an outpatient spine service."
Spine surgeons must partner in outpatient surgery center endeavors and commit to performing cases there to make the investment successful.
"If there is teamwork amongst the surgeons and administration, the program will come into existence and become one of quality service," says Dr. Nottingham. "If you bring in the appropriately selected cases, you will have the monies to purchase the navigational, neuromonitoring and anesthesia systems along with any other instrumentation needed. The critical element is getting interested parties together."