Minimally invasive spine surgery has been evolving for 30 to 40 years, and surgeons should know where the techniques came from before looking forward.
"We are all students of medicine and in our practice it is important to find where minimally invasive spine surgery got its roots and where the process is taking us over the decades," says Hallett Mathews, MD, MBA, Executive Vice President and Chief Medical Officer of New York City-based Paradigm Spine, a non-fusion spinal implant and device technology manufacturer. Dr. Mathews is also a board-certified orthopedic spine surgeon and minimally invasive spine surgery pioneer.
Minimally invasive spine surgery dates back to the 1950s when radiologists and surgeons injected contrast into discs to run diagnostic tests. In the '70s, surgeons began accessing the disc space through small tubular access portals, and in the early '90s improved technology allowed for lasers and other disc removing technologies to remove disc material under direct visualization using scopes and fiber optics. The 2000s then brought better biologics, such as rhBMP-2, to re-grow bone that were then married to newer minimally invasive stabilization techniques.
Today, surgeons are drawing upon the techniques of the past and facing new challenges as they forge ahead. Here are Dr. Mathews' four current challenges facing spine surgeons performing less invasive procedures.
1. Education. One of the biggest challenges in across-the-board implementation of minimally invasive spine surgery is that all training programs are not teaching the same approaches to the spine at the same level of expertise. There is still a bias amongst educators regarding the best access to a certain pathology.
"Not all programs deliver predictably good minimally invasive spine training," Dr. Mathews says. "Some are better than others. If a surgeon has a residency or fellowship in maximally invasive deformity that deals with big incisions, then they might have to do a fellowship or additional training to understand minimal access surgery."
2. Patient selection. As with any type of spine procedure, patient selection for less invasive approaches is critical to a successful outcome, Dr. Mathews says.
"Diagnostic challenges still exist today even with today’s improved imaging and correlative physical exams," he says. "The challenge is finding the right patient that fits your technical ability as a surgeon and matching appropriate and least invasive technique to the pathology that is unique to that patient. So, it’s true that one size does not fit all when it comes to incisions and approaches. Patient selection has become the final challenge."
Patient selection mates a surgeon's capabilities with technology to deliver the least invasive approach and tissue trauma while getting the best possible solution, he says. Once surgeons can figure out how to use less invasive approaches on more types of patients, opportunities open up for more outpatient spine surgeries and shorter hospital stays.
3. Appropriate level of invasiveness. Minimally invasive spine has become a buzz word in the industry, Dr. Mathews says. However, MIS should refer to surgeons performing an appropriately invasive procedure to best access the patient's specific pathology.
"If it's better to do the procedure through a one inch incision than through a tube, that's still minimally or least invasive," he says. "There are no rules to define what it is and what it isn't; hence the discussion should be appropriately invasive techniques."
Not every procedure can be done through a tube and not every patient qualifies for the smallest incisions. Surgeons have their own interpretations based on training.
"The ultimate goal of the surgeon is to create the least injurious pathway and baggage of the approach to the correct pathology," he says.
4. Efficacy. Spine surgery evolved so rapidly from the late 1980s through the early 2000s it became difficult for surgeons to obtain the level 1 data from prospective randomized controlled studies needed to justify procedures to payers and regulatory agencies. The bias against MIS is also built into the technique, Dr. Mathews says, because the procedures are hard to randomize to collect data. Techniques have also merged so they are practically indistinguishable from one another.
"Now the problems of data collection and prospective randomized studies involve getting patients grouped into similar cohorts, getting money to do research and limiting the technology to what we can study," he says. "It all evolves so quickly that it is hard to standardize the technique for appropriate level 1 studies."
It is becoming increasingly challenging to standardize medicine in the research format as techniques are changing so quickly they cannot be standardized to run a study for two years.
However, small, focused societies, such as the Society for Minimally Invasive Spine Surgery, have garnered much success with data collection. "With that effort comes credibility of technique and outcomes to safely look at the efficacy and safety of procedures that involve appropriately invasive techniques," Dr. Mathews says.
That core research needs to happen; payers, patients and surgeons are demanding it.
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