Minimally invasive spine surgery and endoscopic procedures have been available to spine surgeons for several years now, however they are just beginning to gain popularity among the vast majority of spine surgeons in the country. Bryan Massoud, MD, a spine surgeon with Spine Centers of America in Fair Lawn, N.J., has performed more than 1,000 endoscopic spine surgeries. He discusses the trend and why it is important to stay abreast of minimally invasive surgery heading into the future.
Q: How do you see spine surgery trending over the next few years?
Dr. Bryan Massoud: The vast majority of spinal surgery in this country is currently being done in an open fashion. However, in the next 5-10 years we will see a transition to minimally invasive techniques, with a majority of those being done as endoscopic procedures. Orthopedics in general has trended toward less invasive procedures for a few years. It seems that spine is one of the last disciplines where that has not really occurred yet. If you look back 15 years ago, laminectomies and discectomies were done as open procedures, then they trended toward micro discectomies, which have smaller openings and reduce the risk for complications. Endoscopic procedures are the next logical step. The incision is even smaller and doesn’t require stripping muscle layers away or removing bone to perform a laminectomy or laminotomy — it spares the ligament structures that give support to the spine so recovery can be much shorter and less painful.
Q: How have technological advancements in spine surgery supported the trend toward less invasive and endoscopic procedures?
BM: When I first started doing these procedures, the instrumentation was very limited. We had a simple set of instruments and basically the use of a laser — that was about it. As time has gone on, we've developed "burrs" for removing bone spurs, which are used in other orthopedic surgeries, and shavers, which are extremely helpful for removing tissue. When performing endoscopic spine surgery, the surgeon needs to be able to tackle different obstacles, such as removing bone spurs that cause spinal stenosis. We now have tools to remove bone, hypertrophied ligaments and scar tissue. The development of angled instruments and better endoscopes has been crucial in advancing endoscopic spine surgery. It is important that these instruments allow us to do endoscopically what we already do in an open fashion.
Q: Even though the technology is in place for surgeons to perform less invasive and endoscopic procedures, many do not. Why are surgeons wary of these new approaches?
BM: Whenever there is a new technology and our colleagues are not knowledgeable about it or don’t understand it well, they may develop preconceived notions about it or shy away from it. Others simply may not be aware of it because it was not included in their formal or ongoing training. That’s why I believe it is very important to teach our colleagues and get the word out to both patients and physicians about these techniques. I work with organizations offering classes for physicians, as well as offering physicians the opportunity to observe me and train with me. While some of the techniques may be new, they are not considered experimental — we’re just using different instruments and an endoscopic approach to mimic techniques used during open surgery to achieve better results.
Although I’ve found endoscopic procedures to be better in most instances, as a spine surgeon, I still perform certain open procedures. For example, traditional spinal fusions are an integral part of my practice under certain circumstances, such as where there is instability of the spine from spondylolithesis, traumatic fracture or scoliosis. However, at Spine Centers of America, we try to avoid fusion and preserve motion whenever possible. We have been successful in avoiding most fusion surgeries by performing endoscopic techniques to remove stenosis and pressure on neural structures, or we’ll perform endoscopic foraminotomy to decompress nerve roots. Recovery is complete in a few weeks versus three to five months for traditional fusion.
Q: What do you think is included under the umbrella of "minimally invasive" spine surgery?
BM: Minimally invasive spine surgery does not necessarily mean endoscopic spine surgery. The majority of physicians who are performing "minimally invasive spine surgery" are not instituting endoscopic techniques. Much of the minimally invasive spine surgery means using smaller incisions and better retractors, but the surgeon is still performing the same procedures and techniques that they used to do during open surgeries. Many physicians are still performing fusions, but they are taking a less invasive approach.
Q: What will push spine surgeons to learn the minimally invasive techniques in the future?
BM: Patients are much more educated these days. They have a lot of information and resources available to them. Right now, the majority of patients are not offered minimally invasive techniques because their surgeons aren't trained in them. These people search the Internet and look for the latest trends and cutting edge techniques. They can dig deep in the Internet to find alternatives since they elect not to undergo open surgeries or fusions.
For the vast majority of patients who contact us, one of the first statements out of their mouths is that they that don't want any fusions. Often the patient has seen two to three other surgeons and was offered fusion surgery. Many patients know others who have gone through multiple fusions and know that the recovery is hard and can lead to problems in the future. If this patient is a laborer or has a physical job, a fusion surgery could put him or her out of work for several months. With the minimally invasive procedures, the patient goes home the same day, experiences immediate reduction or relief of pain and they get back to life as quickly as possible without major downtime.
We have tremendous success in treating failed back syndrome — where a person has undergone one or more surgeries and they are told there’s nothing a traditional spine surgeon can do — especially if there is a lot of scar tissue. Most can be helped with endoscopic procedures. During endoscopic spine procedures, we go through new tissue — avoiding going through tissue that has tremendous scarring from previous surgeries. We get in and out safely and effectively when the only other alternative the patient might have is chronic pain medication and/or a spinal cord stimulator.
Q: Are there any further advantages for the patients when the surgeon performs endoscopic spine surgery?
BM: The procedure is done through a small incision and the surgeon doesn't have to strip the muscle layers away to access the area. The surgeon preserves ligaments and the supporting structures of the spine by using an endoscopic technique. In many instances laminectomy or laminotomy can be avoided. These less invasive procedures also minimize scar tissue, which can be a problem in traditional surgery.
It is recommended that endoscopic spine procedures be done under twilight anesthesia, not general anesthesia, which is especially important when treating older patients. Older patients often have co-morbidities which would make them poor candidates for open surgery. However, going in endoscopically without general anesthesia will limit the complication rate, decrease the infection rate and allow patients to have surgery who otherwise wouldn't be able to handle the procedure.
Learn more about Spine Centers of America.
15-01 BROADWAY, STE 20
Fair Lawn NJ 07410
877 722 6008
info@spinecentersofamerica.com
Read other coverage on minimally invasive spine surgery:
- Performing Minimally Invasive TLIF Procedures: Q&A With Dr. Navin Subramanian of Houston's Orthopaedic Associates
- 4 Critical Steps Physicians Must Take to Learn Endoscopic Spine Surgery
- Spine Surgery in 2011 and Beyond: 7 Points About the Future of Spine Surgery
Q: How do you see spine surgery trending over the next few years?
Dr. Bryan Massoud: The vast majority of spinal surgery in this country is currently being done in an open fashion. However, in the next 5-10 years we will see a transition to minimally invasive techniques, with a majority of those being done as endoscopic procedures. Orthopedics in general has trended toward less invasive procedures for a few years. It seems that spine is one of the last disciplines where that has not really occurred yet. If you look back 15 years ago, laminectomies and discectomies were done as open procedures, then they trended toward micro discectomies, which have smaller openings and reduce the risk for complications. Endoscopic procedures are the next logical step. The incision is even smaller and doesn’t require stripping muscle layers away or removing bone to perform a laminectomy or laminotomy — it spares the ligament structures that give support to the spine so recovery can be much shorter and less painful.
Q: How have technological advancements in spine surgery supported the trend toward less invasive and endoscopic procedures?
BM: When I first started doing these procedures, the instrumentation was very limited. We had a simple set of instruments and basically the use of a laser — that was about it. As time has gone on, we've developed "burrs" for removing bone spurs, which are used in other orthopedic surgeries, and shavers, which are extremely helpful for removing tissue. When performing endoscopic spine surgery, the surgeon needs to be able to tackle different obstacles, such as removing bone spurs that cause spinal stenosis. We now have tools to remove bone, hypertrophied ligaments and scar tissue. The development of angled instruments and better endoscopes has been crucial in advancing endoscopic spine surgery. It is important that these instruments allow us to do endoscopically what we already do in an open fashion.
Q: Even though the technology is in place for surgeons to perform less invasive and endoscopic procedures, many do not. Why are surgeons wary of these new approaches?
BM: Whenever there is a new technology and our colleagues are not knowledgeable about it or don’t understand it well, they may develop preconceived notions about it or shy away from it. Others simply may not be aware of it because it was not included in their formal or ongoing training. That’s why I believe it is very important to teach our colleagues and get the word out to both patients and physicians about these techniques. I work with organizations offering classes for physicians, as well as offering physicians the opportunity to observe me and train with me. While some of the techniques may be new, they are not considered experimental — we’re just using different instruments and an endoscopic approach to mimic techniques used during open surgery to achieve better results.
Although I’ve found endoscopic procedures to be better in most instances, as a spine surgeon, I still perform certain open procedures. For example, traditional spinal fusions are an integral part of my practice under certain circumstances, such as where there is instability of the spine from spondylolithesis, traumatic fracture or scoliosis. However, at Spine Centers of America, we try to avoid fusion and preserve motion whenever possible. We have been successful in avoiding most fusion surgeries by performing endoscopic techniques to remove stenosis and pressure on neural structures, or we’ll perform endoscopic foraminotomy to decompress nerve roots. Recovery is complete in a few weeks versus three to five months for traditional fusion.
Q: What do you think is included under the umbrella of "minimally invasive" spine surgery?
BM: Minimally invasive spine surgery does not necessarily mean endoscopic spine surgery. The majority of physicians who are performing "minimally invasive spine surgery" are not instituting endoscopic techniques. Much of the minimally invasive spine surgery means using smaller incisions and better retractors, but the surgeon is still performing the same procedures and techniques that they used to do during open surgeries. Many physicians are still performing fusions, but they are taking a less invasive approach.
Q: What will push spine surgeons to learn the minimally invasive techniques in the future?
BM: Patients are much more educated these days. They have a lot of information and resources available to them. Right now, the majority of patients are not offered minimally invasive techniques because their surgeons aren't trained in them. These people search the Internet and look for the latest trends and cutting edge techniques. They can dig deep in the Internet to find alternatives since they elect not to undergo open surgeries or fusions.
For the vast majority of patients who contact us, one of the first statements out of their mouths is that they that don't want any fusions. Often the patient has seen two to three other surgeons and was offered fusion surgery. Many patients know others who have gone through multiple fusions and know that the recovery is hard and can lead to problems in the future. If this patient is a laborer or has a physical job, a fusion surgery could put him or her out of work for several months. With the minimally invasive procedures, the patient goes home the same day, experiences immediate reduction or relief of pain and they get back to life as quickly as possible without major downtime.
We have tremendous success in treating failed back syndrome — where a person has undergone one or more surgeries and they are told there’s nothing a traditional spine surgeon can do — especially if there is a lot of scar tissue. Most can be helped with endoscopic procedures. During endoscopic spine procedures, we go through new tissue — avoiding going through tissue that has tremendous scarring from previous surgeries. We get in and out safely and effectively when the only other alternative the patient might have is chronic pain medication and/or a spinal cord stimulator.
Q: Are there any further advantages for the patients when the surgeon performs endoscopic spine surgery?
BM: The procedure is done through a small incision and the surgeon doesn't have to strip the muscle layers away to access the area. The surgeon preserves ligaments and the supporting structures of the spine by using an endoscopic technique. In many instances laminectomy or laminotomy can be avoided. These less invasive procedures also minimize scar tissue, which can be a problem in traditional surgery.
It is recommended that endoscopic spine procedures be done under twilight anesthesia, not general anesthesia, which is especially important when treating older patients. Older patients often have co-morbidities which would make them poor candidates for open surgery. However, going in endoscopically without general anesthesia will limit the complication rate, decrease the infection rate and allow patients to have surgery who otherwise wouldn't be able to handle the procedure.
Learn more about Spine Centers of America.
15-01 BROADWAY, STE 20
Fair Lawn NJ 07410
877 722 6008
info@spinecentersofamerica.com
Read other coverage on minimally invasive spine surgery:
- Performing Minimally Invasive TLIF Procedures: Q&A With Dr. Navin Subramanian of Houston's Orthopaedic Associates
- 4 Critical Steps Physicians Must Take to Learn Endoscopic Spine Surgery
- Spine Surgery in 2011 and Beyond: 7 Points About the Future of Spine Surgery