Potential of Minimally Invasive Spine Surgery In Complex Spinal Disorders

Abstract

Minimally invasive surgery (MIS) in the spine was primarily developed to reduce approach-related morbidity and to improve clinical outcomes compared with those following conventional open spine surgery. Over the past several years, minimally invasive spinal procedures have gained recognition and their utilization has increased. In particular, MIS is now routinely used in the treatment of degenerative spine disorders and has been shown to be as effective as conventional open spine surgeries. Although the procedures are not yet widely recognized in the context of complex spine surgery, the true potential in minimizing approach-related morbidity is far greater in the treatment of complex spinal diseases such as spinal trauma, spinal deformities, and spinal oncology. Conventional open spine surgeries for complex spinal disorders are often associated with significant soft tissue disruption, blood loss, prolonged recovery time, and postsurgical pain. In this article the authors review numerous cases of complex spine disorders managed with MIS techniques and discuss the current and future implications of these approaches for complex spinal pathologies.

Introduction

Conventional open surgeries have been widely used for decades in the treatment of various spinal disorders. Although conventional open spinal surgery has been considered the standard for most spinal disorders, the clinical outcomes following open surgery can vary. Suboptimal clinical results often occur even after technically successful open spine surgeries. Although contributing factors to the suboptimal outcomes in those cases may be related to poor patient selection, postsurgical scarring, or adjacent level disease, the significant soft tissue and muscle injuries that occur during exposure for open spine surgeries may also be important contributing factors.

Minimally invasive spine surgery was developed to decrease the rate of approach-related morbidity associated with conventional open spine surgery in an effort to improve clinical outcomes. Based on that philosophy, various approaches and techniques have evolved to minimize the disruption of normal surrounding tissues. Although the approach and techniques can differ between open spine surgery and MIS, the surgical goals are equivalent and should not be compromised in MISs.

Over the past several decades, MISs have been gaining momentum and popularity in many surgical specialties, including spine surgery. In 1991 Obenchain first reported a case of laproscopic lumbar discectomy. Since that initial report, MIS has become routinely used in the treatment of degenerative spine diseases, as in herniated disc removal, decompression of spinal stenosis, and fusions for degenerative spinal disorders. Compared with those in conventional open spine surgeries, the clinical outcomes of MISs have indicated that the procedure is at least equally effective. Moreover, recovery time, pain, and the time required to return to work after surgery are reduced for MIS of the spine in several clinical series involving degenerative pathology. Although we have witnessed favorable preliminary clinical results in applying minimally invasive strategies, long-term outcome studies supported by validated outcome measuring instruments are pending. Moreover, it would be interesting to determine the impact of MIS on fusion rates, adjacent segment disease, and sustained pain relief. As spine surgeons become more experienced with the techniques and technology associated with MIS, the indications for MIS continue to expand. Interestingly, the benefit of decreasing approach-related morbidity might be far greater for more complex surgeries in spinal trauma, spinal deformity, and spinal oncology. In this report, we discuss the techniques in, and the rationale for, using MIS in these complex spinal disorders and provide illustrative cases for each.