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What does Minimally Invasive Spine
Surgery mean to you and your patients?
DR. BRIAN MILLERAPEX NEUROSURGERY
GOAL IS TO HELP ANSWER THE QUESTION: WHEN TO REFER TO THE NEUROSURGEON
AND WHAT IS MINIMALLY INVASIVE SURGERY REALLY ABOUT?
Jarvik et al (2001) and McCullough et al (2011):
• Patients WITHOUT back pain have the following findings on MRI:
83% had severe disc desiccation or degeneration of one or more levels
64% had one of more bulging discs
56% had loss of disc height
6% had disc extrusion
MOST LOW BACK PAIN IS NON SPECIFIC (NO
RADIOLOGICAL FINDINGS)
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MCCULLOUGH (2011) HAS RECOMMENDED THE FOLLOWING
BE ADDED TO ALL LUMBAR MRI REPORTS:
Follow up studies showed that among patients whose reports had this disclaimer were significantly less likely to receive narcotic prescriptions for their pain but had no difference in whether they were referred for steroid injections or to a surgeon.
SEVERE DEGENERATIVE DISC DISEASE
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DISC SPACE COLLAPSE/DESICCATIO
N
DEGENERATIVE DISC DISEASE
• Rarely caused by major trauma • Everyone has it. (Normal finding on MRI
over age 60)• When severe, chronic inflammation to the
disc annulus produces irritation to adjacent nerve root and joints: Normal spine ROM becomes painful (Focally) often with radiculopathy
FORAMINAL STENOSIS
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FORAMINAL STENOSIS
• Usually unilateral in nature from bony overgrowth (Osteophytes, facet hypertrophy) or occasionally soft tissue (ligaments, disc fragment, synovial cyst)
• Less likely to have focal pain and spasms, more likely to have radiculopathy and weakness of a specific nerve root
LUMBAR DISC HERNIATION
CERVICAL DISC HERNIATION
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DISC EXTRUSION
DISC HERNIATIONS AND EXTRUSIONS
• Lots of poorly defined synonyms: Bulging disc, Slipped disc, Herniated disc, Pinched Nerve, Ruptured disc.
• Extrusions, or free disc fragments, seldom resolve without surgery and can produce severe pain and cauda equina symptoms.
• ~10% of Disc Herniations will end up having surgery even with maximal conservative treatment
SPONDYLOLISTHESIS
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SPONDYLOLISTHESIS
• Graded from I-IV based on % of overlap of the 2 vertebrae involved.
• Isthmic: Pars interarticularis fracture (“Scotty dog”), often occult
• Degenerative: Represents ligamentous laxity, usually present > age 60
• Pain with position change (sitting to standing), sometimes a “Clunk” is felt, leg spasms and intermittent leg weakness common
CENTRAL CANAL STENOSIS
CENTRAL CANAL STENOSIS
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CENTRAL CANAL STENOSIS
• Can produce multi-level nerve root or diffuse spinal cord dysfunction symptoms:
• bowel/bladder/sexual dysfunction• Pain and paresthesias and/or weakness of
multiple dermatomes• Often Slow and progressive symptoms if from
facet and ligamentous hypertrophy, tumor versus Fast onset if disc herniation, spondylolisthesis, hematoma, infection
COMPRESSION FRACTURE
COMPRESSION FRACTURE
• Clinically significant when more than 15% compressed
• Important to also assess for angulation or any retropulsion of fragments (Need axial images to do this)
• Establish and document precise time frame of symptoms and if history supports pathologic or osteoporotic cause
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OTHER RADIOGRAPHIC FINDINGS IN PATIENTS
WITH BACK PAIN
KYPHOSIS
SCHMORL’S NODES
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SCHMORL’S NODE
FACET HYPERTROPHY/ FACET DISEASE
FACET HYPERTROPHY
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REVERSAL OF LORDOSIS
Algorithm for the management of low back pain in adults.Adapted with permission from Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [published correction appears in Ann Intern Med. 2008;148(3):247–248]. Ann Intern Med. 2007;147(7):482.
KEY: Clinical findings correlated with radiographic findings
Review old imaging reports for mention of same findings from when patient was asymptomatic.
Progression of symptoms and radiographic findings in tandem
Any progressive neurological deficit even in the absence of convincing imaging findings.
Pain control or symptom control failure after conservative management, PT referrals or Pain management
SO WHO DO I REFER TO A SURGEON?
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Lumbar stenosis: Neurogenic Claudication
Cervical Stenosis: Any signs of myelopathy
Formaminal Stenosis: Drop foot, Dropping objects from hands
Spondylolisthesis: Severe back pain, sensory loss
Compression fracture: any detectable pinprick level or band of anesthesia
SO WHO DO I REFER TO A SURGEON?
OPEN VS MINIMALLY INVASIVE SURGERY
• All Spinal surgical procedures break down into 3 broad categories:• Decompression, Fusion or Arthoplasty• Minimally Invasive Spine Surgery (MIS) changes
the road, not the destination, of these procedures
• Improvement in: Post-op Pain, Blood Loss, Hospital Days, and Return to Work associated with MIS procedures
MIS BENEFITS
• Better outcomes when treating pain as asurgical indication because of less muscle and soft
tissue destruction and atrophy• Improved cosmesis (Surgical scar and swelling
significantly reduced) and wound healing time• Reduced post-op Infections (1.5-4% vs 5-6%)• Less rehab and Post-op PT indicated• Global cost-saving for patient and facility (after
initial investment)
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MIS LAMINECTOMY TRADITIONAL
SURGICAL SCAR COMPARISON
• Steep learning curve with MIS surgery
• Many older surgeons reluctant to change practice style and
undergo more training• High initial cost: imaging, retractors, OR suite re-design
• Long term outcomes are statistically
equivalent (Fusion rates, satisfaction, re-
operation rate)• Radiation exposure is
significantly higher for surgeon over
course of a career
WHY DOESN’T EVERY SPINE SURGEON OFFER MIS SURGERY?
Tradi t iona l Open Fusion MIS Fusion
MIS VS OPEN
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• Image Guidance or assisted surgery
• Advanced knowledge of anatomic planes for surgical planning to
maximize results• Use of specialized tools,
training and products to achieve conventional
spine surgery outcomes
• “Laser Surgery”• Called a “Treatment” or
“Procedure”• Is a label that can be
used by any spine surgeon
• The best approach for all conditions
• Used by most Spine Surgeons (Only 10% in US are trained in MIS)
MIS IS:MIS IS NOT
WHAT MIS SURGERY IS AND ISN’T
OR With Imaging Guidance for MIS Spine Surgery
TREATMENT OF RADICULOPATHY
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LAMINECTOMY AND FORAMINOTOMY
TREATMENT OF CENTRAL STENOSIS
LAMINECTOMY
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LUMBAR DISC HERNIATION OR EXTRUSION
DISC HERNIATION OR EXTRUSION
DISCECTOMY
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CERVICAL DISCECTOMY
ACDF INTERBODY PEEK CAGE
ACDF INSTRUMENTATION
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CERVICAL ARTHOPLASTY
CURRENT ARTHOPLASTYDEVICES
SPONDYLOLISTHESIS
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SEGMENTAL INSTRUMENTATION AND FUSION
VERTEBRAL COMPRESSION FRACTURE
VERTEBROPLASTY/KYPHOPLASTY
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MINIMALLY INVASIVE DESCRIBES SOFT-TISSUE ROUTES
MINIMALLY INVASIVE IS NOT NON-INVASIVE
TAKE HOME POINTS
• Patients who require spine surgery have more treatment options when evaluated by a Minimally Invasive Spine trained surgeon
• They are statistically more likely to recover quicker, with less post-op pain and blood loss, less narcotic usage, and less surgical morbidities with MIS surgery.
• Outcomes are equivalent at >1 year regardless of surgical approach used
