1. Transition to minimally invasive surgery gaining ground. While minimally invasive techniques for spine surgery have been around for more than a decade, they are only now gaining traction among surgeons and patients across the country. More patients are demanding these less invasive techniques, and for some techniques outcomes data shows better short term and positive long term results. These factors are driving more surgeons to learn minimally invasive surgery during their fellowships or take time out of their practice to train in the technique.
“More surgeons are performing minimally invasive spine surgery and it’s becoming more of the standard than it has been in the past,” says Joseph M. Zavatsky, MD, section chief of orthopedic spine at Ochsner Medical Center in New Orleans. “I think the old guard is starting to see the benefits of minimally invasive surgery as more data is being published in the peer reviewed literature.”
In the past, some surgeons have been reluctant to support minimally invasive procedures, but as clinical outcomes are proving the same or better the focus has shifted to the cost and quality benefits. Minimally invasive procedures have been shown to decrease hospital stays by anywhere from one to three days, decrease operating time and blood loss.
“If you aren’t doing minimally invasive surgery today, your practice may suffer,” says Dr. Zavatsky. “Patients are much more informed and they are coming into doctor’s offices asking for it specifically. It’s definitely coming of age and as we get more and more data about the safety, effectiveness and benefits of the these procedures and more surgeons gain more experience with these techniques, patients will ultimately benefit.”
However, not all techniques described as “minimally invasive” have been proven in the literature, and not all conditions can be treated in a less invasive procedure. “I think it’s important to ensure that minimally invasive spine surgery doesn’t mean less effective surgery,” says Sanjay K. Khurana, MD, an orthopedic spine surgeon at DISC Sports and Spine Center in Marina del Rey, Calif. “It still means maximally effective spine surgery and the goals of an effective spine surgery are accomplished.”
2. Lateral technique shows a lot of promise. While it’s still relatively new to the spine world, the lateral approach to surgery has shown a great deal of promise in treating several spinal conditions. “The reason it has become so transformative has been because it’s truly taking a procedure that has required hospitalization to one we can routinely do in an outpatient environment,” says Dr. Khurana. “It has been even more effective than existing procedures for achieving lumbar fusion.”
Even though surgeons go through a small incision for the lateral approach, they are able to put in a larger cage than with other minimally invasive approaches. The lateral incision also allows surgeons to avoid disrupting the patient’s back muscles, which makes the procedure generally less painful for patients.
“Unlike traditional surgery, where collateral damage from spine surgery can be worse than the condition itself, the lateral approach allows the benefits of fusion to be realized less invasively, more effectively, and efficiently,” says Dr. Khurana. “This approach positions the graft, which his much larger, but without the musculature disruption of the traditional approach.”
3. More powerful microscopes continually enhance visualization. More powerful microscopes are continuously being developed to give surgeons a better view of the surgical site with minimal disruption of the patient’s anatomy. Coupled with the lateral procedure, these microscopes can make a big impact on the surgical experience.
“Enhanced by microscopic visualization that allows for more predictable placement of the graft, we can demonstrate that the lateral approach is highly effective and that will likely gather momentum in the future,” says Dr. Khurana. “I think the microscopic enhanced lateral psoas approach is going to be a game changer in our practice. It’s effective for patients because it doesn’t require any division of muscles around the spine.”
Like minimally invasive surgical approaches, learning to use these microscopes does take time and effort, but can easily be incorporated into a practice. “Microscopic lateral approach is readily teachable, reproduced and should be part of the spine surgeon’s armamentarium,” says Dr. Khurana.
4. Less invasive surgeries for deformity correction. The minimally invasive approach has moved past the more simple spinal procedures and now even spinal deformity corrections have less invasive options than in the past.
“Utilizing minimally invasive techniques for deformity correction may allow you to offer patients options other than the standard open posterior deformity correction and fusion procedures which are often associated with increased blood loss,” says Dr. Zavatsky. “The risk of the increased blood loss may often prevent surgeons from offering large deformity procedures to patients, especially highrisk patients with medical comorbidities. But minimally invasive techniques can be utilized in these complex deformity patients providing an alternative way to address their pathology that is safer and more well tolerated. We can provide a safer solution to patient’s complex spinal problems in an attempt to make their quality of life better.”
There is a learning curve to the minimally invasive procedures for deformity correction that initially makes operating time longer, but in the long run it will make a difference on in your practice
“There is a steep learning curve when it comes to utilizing minimally invasive procedures to correct complex spinal deformity pathology and can initially make operating room times longer, but in the long run it can make a significant difference in patient care and ultimately in your practice,” says Dr. Zavatsky. “If indicated, I always try and use these minimally invasive techniques because of these benefits. The learning curve is steep, but after you do several cases and become more comfortable and efficient with these techniques, I feel it’s a game changer.”
5. More surgeons enrolling in minimally invasive cadaver labs. There are several new minimally invasive techniques brought forth by different companies and spine surgeons are able to compare them side by side at cadaver labs during events such as the Society for Minimally Invasive Spine Surgery annual meeting.
“The SMISS meeting is a great opportunity for spine surgeons to get their feet wet and get exposed to these procedures and the supporting literature that’s out there,” says Dr. Zavatsky. “Surgeons can interact with nationally and internationally respected spine surgeons and ask questions about how to approach different problems and avoid complications. It’s a great forum for surgeons to interact and learn.”
Surgeons can also shadow experienced spine surgeons to watch the procedures in action and learn how to use new equipment for the technique.
“Some surgeons are very open to allowing you to come into their OR and watch these surgeries,” says Dr. Zavatsky. “My operating room is always open to visiting surgeons and I truly enjoy sharing my experiences with MIS. But you also need the experience of the cadaver lab because minimally invasive procedures are a totally different animal when compared to traditional open surgery. You have to visualize things three-dimensionally and spatially know where you are. Cadaver courses and visiting an experienced surgeon’s OR are two great ways to become more comfortable with this procedure and technology.”
6. Motion preservation with disc arthroplasty preformed in outpatient settings. Surgeons and device companies have had developed cervical disc arthroplasty procedures as an alternative to spinal fusion and proven their effectiveness, but insurance companies are still hesitant to reimburse for these surgeries.
“Motion preservation and disc arthroplasty are areas that show promise for the future,” says Dr. Khurana. “I have found that cervical arthroplasty is more predictable and has less of a downside than lumbar disc replacement. We can do some procedures in the outpatient surgery center that were traditionally done in the hospital.”
Artificial discs continue to advance and companies are producing new innovations in this area, but insurance company coverage and approval remains an issue in this area.
7. Biologics and stem cells will have a place in the future. Biologic solutions are intriguing for spine surgery, but in most cases they are still in the developmental and experimental stage of utilization. Bone morphogenic proteins have been used to enhance fusion, but recent controversy about adverse events have prompted several surgeons to refine how they use BMPs.
“My personal practice is not to use BMP as much as I had in the past and reserving it only for high risk cases,” says Dr. Khurana. “Instead, I think biologics, including mesenchymal rich solutions — like OsteoCell or Trinity used with the iliac crest — will prevail.”
In the distant future, stem cells stand to play a big role in spinal care. “I think the final frontier is related more to stem cells than any other technique,” says Dr. Khurana. “Right now, there isn’t very good scientific knowledge to suggest stem cells are superior to traditional techniques, but I think they will have a role to play in the future.”
However, this future is still a far way off and we should expect fusions to remain popular. “Fusion still plays a very important role and will continue to play an important role for years to come, until we can develop ways to biologically treat disc degeneration and instability, fusion will remain a mainstay of treatment,” says Dr. Khurana. “For the next decade, optimizing lumbar fusion with a minimal downside and risk, and maximizing the upside of recovery and return to activity, are the key things people should focus on.”
7 Trends Impacting the Future of Spinal SurgeryWritten by Laura Miller | Sunday, 14 October 2012 22:22
Here are seven trends making a huge impact on the future of spine surgery.
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