"My patients are happier with the minimally invasive procedures," says Scott Kitchel, MD, of NeuroSpine Institute in Eugene, Ore. "They are undergoing outpatient surgery or shorter hospital times with quicker recoveries. There are increased costs for specialized instrumentation for some procedures, but as the field evolves, the cost curve will be driven down for minimally invasive surgery because the procedure can be done in a setting where patients return home quickly."
He sees value spreading in two separate arenas: improved outcomes and cost reduction. There are an increasing number of researchers dedicated to proving value in clinical outcomes for minimally invasive surgery and publishing their results.
The value of outpatient setting
The outpatient surgery center affords convenience for the patient and surgeon, with less administrative burden and increased efficiency.
"The next major phase of MIS surgery is the concept of making routine lumbar degenerative spine surgery in the ambulatory surgery center," says Charla Fischer, MD, with Columbia Doctors and The Spine Hospital at New York-Presbyterian in New York. "Through patient safety, quality management, good pain protocol, infection prevention, and proper patient selection, I am achieving good results with outpatient spine surgery. That's the next step."
The outpatient surgery center allows surgeons to perform cases faster and patients return home quicker. But patient selection is key and surgeons must ensure the outpatient center is helping the patient and preventing postoperative issues.
"I think we are almost at the tipping point where MIS surgery will become more prevalent because the technology allows us to feel comfortable with it," says Dr. Fischer. "Everyone will see how well patients do with it and then it will become the standard of care."
Data shows patients like the outpatient setting and ambulatory surgery centers prize spine procedures if they can be performed safely.
"The surgeons I know who have experienced spine surgery at the outpatient center are always looking to adopt new cases there as long as they can achieve equal or superior results," says Dr. Kitchel. "The primary goal of the surgeons on the behalf of their patient is outcomes, and the outcomes of any minimally invasive procedure have to be as good or better than the traditional approach. I don't think you'll see many surgeons willing to compromise patient outcomes to turn a procedure outpatient."
The value of technology
One of the primary developing areas in technology for less invasive procedures is imaging and real-time visualization to techniques. Thirty years ago, surgeons often took multiple plane X-rays for a case to confirm placement. Now, surgeons are performing cases with real-time fluoroscopy, multiplane fluoroscopy and computer-guided technology.
"The technology is just getting better and better, and the MIS approaches can be done safely for a wider range of patients," says Dr. Fischer. "Some of the technologies that are helping surgeons provide MIS surgery for more patients includes Invuity's Intelligent Photonics™. The technology allows me to see more of what I’m doing with a smaller incision. I am exposing less, but I’m still able to see the whole surgical field."
Surgeons have more confidence in their less invasive procedures when they can visualize the surgical field. Invuity’s Intelligent Photonics Technology is integrated into illuminated access systems, handheld illuminators and “drop-in” illuminators, which illuminate the surgical cavity from the inside out. That allows surgeons to operate with better precision, efficiency and safety. Dr. Fischer is now training residents with the technology.
"With technology improving and surgeons gaining more experience with this new technology, they can do more advanced procedures," says Dr. Fischer. "I may need to perform surgery on multiple levels such as revision surgeries or deformity surgeries, and with new technology I can use an MIS approach. This allows me to do more with less time for recovery, and this is particularly helpful for older patients in whom a long recovery would be very difficult.”
The technology shift in spine now is similar to the shift in knee arthroscopy. The older generation of surgeons said knee arthroscopy wouldn't catch on in the 1980s and that it was just a fad, but now knee arthroscopy is the gold standard.
"I can't recall the last time I saw an open meniscectomy," says Dr. Kitchel. "I think this is an evolutionary pathway and generational change. When I went through my orthopedic fellowship, we didn't have MIS training. But the data collection now is showing outcomes are adequate for minimally invasive approaches in spine."
There are many operating rooms with CT scans available interoperably. "I think we'll continue to see evolution here," says Dr. Kitchel. "Often the most challenging part of the procedure is tying the imaging to the procedure to make sure you are doing it safely and efficiently. The positive data will lead to further adoption."
The value of new techniques
Minimally invasive techniques for spinal disorders and diseases have evolved tremendously over the past 15 years, but there is a learning curve for surgeons trained in traditional open techniques.
"I think the training should be done in a lab and under observation by other surgeons," says Dr. Fischer. "A lot of surgeons aren't comfortable with these techniques if they've been doing open surgery for a long time. That’s why it’s nice to have navigation tools and technology like intracavity illumination, because surgeons can feel more comfortable that they've achieved what the patient needs."
One of the biggest value areas has been in the sacroiliac joint. For years, patients presented with low back pain and surgeons treated the lumbar spine instead of the SI joint because of lack of experience with the SI joint.
However, minimally invasive SI joint fusions and a new push to re-examine the SI joint as a pain generator are yielding positive results.
"The whole diagnosis and approach is being reconsidered," says Dr. Kitchel. "It's really revolutionized our patient care as sacroiliac joint pain represents a significant percentage of lower back pain and the new minimally invasive technique and rapidly growing diagnosis understanding bodes well for patients."
He participated in a prospectively randomized comparison of patients who received surgical or non-surgical treatment for SI joint disease with positive results. Three new studies were recently published examining the iFuse system from SI-BONE and the results include:
1. In the first study researchers found iFuse achieved a 52-point reduction in SI joint pain at six months on the Visual Analog Scale compared with a 12.2-point decrease in the non-surgical management group. At 12 months, the surgical group reported a 54.2-point reduction from the baseline VAS measurement. Nearly 80 percent of the non-surgical group elected to have the iFuse procedure after six months of non-surgical care.
2. The second study reported one-year results from a multicenter clinical trial of minimally invasive SI joint fusion that included 172 subjects at 26 centers in the United States; twelve-month postoperative follow-up was available in 157 of 172 initially enrolled subjects (91 percent). Six months after surgery, 81 percent of the patients reported a "successful" treatment; at 12 months, the procedure had an 80 percent success rate. The average SI joint pain improved from 79.8 at baseline to 30 and 30.4 at six and 12 months. There were around 92 percent of the patients reporting they would have the procedure again at six months after surgery; 91 percent said the same one year after surgery.
3. The third study was a systematic literature review examining 18 articles measuring patients' pain, disability and quality of life following MIS SI joint fusion. The researchers found the procedure was 59 minutes on average, blood loss was 36.9 cc and hospital length of stay was 1.7 days. Pain scores and ODI scores improved for patients after surgery.