Making Minimal Access Spine Surgery the Standard Procedure: Q&A With Dr. Robert Greenfield of Resurgens Orthopaedics


Robert T. Greenfield, MD, a spine surgeon with Resurgens Orthopaedics in Atlanta, discusses the benefits and challenges of minimal access spine surgery, and its natural progression to become the standard of care in the future.
Q: How do you define minimally invasive surgery?

Dr. Robert Greenfield:
The most important thing to understand is you are performing the same procedure through a smallest access point. You aren't doing less of a decompression or fusion because you are working through a smaller access point. Years ago we were doing the open laminectomy, decompression and fusion. Technological advances in visualization have allowed us to do the same procedures but through a smaller incision. The standard procedure for lumbar laminectomy is a fairly larger incision — 15 cm to 20 cm. Through minimal access, I can make a 3.6 cm incision and I don't have to go directly through the midline.

Even though the incision is 3.5 cm, opening the retractor gives me access of about twice that distance. I use my microscope to view the surgical space, and perform the decompression. Once I see what I need to see, the procedure is done in a similar fashion as open surgery.

Q: Why is it important to perform the same procedure?

It's important because there are some surgeries not performed by spine surgeons that don't allow the surgeon to visualize the spine; that is the important thing for spine surgeons. We visualize the nerves and we see them when we decompress the nerves, so we do it in the same way as an open decompression.

Q: Are there any challenges to the minimal access procedure?

Minimal access surgery has advantages and disadvantages. The disadvantage of any new procedure is the learning curve. It is a very steep learning curve to perform the procedure and have a degree of confidence in doing it. The learning curve also involves understanding who is a good candidate for the procedure. Some patients might have too many comorbidities for good results.

I've been doing it for eight years and have experienced the learning curve. Another disadvantage is during the learning curve the procedure may take longer.

Q: What are the advantages of performing minimal access surgery?

The advantages include decreased blood loss, significant decrease in tissue damage — because it doesn't involve splitting muscle — and less pain postoperatively. There is a quicker recovery and decreased hospital stay. When you decrease tissue disruption, blood loss and hospital stay, you decrease incidence of infection as well.

I don't want to imply that the open method is a bad method; it's a great way to do a decompression and in many people you have to do the decompression that way. I just think there are advantages to the minimal access procedure.

Q: What will it take to make minimal access surgery more pervasive?

We'll need to see training during the course of residency in minimal access procedures. As this generation of spine surgeons learns the technique, we will see it performed more and more. There will be a natural progression and within 10 years from now it will be a fairly standard procedure.

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