Over the years, surgery in most specialties has become less invasive to preserve the patient's natural anatomy and achieve quality outcomes. Spine is no different; however, the explosion of minimally invasive techniques over the past decade has caused controversy as well as realized benefit.
"One of the things that makes spine surgery so exciting is the sustained growth of knowledge and technology in the field," says Brian Grossman, MD, of Southern California Orthopaedic Institute in Van Nuys. "It is incumbent on the spine surgeons to keep up with the growth of knowledge in the field and adopt those techniques which are supported by evidence and they personally feel allow them to do a better job in the OR."
Several compounding factors will impact how minimally invasive spine surgery is received in the future:
• Long term quality and cost comparisons;
• Technology development;
• Training techniques;
• Patient demand;
• Downward pressure on reimbursements.
"Unquestionably, spine surgery is heading to a less invasive surgical technique," says Kern Singh, MD, Co-Founder of the Minimally Invasive Spine Institute at Rush in Chicago. "Patients are becoming much more educated about the surgical options available and are placing a premium on return-to-work and function. Five years ago minimally invasive spine surgery was only done in a few centers; now it's exploded. Younger surgeons are learning the technique earlier in their career and advancing the field in a logarithmic fashion."
Imaging technology also plays a role in minimally invasive surgery development. "The complexity and learning curve required for MIS surgery will lessen as more reliable imaging technology is developed that will aide safe guidance of tools and implants to desired anatomic locations," says Alexander Vaccaro, MD, of Rothman Institute in Philadelphia. "The learning curve now involves mastering how to work through a tubular corridor with instruments that are elongated where one must master the ability to effect movement of the proximal end of the instrument over a greater distance."
Neurosurveillance technology can also help prevent neural injury when surgeons access the spine, which is important when using indirect methods to visualize spinal anatomy.
"Surgeries will become less invasive over time as long as safety can be insured," says Dr. Vaccaro. "These techniques are welcomed in revision procedures when open dissection can be technically difficult and associated with greater soft tissue morbidity. If one has to decompress the neural elements in the setting of significant scarring from previous surgeries, open techniques may be more reliable if superb visualization with MIS methods cannot be achieved."
Minimally invasive techniques also open the door for spine surgeons to perform cases in the outpatient ambulatory surgery center setting. A select group of surgeons is already performing such cases.
"Eighty percent or more of my cases are now done with a minimally invasive technique," says Richard Kube, MD, Founder of Prairie Spine & Pain Institute in Peoria, Ill. "That's a huge difference from the 20 percent it was five years ago. My practice is migrating that way and with the ability to do minimally invasive procedures, a lot of spine can be done in the ASC. Typically ASCs are cheaper and provide greater value with fewer complications and higher patient satisfaction rates. I think that's the reason we will see even more of these procedures performed this way in the future."
However, open spine surgery isn't going away any time soon.
"I think there will always be a role for traditional open approaches as well as minimally invasive spine cases," says Zachary A. Smith, MD, of Northwestern Memorial Hospital in Chicago. "I think the role for minimally invasive surgery will continue to expand and I think at a certain point as more surgeons become comfortable with it, it will be less of a novelty. It will be the regular way we do things. But there will always be indications for open surgery, like revision cases or larger tumor cases. There will also be cases that demand a hybrid of the two techniques."
More Articles on Spine Surgery:
Cost-Effectiveness: How Do MIS & Open Spine Surgeries Compare?
Cervical Artificial Disc Replacement: What the Long-Term Data Means for Spine
20 Recent Spine Surgery Studies and Findings