14 spine and neurosurgeons share their insight on the future of minimally invasive treatments for spinal disorders.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.
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Note: The following responses were edited for length and clarity.
Question: What are the most promising developments in minimally invasive treatments for spinal disorders?
James Chappuis, MD. Spine Center Atlanta: I believe the endoscope is going to revolutionize minimally invasive spine surgery. We are at the tip of the iceberg and the next three to five years will most likely see a dramatic increase in procedures done endoscopically, including spinal fusions.
Nitin Bhatia, MD. UCI Health (Orange, Calif.): Improvements in treatments for spinal disorders must help surgeons achieve our spine surgery goals including decompression, stabilization and realignment. The developments specific to MIS treatments should minimize the challenges of MIS. Some developments that may be particularly useful in minimally invasive spine surgery include improved visualization, such as advanced microscopes and endoscopes. Additionally, intraoperative navigation systems will be especially useful in MIS due to the decreased field of view and lack of anatomic landmarks for the surgeon to use. MIS specific implants and associated instrumentation will continue to make spinal fusion cases feasible, even in larger and more complex cases. In minimally invasive spinal fusions, the ability to prepare the fusion bed for graft material is more challenging than open cases, and improved biologics may help compensate for this challenge.
Khalid, Kurtom, MD. University of Maryland Shore Medical Center at Easton: Robotics and intraoperative navigation are the focus of future advancements in MISS. Now, we have systems that allow for optimal and safe pedicle screw insertion in MISS, including patients with severe deformity needing correction. Moving forward, the focus will be to expand the capability of robotic systems to assist with the decompression portion of the operation. Ideally, we will move toward total robotic MIS, where the entire operation — including the decompression and fusion — will be performed with the robot. Operating with the robot will require training and will have a steep learning curve, which is also exciting for MIS surgeons eager to advance their surgical scope and capacity.
Brian R. Gantwerker, MD. Craniospinal Center of Los Angeles: Single position surgery, while perhaps not 'minimally invasive,' is offering less operative time and shorter anesthetics for patients. Coupled with robot technology, time savings and less radiation exposure, it is a watershed moment in spinal instrumentation. The wider adoption of endoscopic spine is now bringing in truly minimal incisions and even awake spine surgery.
Raymond Gardocki, MD. Campbell Clinic Orthopedics (Memphis, Tenn.): Endoscopic spine surgery for adult degenerative pathology will become mainstream. As equipment improves and implants are developed, endoscopic interbody fusion will become more popular and allow these cases to transition to the outpatient center. Decreased morbidity, less need for postoperative narcotics and a higher fusion rate — due to direct visualization of the endplate preparation — should be the result.
Neal Washburn, DO. MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): Orthobiologics and regenerative medicine have become one of the more promising forms of treatment for certain spine disorders. The science is still developing, and there are questions still to be answered, but these procedures are offering patients alternative options for chronic spine pain. Such procedures include platelet-rich plasma and bone marrow concentrate injections, which contain hundreds of growth factors that promote healing in areas of chronic injury. The procedures are considered minimally invasive and are performed on an outpatient basis.
Brian Adams, MD. Spine Center Atlanta: As an interventional spine physician, I have seen an explosion of new advancements to the specialty over the past five years. Neuromodulation, including dorsal column, dorsal root ganglion and peripheral nerve stimulation, continues to improve and new products are introduced regularly. This allows the technology to be custom-tailored to specific patient needs. We have to become better as physicians in combating the opioid epidemic for patients suffering in pain. This provides an excellent treatment platform for patients who have exhausted other options. New advancements in vertebral ablation for refractory anterior vertebral column pain are producing promising results. In addition, the field of regenerative medicine continues to provide an alternative option to help repair damage tissue and decrease suffering.
Mark Mikhael, MD. NorthShore Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): Robotics is the future in minimally invasive treatments for spinal disorders. It has the potential to provide minimal access placement of implants. It will likely be another five years before we find the right platform and computer software. There is a big learning curve to transition to this technology, but once perfected, I anticipate better patient outcomes to follow. Efficiency and workflow in the OR seem to be the biggest hurdles at this time.
Issada Thongtrangan, MD. Microspine (Phoenix): Endoscopic instruments and techniques will continue to evolve. I am a big believer in the technology as I have seen many of my own patients have tremendous success after endoscopic spine surgery. Endoscopic fusion is coming. Also, I believe navigation, 3D printing, virtual reality and artificial intelligence will be on the rise.
William Taylor, MD. University of California San Diego Health System: Minimally invasive spine continues to increase opportunities for outpatient procedures and short hospital stays. This will not be only procedure-based, but in combination with enhanced recovery after anesthesia techniques and long acting local anesthetic. These will broaden the options for what are not normally considered outpatient procedures. For example, mini anterior lumbar interbody fusion, anterior cervical discectomy and endoscopic fusion.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Computer navigation and robotic technologies are making MISS more precise, safe and efficient. So far robotic-assisted spine surgery has been mostly applied to screw placement. As the technology becomes more advanced, more parts of the spine procedures will be navigated and automated, leading to better patient outcomes.
Expandable spacers for interbody fusion are also becoming more advanced, allowing for less trauma to the endplates and surrounding soft tissues. This will reduce the chance of complications and improve fusion rates. Finally, endoscopic spine surgery technology and instruments are becoming more advanced and reliable, which will further push the envelope of MISS.
Ram Mudiyam. Hoag Orthopedic Institute (Irvine, Calif.): Over the past ten years, there has been an increasing interest shown in minimally invasive spinal deformity surgeries, including long segment pedicle screw instrumentation as well as posterior, anterior and lateral interbody fusion with cages. Recent advances such as percutaneous sacroiliac fusion and minimally invasive posterior cervical facet fusion with instrumentation are gaining popularity. Other areas where MIS is being adopted include trauma and tumor surgery.
Injectable biologics and regenerative techniques may hold the keys to true innovation, with MISS perhaps eliminating the need for extensive spinal instrumentation. While many of these techniques hold a lot of hope and promise, they have not been subjected to vigorous testing with long term follow-ups, which are essential in determining which of them will endure and survive, and which will fall by the wayside.
Daniel Hoernschemeyer, MD. University of Missouri Health Care (Columbia): The most promising development for spinal systems is vertebral body tethering. This approach can be used to patients diagnosed with the most common form of scoliosis, which is idiopathic scoliosis, a curvature of the spine. Although many pediatric patients with idiopathic scoliosis are treated with bracing, not all are candidates for this treatment. VBT is a minimally invasive alternative that can markedly correct this condition, especially for patients who are skeletally immature and have some spinal flexibility.
As a pediatric orthopedic specialist, this is an especially exciting development, given it improves correction of scoliosis and allows for continued growth and additional straightening of the spine as the patient develops. It offers an additional treatment to children with operative scoliosis or who have a high risk of progression.
Neel Anand, MD. Cedars-Sinai Spine Center (Los Angeles): The minimally invasive treatment of adult spinal deformity and scoliosis has been one of the most significant advancements in minimally invasive spine surgery. The surgical treatment of scoliosis has evolved immensely over the past few decades and can now be treated using minimally invasive techniques. These techniques include smaller incisions that enable surgeons to preserve delicate tissues surrounding the spine, reduce the risk of complications and help the patient recover faster — usually with a fraction of the pain that is associated with open surgical correction of scoliosis.