What Minimally Invasive Spine Surgery Means and Why it Will Survive: 5 Points From Dr. Frank Phillips

Written by Laura Dyrda | July 18, 2011 | Print  |
Frank Phillips, MD, a spine surgeon and partner at Midwest Orthopaedics at Rush, discusses five points on minimally invasive spine surgery.  Dr. Phillips is a founding member and Past-President of the Society of Minimally Invasive Spine Surgery (SMISS).

1. What defines a "minimally invasive" spine surgery.
The definition of minimally invasive spinal surgery remains elusive. Although some physicians define "minimally invasive" surgery  by the size of the incision or as a percutaneous procedure, the essential goal of minimally invasive spine surgery is to limit collateral damage to uninvolved structures, in particular the muscles, surrounding the spine. Patients seek out minimally invasive surgeries because of the perceived advantages associated with the procedures, but the tag "minimally invasive" doesn't mean the procedure will necessarily work l for all patients.

"Patients associate 'minimally invasive' with the size of the incision, but I consider it as a less-disruptive procedure, minimizing para-spinal muscle injury and damage," says Dr. Phillips. "I think the minimally invasive procedures that are most effective are the same procedures for the same indications that have been proven to work when done in an open fashion. Ideally, you want to be able to do the same operations we have done open in a less invasive way."

2. How minimally invasive surgery has evolved.
Early on in the spine minimally invasive experience, most of the efforts were focused on smaller procedures, such as discectomies. Now, there are specialized instruments, retractors and microscopes that enable minimally invasive approaches to more complex procedures. "We can now do many open surgeries through a minimally invasive approach, particularly for degenerative conditions," says Dr. Phillips. "For example, I routinely do a minimally invasive fusion procedure using screws and cages where the patients can leave the hospital the day after surgery."

In addition to established procedures, there are newer types of fusion procedures that lend themselves to minimally invasive surgery, such as the lateral lumbar interbody fusion technique. For this procedure, surgeons access the spine through the side of the body to avoid disruption of the back muscles. They implant the cage and perform fusion through the lateral incision. Dr. Phillips was involved in the development of lateral lumbar interbody fusion and was one of the initial surgeons to perform the procedure, says the "procedure has grown over the past six or seven years. It's become widely performed and has data to support it being a safe and reproducible technique."

3. Minimally invasive procedures need more clinical quality and cost-effectiveness data. In today's healthcare environment, the spine community must show that at a minimum, minimally invasive techniques are safe with good clinical outcomes. In addition, we need to show that any added costs associated with minimally invasive spine surgeries are commensurate with the clinical advantages of the procedure. "It's easy to sell minimally invasive surgeries to patients, but there needs to be quality evidence to support their effectiveness," he says. "It's been difficult to prove there is a difference between the minimally invasive and open surgeries because a lot of the standard outcome measures we use aren't designed or validated to detect difference in clinical results during the early post-operative period (first three to six months)."

Payors may balk at the cost of minimally invasive spine surgery, especially since the data doesn't yet show it is better than conservative treatment or the open procedure for certain conditions. However, when looking at the overall cost for conservative treatment versus a minimally invasive surgical procedure and considering the quality metrics associated with each treatment modality, the minimally invasive procedure may be beneficial and less expensive in the long term. "For solid indications, there is data showing that minimally invasive spine surgery works well," says Dr. Phillips.

Conservative treatment can be less expensive than surgery in the short term; however if the treatments continue over a long period of time, they can exceed the cost of a single, effective surgical procedure. "There is a lot of good evidence for a lot of what we do in spine surgery, but we haven't done a good job of getting the word out," says Dr. Phillips. "In a study out of Europe comparing a number of orthopedic diagnoses and treatments, spine surgery has had the best improvement in quality of life, even compared to hip and knee replacement."

4. The media needs more information on positive outcomes. The commercial press has recently focused on negative clinical results and high costs associated with certain spinal procedures. The positive news about good and cost-effective outcomes hasn't been as widespread. "Our professional societies need to play a role in spreading the message about positive outcomes of spine surgery and they are trying to do that," says Dr. Phillips.

Another way to combat the negative press associated with spine surgery is by encouraging patients to become involved in the advocacy efforts. "A number of patients and groups are starting to spring up to promote spine surgery when patients have done well," he says. "I think it will take patients getting involved to change the way payors and society look at this issue." Sometimes, patients come into the office and would benefit from surgery, but their insurance companies won't approve the procedure. These patients become upset and Dr. Phillips tells them to join him in the fight for broader coverage.

5. The improvements to look for in the future. Minimally invasive procedures, such as the lateral incision procedure, have become more sophisticated than it was when surgeons first started performing it in the early days. However, there are still improvements that could be made. "In terms of achieving fusion, we do pretty well, but in the future some of the instruments or techniques will become more diseases-specific," says Dr. Phillips. "Right now, we have the same instrumentation and implants for young patients with disc degeneration and older patients with spinal deformity. I think the surgical techniques will become tailored to the specific pathology, which could lead to a higher level of reproducibility and better results."  

In addition to procedural advances, spine treatment algorithms need to incorporate perioperative pain management to expedite patient recovery and resumption of activities. "Right now the perioperative pain management side of minimally invasive spine surgery hasn't been emphasized as it has in other minimally invasive orthopedic procedures," he says. "The success of minimally invasive hip and knee replacement isn't all about the surgeries; it's also about the perioperative pain management. We haven't done as much with that in spine, and I think we could."


Learn more about Dr. Frank Phillips.

Related Articles on Spine Surgery:

6 Things to Know About Minimally Invasive Spine Surgery

Spine Surgery in 2011 and Beyond: 7 Points About the Future of Spine Surgery

Dr. Richard Hynes: Why a Spine-Focused ASC is Important for the Future of Minimally Invasive Spine Surgery

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