MDNews - Cleveland-Akron-Canton

++++++++++++++++++++++++++++++++++++++++ + +++ + +++ ++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: NEUROSCIENCES O VER THE LAST several decades there have been significant technological achievements in modern spine surger y. Minimally invasive surgery (MIS), which combines principles of endoscopy and microsurgery, was conceived more than 100 years ago. There are reports about the use of endoscopy by Philipp Bozzini in 1806. Modern MIS of the spine was started in the US by Foley and Smith in 1997 by attaching an endoscope to a tubular retractor system. 1 Since then, rapid growth of MIS techniques appli- cable to all areas of the spine has evolved. The principle of MIS is using portals or limited corridors for surgical approach, which decreases surgical tissue trauma. One potential downside of conventional open spine surgery is tissue damage that occurs during the dissection, retrac- tion, and blood vessel cauterization. The potential benefits of MIS include decreased tissue injury, decreased blood loss, smaller surgical incisions, less scar- ring, shorter hospital stay, decreased requirements for narcotics, and quicker return to work. MIS of the spine has evolved from simple diskectomy and foraminotomy to complex surgical techniques for spinal deformity, tumor, instability, fractures, etc. As surgical techniques have developed, so have advancements in retractors, optics and a subset of instruments for MIS. As more surgeons became involved with MIS of the spine it was noted that there was a significant steep learning curve and exposure to radiation, increased surgical time. Not all patients are appropriate for MIS and, as with open procedures, patients should undergo conservative management including physical therapy and pain management. One of the most common spine surgery procedures is decompression for lumbar stenosis. Nearly 38,000 procedures were performed in 2007 in the Medicare popu- lation. 2 Lumbar stenosis is a major cause of lower back pain, leg pain and disability. Advanced MIS introduced the concept of the unilateral approach for a bilateral decompression. Using that technique, ipsilateral side is decompressed first fol- lowed by contralateral canal and lateral recess. This approach enables the surgeon to decompress spinal canal by unilateral approach, preserving spinous processes and decreasing procedural instability. This also helps to preserve facet joints. It has been effective with neurogenic claudication or radiculopathy. In the face of spondylolisthesis, lateral listhesis and scoliosis, the revision surgery rate is as high as 50 percent and simple decompres- sion is not recommended. With all the advancements of MIS there have also been reports urging caution about this technique. Patient selection and the surgeon's experience with the technique seem to be paramount. There are reports which support less favorable outcomes for leg pain, back pain, and perceived recovery after tubular diskectomy in comparison of conventional microdiskectomy. 3 Also, recent random- ized controlled trial demonstrated no difference in muscle damage between techniques, but patients who underwent tubular diskectomy reported more lower back pain during the first year after surgery. 4 In summary minimally invasive spine surgery technique is evolving rapidly. It is a safe alternative to conventional surgery. However, the surgical approach should be individualized based on the pathology, patient and surgeon's comfort. Dr. Toomas Anton is a board certified neurosurgeon. He leads Cleveland Clinic Neurosurgery at Western Reserve Hospital in Cuyahoga Falls, Ohio. ■ References: 1. Foley KT, Smith MM. Microendoscopic diskectomy. Tech Neurosurg 3:301-307,1997. 2. Deyo R A. Treatment of lumba r spina l stenosis:a balancing act. Spine J 2010;10:625-7. 3. Arts MP, Brand R, van den Akker ME, Koes BW, Bartels RH, Peul WC. Tubular diskectomy vs conventional microdiskectomy for sciatica: a randomized controlled trial. JAMA 302:149-158 4. Arts M, Brand R, van der Kallen Bas, . Does MIS lumbar disk surgery result in less muscle injury then conventional surgery? A randomized controlled trial.ESJ 20, volume 1. 51-7. Minimally Invasive Spine Surgery: Pros and Cons By Toomas Anton, MD 2 0 1 4 J U LY/AU G U S T ■ M D N E W S . CO M ■ MD NEWS Cleveland/Akron/Canton | 1 7

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