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Return to Techniques Advance Minimally Invasive Spinal Surgery Overview

More on Techniques Advance Minimally Invasive Spinal Surgery

Techniques Advance Minimally Invasive Spinal Surgery

New York (Feb 18, 2010)

Man with back pain

While minimally invasive techniques are the standard of care for a variety of surgical procedures, these techniques are just beginning to be applied to spinal surgeries. Surgeons at NewYork-Presbyterian Hospital are pioneering research in this field and bringing the benefits of minimally invasive surgery to patients with problems ranging from degenerative spinal disorders, such as disc herniations, to more severe conditions such as spinal tumors and scoliosis.

"The goal of minimally invasive spine surgery is to perform the same operation with less side effects, pain, and potential complications and with the same or better outcomes," explained Roger Härtl, MD, Chief of Spinal Surgery at NewYork-Presbyterian/Weill Cornell Medical Center and an Associate Professor of Neurological Surgery at Weill Cornell Medical College.

Roger Hartl, MD
Roger Härtl, MD

"Common back conditions that can be treated with these techniques include disc herniation, lumbar spinal stenosis, spondylolisthesis, and spondylolysis," said Alfred Ogden, MD, Director of the Minimally Invasive Spine Surgery Program at NewYork-Presbyterian Hospital/Columbia University Medical Center and an Assistant Professor of Neurological Surgery at Columbia University College of Physicians and Surgeons.

The benefits of the minimally invasive approach include less blood loss, less postoperative pain, lower risk for postoperative infection, less damage to collateral musculature and tissue, and earlier return to normal function and work. "Typically, this approach cuts the post-operative pain level, length of hospital stay, and recovery time in half," said Dr. Ogden, adding that the degree of these benefits depends on the type of surgery. Dr. Ogden also believes that the greater preservation of the normal spine anatomy achieved with minimally invasive techniques may translate into a reduction in the risk for long-term spine degeneration in the areas around the surgical repair. Research by Dr. Ogden and Dr. Härtl suggests that these techniques are safe and effective regardless of the patient's weight.(1,2) With traditional open surgery, an obese patient would require a longer than normal incision to access the spine.

Alfred T. Ogden, MD
Alfred T. Ogden, MD

"In the hands of a skilled surgeon, the risks of minimally invasive spine surgery are the same as a traditional open surgery," noted Dr. Ogden. "The techniques are 'technically' more demanding and require more training and experience, but I think those surgeons who are experts and have mastered these challenges will be able to do these procedures with the same or better outcomes than conventional surgery and with less complications," said Dr. Härtl. "Thus, it is important to seek out surgeons with adequate training and experience in this field as there is a considerable learning curve."

Specific Innovations

Tubular Retractors

In traditional spine surgery, a midline incision is made along the length of the spine and the muscles, ligaments, and tissue in the area of the repair must be retracted. The more lateral the area of repair is, the longer the incision and the more tissue that needs to be cut. But, the introduction of tubular retractors has allowed for major advances in spine surgery by allowing the surgeon to use a small incision and insert a small tube through the muscle belly to spread apart the muscle rather than cutting it to gain access to the problem area.

Bioabsorbable Implants

Bioabsorbable implants eliminate the need to use permanent metal implants for spinal fusions. Fusions are used to treat such conditions as disc herniation, spondylolisthesis, and spondylolysis. The metal implants are used to provide stability until the bone grows to form its own fusion, typically over a year after surgery. Because of the risks of surgery, the metal implants are never removed after bone fusion occurs even though the implants are no longer necessary. "These metal plates cause rigidity to the surrounding area and may be linked to degenerative conditions in the vertebrae above and below the fusion," Dr. Härtl said. The bioabsorbable plates are "digested" by the body over about 18 months to two years and eliminate this risk. Research by Dr. Härtl and colleagues suggests that the bioabsorbable implants have similar outcomes to metal implants.(3)

Computer-Assisted Neuronavigation

Computer-assisted neuronavigation allows surgeons to use precise, small incisions and eliminates the need to expose large areas of the spine in order to locate the area for repair. Neuronavigation is regularly used for brain surgery, but development in the field of spine surgery has been slower as the technique required is more complicated. Dr. Härtl is actively involved in a number of research trials with international spinal organizations to look at the benefits of neuronavigation and thinks that it will become a standard of care over the next 5 to 10 years.

Bioengineered Interverterbral Discs

Dr. Härtl is involved in developing tissue-engineered intervertebral disc implants grown from human cells that have the potential to reduce the need for more invasive fusion surgery in patients with degenerative disc disease. Mechanical disc prostheses have been developed and are currently available, but these are made of metal alloys and polymers that are subject to wear and fatigue and do not fully integrate with patient anatomy. This research is currently being tested in animal models.

Expanding the Field

Dr. Ogden is currently involved in research that expands use of minimally invasive techniques for scoliosis, spinal cord tumors, as well as vertebral body tumors from metastatic disease. Dr. Ogden and colleagues recently published data suggesting that minimally invasive hemilaminar exposure for treatment of an L4 intradural tumor was as effective as a typical open laminectomy, preserves the structural integrity of the spine, and minimizes changes in segmental motion postoperatively.(4) In addition, he was involved in preliminary research showing that a minimally invasive posterolateral approach for thoracic corpectomy is as effective as traditional open thoracotomy in achieving decompression of the spinal canal and ventral reconstruction of the thoracic spine.(5,6) While traditional open thoracotomy provides a direct view of the anterior thoracic spine, it involves significant muscle dissection and can result in pulmonary contusion, atelectasis, pleural effusion, hemothorax, and other complications because of the approach taken. Dr. Ogden is working to confirm the benefits of this minimally invasive procedure in a larger trial.

Dr. Härtl is involved in research on minimally invasive techniques for spinal tumors and spinal trauma. In addition to his research on tissue-engineered intervertebral discs, he recently published research on a minimally invasive presacral approach to L4-L5-S1 fusion performed using neuronavigation.(7) In addition, Dr. Härtl is involved in working to build a minimally invasive spine surgery center at NewYork-Presbyterian/Weill Cornell Medical Center that should be finalized in the next six months.

Contributing faculty for this article:

Roger Härtl, MD, is the Chief of Spinal Surgery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and an Associate Professor of Neurological Surgery at Weill Cornell Medical College.

Alfred T. Ogden, MD, is the Director of the Minimally Invasive Spine Surgery Program at NewYork-Presbyterian Hospital/Columbia University Medical Center and an Assistant Professor of Neurological Surgery at Columbia University College of Physicians and Surgeons.

References

  1. Rosen DS, Ferguson SD, Ogden AT, Huo D, Fessler RG. Obesity and self-reported outcome after minimally invasive lumbar spinal fusion surgery. Neurosurgery. 2008;63(5):956-960.
  2. Tomasino A, Parikh K, Steinberger J, Knopman J, Boockvar J, Härtl R. Tubular microsurgery for lumbar discectomies and laminectomies in obese patients: operative results and outcome. Spine. 2009;34(18):E664-672.
  3. Tomasino A, Gebhard H, Parikh K, Wess C, Härtl R. Bioabsorbable instrumentation for single-level cervical degenerative disc disease: a radiological and clinical outcome study. J Neurosurg Spine. 2009;11(5):529-537.
  4. Ogden AT, Bresnahan L, Smith JS, Natarajan R, Fessler RG. Biomechanical comparison of traditional and minimally invasive intradural tumor exposures using finite element analysis. Clin Biomech. 2009;24(2):143-147.
  5. Kim DH, O'Toole JE, Ogden AT, et al. Minimally invasive posterolateral thoracic corpectomy: cadaveric feasibility study and report of four clinical cases. Neurosurgery. 2009;64(4):746-752.
  6. Ogden AT, Eichholz K, O'toole J, et al. Cadaveric evaluation of minimally invasive posterolateral thoracic corpectomy: a comparison of 3 approaches. J Spinal Disord Tech. 2009;22(7):524-529.
  7. Luther N, Tomasino A, Parikh K, Härtl R. Neuronavigation in the minimally invasive presacral approach for lumbosacral fusion. Minim Invasive Neurosurg. 2009;52(4):196-200.

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