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Minimally invasive methods of spine surgery have been around for over a decade, but they aren’t used as widely as might be expected, especially in the central part of the United States.

Traditional spine surgery opens a fairly large incision through which the surgeon cuts muscle tissue and peels it away from the spine. Organs, blood vessels, and nerves are moved to provide access to the spine, and then the spinal surgery is completed.

Minimally Invasive Surgery (MIS) is different. Using microendoscopes and high tech imaging systems, surgeons insert small tubal retractors through incisions only five to ten millimeters in size. The opening is gradually dilated, pushing muscles aside rather than cutting them, and instruments are inserted through the tubes. The incision is closed and requires only a small dressing.

The benefits of MIS are impressive. Using a very small incision and very small microendoscopic tubes allows a surgeon to reach and repair the spine without cutting muscles or significantly damaging soft tissues. Because less damage is done to the tissues, patients have less blood loss, less scarring, a shorter hospital stay, and shorter recovery time.

Clinical studies have reported striking differences in recovery time: 45 days of bed rest for traditional spine surgery compared with less than a week for MIS. This difference alone leads to less chance of infection, less pain, and less disruption in the lives of the patients.

These are proven results in my own experience. Using these techniques to treat football players with ruptured discs gets those players back onto the field faster. Nearly all patients experience a return of functionality quicker with MIS. The results, when it comes to lower back surgery, are essentially the same except for the recovery time – but that makes a big difference in the lives of our patients.

Why has MIS not become the standard approach?

It’s important to recognize that minimally invasive spine surgery is quite different from traditional open surgery. Some surgeons work to bring the traditional five to seven inch incision down to a few inches and call that "minimally invasive," even if they still cut muscles and bone and follow traditional open surgery practices. Such procedures are actually quite invasive; the size of the incision isn’t the only point of difference.  MIS uses different equipment and methods from open spine surgery.

Medical facilities have to invest in the necessary equipment if they are going to support the surgeon using MIS. Imaging equipment and microendoscopic systems aren’t inexpensive. Hospitals in areas like Arkansas where fewer surgeons use MIS techniques may hesitate to make the investment. In a recent article by a physician, he claimed that communities where few doctors are performing MIS will not be forced by competition to take up the practice and therefore will not be able to justify the costs associated with the specialized equipment.

Perhaps more importantly, MIS techniques have a steep learning curve. These techniques cannot be picked up in a weekend seminar.  While courses with cadavers are available, surgeons must perform several operations utilizing these techniques in order to become comfortable with them.

The methods are highly technical and complex, and not all surgeons will find them natural. Some traditional surgeons try minimally invasive techniques during a course and decide that they are unable to provide as good an outcome with these methods than with their traditional approaches. If they are already satisfied with their current methods, they may not be willing to take the time required to become skillful with the minimally invasive techniques.

For me performing MIS has become second nature.

The decision comes down to this: is it worth making the effort to implement the newest developments in our field, or not? In cases where the outcome for my patient is greatly improved because of minimally invasive spine surgery, the answer has to be "Yes."

As patients become more and more knowledgeable about their healthcare they will begin to expect minimally invasive surgery, since it is clearly an advantage for them. As surgeons, we should be ready.


Dr. Calhoun completed his undergraduate work at the University of Arkansas, Fayetteville, in 1981. After receiving his MD from UAMS in 1985, he completed an internship and residency at UAMS followed by additional training on instrumentation of the cervical and lumbar spine and in minimally invasive techniques using the MED system. Dr Calhoun is a Fellow of the American College of Surgeons, a member of the American Association of Neurological Surgeons, a member of the Congress of Neurological Surgeons, the North American Spine Society, the Society for Minimally Invasive Spine Surgery and the Arkansas Medical Society. Dr. Calhoun is also a member of the American Medical Association and the Pulaski County Medical Society, and is a board certified neurosurgeon practicing at Arkansas Surgical Hospital in North Little Rock.

 

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