Minimally invasive spine surgery, also known as MISS, has no specific meaning or definition. It implies a lack of severe surgical invasion. The older style of open-spine surgery for a relatively small disc problem used to require a 5-6 inch incision and a month in the hospital. MISS techniques utilize more modern technology, advanced imaging techniques and special medical equipment to reduce tissue trauma, bleeding, radiation exposure, infection risk, and decreased hospital stays by minimizing the size of the incision. Modern endoscopic procedures (see below) can be done through a 2 to 5 mm skin opening. By contrast, procedures done with a microscope require skin openings of approximately one inch, or more.
MISS can be used to treat a number of spinal conditions such as
degenerative disc disease
Degenerative disc disease (DDD) is a medical condition typically brought on by the normal aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with ...
,
disc herniation
Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical ...
,
fractures
Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displa ...
,
tumors
A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
, infections, instability, and deformity. It also makes spine surgery possible for patients who were previously considered too high-risk for traditional surgery due to previous medical history or the complexity of the condition.
Methods
Traditionally, spine surgery has required surgeons to create a 5-6 inch incision down the affected portion of the spine and to pull back the tissue and muscle using
retractors in order to reveal the bone. The wound itself takes a long time to heal; the aim of minimally invasive surgery is reduce tissue trauma and the associated bleeding and risk of infection by minimizing the size of the incision.
Some minimally invasive spine surgery may be performed by a
spinal neurosurgeon or an
orthopedic surgeon
Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
and a trained medical team. Typically, they will begin the operation by delivering a type of
anesthesia that numbs a particular part of the body in conjunction with sedation or simply give a general anesthesia that prevents pain and allows the patient to sleep throughout the surgery.
[
Next, the surgeon may begin taking continuous X-ray images in real time, a process called ]fluoroscopy
Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and function ...
, of the affected portion of the spine. This allows them to see what they're operating on, in real-time, throughout the surgery without creating a large incision.[
At this point, the surgeon may begin performing the operation, by creating an incision in the skin above the affected portion of the spine and then using a device called an obturator to push the underlying tissue apart; the obturator is inside a tube, which is left behind after the obturator is removed, leaving a channel down to the spine. Small operating tools as well as cameras and a light are used through this tube. In other surgeries this is called a ]trocar
A trocar (or trochar) is a medical or veterinary device that is made up of an awl (which may be a metal or plastic sharpened or non-bladed tip), a cannula (essentially a hollow tube), and a seal. Trocars are placed through the abdomen during lap ...
; in spine surgery it is called a "tubular retractor."[
The surgeon makes the necessary repairs to the spine, extracting affected disc material out through the tubular retractor and inserting ]medical device
A medical device is any device intended to be used for medical purposes. Significant potential for hazards are inherent when using a device for medical purposes and thus medical devices must be proved safe and effective with reasonable assura ...
s, such as intervertebral spacers, rods, pedicle screws, facet screws, nucleus replacement devices, and artificial discs, through the retractor.
Robot-assisted surgery is another technique that is used occasionally in minimally invasive spine surgery.
When the procedure is done the tube is removed, and the wound is stitched, stapled, or glued shut.[
]
Specific procedures
There are many spinal procedures that make use of minimally invasive techniques. They can involve cutting away tissue (discectomy
A discectomy (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an int ...
), fixing adjacent vertebrae to one another (spinal fusion
Spinal fusion, also called spondylodesis or spondylosyndesis, is a neurosurgical or orthopedic surgical technique that joins two or more vertebrae. This procedure can be performed at any level in the spine (cervical, thoracic, or lumbar) and pre ...
), and replacing bone or other tissue.The main philosophy is least bloods, tissue damage, and keep bone/tissue architecture The name of the procedure often includes the region of the spine that is operated on, including cervical spine
In tetrapods, cervical vertebrae (singular: vertebra) are the vertebrae of the neck, immediately below the skull. Truncal vertebrae (divided into thoracic and lumbar vertebrae in mammals) lie caudal (toward the tail) of cervical vertebrae. In sau ...
, thoracic spine
In vertebrates, thoracic vertebrae compose the middle segment of the vertebral column, between the cervical vertebrae and the lumbar vertebrae. In humans, there are twelve thoracic vertebrae and they are intermediate in size between the cervical ...
, lumbar spine
The lumbar vertebrae are, in human anatomy, the five vertebrae between the rib cage and the pelvis. They are the largest segments of the vertebral column and are characterized by the absence of the foramen transversarium within the transverse p ...
. These procedures include:[
* Anterior cervical discectomy
* ]Artificial disc replacement
Artificial disc replacement (ADR), or total disc replacement (TDR), is a type of arthroplasty. It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial disc implants in the lumbar (low ...
or total disc replacement
* Epidural lysis of adhesions, also known as percutaneous adhesiolysis or the Racz procedure
* Laminectomy
A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending ...
* Laminotomy
A laminotomy is an orthopaedic neurosurgical procedure that removes part of the lamina of a vertebral arch in order to relieve pressure in the vertebral canal. A laminotomy is less invasive than conventional vertebral column surgery techniques, ...
* OLLIF Oblique lateral lumbar inter body fusion
* Percutaneous vertebroplasty, a.k.a. Kyphoplasty
* Endoscopic Discectomy
Small or ultra-small endoscopic discectomy (called Nano Endoscopic Discectomy or Endoscopic Transforaminal Lumbar Discectomy and Reconfiguration) does not have bone removal, like laminectomy or laminotomy. These procedures do not cause post-laminectomy syndrome (Failed back syndrome
Failed back syndrome or post-laminectomy syndrome is a condition characterized by chronic pain following back surgeries. Many factors can contribute to the onset or development of FBS, including residual or recurrent spinal disc herniation, persi ...
).
Risks and benefits
Risks include damage to nerves or muscles, a cerebrospinal fluid leak
A cerebrospinal fluid leak (CSF leak or CSFL) is a medical condition where the cerebrospinal fluid (CSF) surrounding the brain or spinal cord leaks out of one or more holes or tears in the dura mater. A cerebrospinal fluid leak can be either cr ...
, and typical surgical risks, such as infection or a failure to resolve the condition that prompted the surgery.
Claims are made that the larger style of MISS has better outcomes than open surgery with respect to fewer complications and shorter hospital stays, but data supporting those claims is non-conclusive.
History
Humans have been trying to treat spinal pain for at least 5,000 years. The first evidence of spine surgery appeared in Egyptian mummies buried in 3,000 BC. However, Hippocrates
Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history o ...
is often credited with being the father of spine surgery due to the extensive amount of writing and proposed treatments he produced on the topic. The first operative spine surgery is credited to Paul of Aegina
Paul of Aegina or Paulus Aegineta ( el, Παῦλος Αἰγινήτης; Aegina, ) was a 7th-century Byzantine Greek physician best known for writing the medical encyclopedia ''Medical Compendium in Seven Books.'' He is considered the “Father ...
who lived during the 7th century.
However, only within the last 50 years have advances in digital fluoroscopy, image guidance, endoscopy and minimally invasive surgical tools allowed minimally invasive spine surgery to rise to the forefront of spinal procedures.
References
{{Reflist
Minimally-invasive surgery
Surgical procedures and techniques