Minimally Invasive Spinal Surgery (Keyhole Surgery)

The concept of minimally invasive surgery is not new and over the years newer techniques have been developed that make surgery more efficient and safer. Part of this development has allowed surgery to be performed through smaller incisions without compromising safety. Some commonly performed procedures which involve minimally invasive techniques include

• Microdiscectomy

• Microdecompression

• Kyphoplasty

• Vertebroplasty

• Cervical disc replacement surgery

• Tumour and fracture stabilisation

• Lumbar spine fusion

Some of these techniques are truly percutaneous procedures while others are minimally or less invasive. The addition of an operating microscope as a routine tool for use in surgery and effective and accurate fluoroscopy in the operating theatre have made this possible. These are not simple techniques and should only be performed by surgeons with training and experience in their use with the abilities to deal with any complications which may arise.

Now minimally invasive techniques have been extended to be used in fusion surgery and in particular these techniques may be used for posterior spinal fusion and for management of tumours and spinal fractures.

This means previously where fairly large incisions with large muscle dissection was required to expose the spine, similar outcomes may be achieved using minimally invasive techniques. Patients should be encouraged to ask their surgeon if minimally invasive options exist for surgery when a surgical solution to their symptoms is offered by their surgeon.

Fracture Management

Fractures of the spine are common and the most common causes for these are typically high energy trauma (car accidents, falling from a height or horse) or in the older patient in the presence of osteoporosis.

Fortunately, the majority of fractures in both these groups do not require surgery but when surgery is indicated, minimally invasive options can be considered. Traumatic fractures may be effectively managed with the use of percutaneously placed pedicle screws.

This may result in smaller scars, shorter hospital stay / day case operations and less additional trauma to the already injured soft tissues such as muscle, ligaments and tendons. Commonly, spinal fusion is not required for the management of a fracture and so these techniques may be particularly attractive as an alternative to traditional wide open techniques.

Osteoporotic fractures that remain symptomatic can effectively be managed with cement augmentation and techniques such as kyphoplasty and vertebroplasty. These techniques should be performed by a surgeon with experience and training in performing and dealing with any complications which may arise, albeit rarely.

Tumour Management

Symptomatic spinal metastatic disease is common and previously very little options existed for patients that experienced pain or neurology associated with the expanding tumour or fractures that occurred with weakened bone.All patients with metastatic spinal lesions should be under the care of an oncologist.

The oncologist will have a through knowledge of chemotherapy and radiotherapy options for the treatment of pain and metastasis related spinal cord compression. In the presence of spinal cord compression surgery needs to be considered and often this may be an urgent priority.

Minimally invasive options may be a good option in that surgical trauma is limited without an increase in risk to the patient. Cement augmentation can be used for the management of painful metastasis and has the advantage that it may often be performed under local anaesthetic and as a day case procedure.

Patients should ask their surgeon about their involvement with a multi-disciplinary team for the management of tumours and their experience and training in the use of these techniques.

Disc Replacement Surgery

Disc prolapses occur in the cervical in a similar way to the lumbar spine and cause neck and arm pain ( brachialgia). Successful decompression of the disc prolapse is an effective way of managing pain and this is performed through an incision in the front of the neck. Once the disc is removed the surgeon has a choice as to what is put in its place and typically this would be either bone (fusion) or an artificial disc replacement.

There are specific indications for when each is used and your surgeon should be able to inform you which is best suited for your specific condition.

Microscopes

The use of an operating microscope has meant that not only can surgery be performed carefully around the delicate neurological structures of the spine, but also smaller incisions can be used as the microscope aids the surgical view for the surgeon.

Procedures routinely performed with the aid of the operating microscope are discectomies/microdiscetomies, cervical disc replacements, lumbar microdecompression surgery, minimally invasive fusions. The microscope vastly improves the surgical view making these procedures safer and lowers the risk of complications.

Suggested links for additional information:

• Viper 11

• XLIF

• Longtitude