Minimally invasive technologies were introduced in the field of spinal surgery later than in other surgical fields. This is due to the difficulty in forming a complete surgical approach and imaging of the spinal cord while working with miniature endoscopic instruments, through small incisions in the surrounding tissues.
Nevertheless, after the beginning of the active use of computed tomography (CT) and magnetic resonance imaging (MRI), a better understanding of the biomechanics of the spine has led to a wider introduction of microsurgical procedures in clinical practice. The development of more modern instruments and surgical techniques has also contributed to this. Today, minimally invasive spine surgery ranks among the list of first-line procedures in case of ineffectiveness of conservative treatment.
What types of diseases can be cured with minimally invasive surgery?
According to the World Health Organization, back pain or back pain occurs at least once in a lifetime in 80% of the world's population. In addition, more than 2% of patients need surgical treatment. Minimally invasive operations are performed in case of lack of effect of conservative therapy and physiotherapy in the following cases:
- Spinal disc herniation
- Congenital malformations of the spine, such as spina bifida
- Degenerative spinal changes
- Traumatic spinal injuries, including compression fractures
- Persistent deformities of the spine, such as scoliosis
- Spinal instability, spinal stenosis
- Tumors of the spine and spinal cord
- Infectious spinal lesions, including infectious spondylodiscitis
Aspects of age, weight and concomitant pathology are taken into account in the selection of suitable patients for whom microsurgical interventions could be performed. Also, the hospital equipment significantly influences the choice of surgical technique. In order to perform the endoscopic operation, the medical institution must have appropriate equipment and specialists who are authorized to work with it.
Types of minimally invasive surgical procedures
Microsurgical techniques are most widely used for the following types of interventions:
- Discectomy is the resection or complete removal of a herniated disc, followed by replacement surgery. It is most commonly used to treat lumbar disc herniation.
- Spinal cord decompression or laminectomy is most often performed in pathologies of the lumbar spine. During the operation, part of the lumbar vertebra arch is removed. Therefore, the pressure on the spinal cord and spinal nerve roots is reduced. In addition, intervertebral joints and pathologically altered spinal ligaments can be removed.
- Transforamine fusion of lumbar interferences occurs in case of degenerative changes in the intervertebral discs, recurrent hernias, displacement (spondylolisthesis) or instability of the vertebrae.
- Treatment of radiculopathy. With persistent spinal pain and irreversible changes in the nerve endings, the affected spinal nerve roots intersect. Another effective method of therapy is the implantation of an infusion pump to inject painkillers directly into the affected nerve area.
Depending on the type of operation, different endoscopic systems and treatment programs are used, such as:
- TESSYS is the transforaminal access system. Access to the spine and spinal cord structures through the dilated intervertebral foramen is the safest and is used in patients of all ages.
- iLESSYS is the intralaminar access system. The system is used in interventions on the dorsal part of the spinal canal. Access to the surgical field is created through an opening in the vertebral arch, at a site previously determined by CT / MRI.
- CESSYS is the system for surgery for cervical disc herniation. The system creates anterolateral access through the body of the intervertebral disc. This approach is used in the treatment of cervical disc herniation.
- MultiZYTE RT is a radiofrequency endoscopic rhizotomy system. The system is designed specifically for intervertebral joint interventions and is used in the treatment of “facet syndrome”.
Surgical equipment is constantly being modified according to new scientific inventions. For example, the software for pre-computer simulation of the operative course, as well as intraoperative neuromonitoring and controlled anesthesia care techniques are constantly updated.
Performing invasive surgical interventions
Surgical interventions of the spine are performed by operating orthopedists with additional specialization in neurosurgery. Surgeons also receive an additional certificate that allows them to perform endoscopic operations.
Before the operation, antibiotic prophylaxis is performed with the help of broad-spectrum drugs. This is a preventive measure that minimizes the risk of infectious complications. A patient also receives anesthesia. Depending on the planned surgical technique, the anesthesia can be local (the patient is conscious during the procedure) or general (the patient is able to sleep with medication).
After the onset of anesthesia, the medical team evaluates such vital signs as heart rate, blood pressure, oxygen saturation, and more. health indicators. Under close supervision, the surgeon makes a small incision near the affected spinal area. A pipe retractor is inserted through the incision. The device provides access to the surgical field without extensive dissection of tissues and blood vessels.
The specialist presents miniature surgical instruments, such as microscopic instruments, a camera and a light source through the retractor. If necessary, the intervertebral discs or vertebral bodies are replaced in the same way. The surgeon then performs the necessary actions under visual guidance or in some cases under control by CT and / or MRI. An O-shaped shoulder is used for additional protection of the spinal cord. This is a computer-assisted neuronavigation system.
After the operation, the surgical instruments and the retractor are removed from the wound, the skin incisions are closed with a suture or surgical glue. A small bandage is applied to the damaged area. During the postoperative period, repeated antibiotic prophylaxis is performed, and if necessary, over-the-counter pain medications are prescribed.
Advantages of minimally invasive surgery compared to conventional
Compared to conventional open surgery, minimally invasive interventions have a number of significant advantages, such as:
- Simple preoperative preparation, which includes quitting smoking, temporarily stopping anticoagulants (such as aspirin) and performing a new MRI or X-ray. Also, the patient should not eat or drink after midnight before surgery.
- Preliminary 3D planning of the operation with the help of a computer. For example, CT, MRI, or MSCT are required during the diagnosis of a spinal disc herniation. Also during the operation a computer-assisted neuronavigation system is used in order to protect the spinal cord and increase the accuracy of the manipulations.
- Reduced risk of paravertebral muscle damage. During the operation, the muscles move mainly in a “blunt” way, without dissection. After the removal of the microsurgical instruments, the muscle function is completely restored.
- Reduction of developing infectious complications due to preliminary antibiotic prophylaxis and maximum preservation of skin integrity.
- Minor intraoperative blood loss. Magnifying optical instruments, which are used to visualize the surgical field, allow the surgeon to see the blood vessels and not dissect them during the operation.
- Less pronounced postoperative pain syndrome, patients do not need to take painkillers for a long time. It also eliminates the risk of developing psychological dependence on analgesics.
- Faster recovery after surgery, short rehabilitation period. The patient is discharged from the hospital on the second or third day after surgery. Certain microsurgical interventions are performed even in an outpatient setting.
- Good cosmetic result. Skin incisions of 2-3 cm are sufficient for the introduction of endoscopic instruments. Such incisions are closed with single sutures and treated without scarring.
In addition to the obvious benefits, microsurgical interventions are more cost effective. The cost of the procedure often exceeds the cost of classic open surgery, but the short period of hospitalization and rapid recovery significantly reduce the overall cost of treatment.
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