Minimally Invasive Spine Surgery Current Aspects

Ali Arslantaş, Sedat Dalbayrak, Serkan Şimşek, Sedat Çağlı, Cumhur Kılınçer, Murat Coşar, A. Fahir Özer

Minimally Invasive Spine Surgery Current Aspects

ISBN: 978-605-5004-09-5

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Contents

Intro

1. Minimal Invasive Spine Surgery and Historical Development

2. What is Minimal Invasive Spinal Surgery and What is its Scope?

3. Imaging Methods in Minimally Invasive Spine Surgery

4. Anterior Cervical Microdiscectomy

5. Cervical Endoscopic Discectomy

6. Anterior Approach to the Upper Cervical Region

7. Posterior Approach to Upper Cervical Region

8. Cervical Anterior Foraminotomy

9. Cervical Posterior Laminoforaminotomy

10. Cervical Percutaneous Instrumentation

11. Lumbar Interlaminar and Foraminal Microdiscectomy

12. Full-Endoscopic Interlaminar Lumbar Discectomy

13. Transforaminal Endoscopic Discectomy

14. Microdecompressionin Lumbar Spinal Stenosis Surgery

15. Transforaminal Endoscopic Foraminotomy in Lumbar Spinal Stenosis

16. Percutaneous or Endoscopic Treatment of Facet Cysts

17. Percutaneous Instrumentation in the Degenerative Patient

18. Lumbar Degenerative Deformity: Clinic-Oriented Micro-Decompressive Approach

19. Spinal Arthroplasty Outcome

20. Disc Repair and Disc Replacement-Innovations Intervertebral Disc Transplantation

21. Dynamic Stabilization: Are Motion Sparing Implants Effective?

22. Dinamic Stabilization

23. Minimally Invasive Transforaminal Lumbar Interbody Fusion

24. Percutaneous Extreme Lateral and Direct Lateral Fusion Techniques

25. Presacral Anterior Lumbar Interbody Fusion (AXIALIF), Mini ALIF

26. Neuromodulation

27. Facet Blocks in Diagnosis and Treatment

28. Spinal Injections

29. Procedures Targeting Disc

30. Epiduroscopy (Epidural Endoscopy)

31. Use of Ozone in Pain Deriving From Spine

32a. The Role of Muscles in Functional Stability of the Lumbar Spine

32b. Core Strengthening in Lumbar Spinal Disorders

33. Position of Physiotherapy in Degenerative Disease

34. Rehabilitation Following Lumbar Surgery

35. Failures in Neck and Low-Back Surgery: Causes and Outcomes

36. Neuropathic Component of Low Back Pain

37. Thoracoscopic Disc Surgery

38. Thorascopic Instrumentation

39. Applications in Vertebro - Kyphoplasty and Osteoporotic Fractures

40. Is Vertebroplasty Really Useless in Osteoporotic Fractures? (Analysis of Randomized Controlled Studies)

41. Vertebro - Kyphoplasty Procedures in Trauma and Tumor

42. Percutaneous Fixation in Trauma

43. Minimal Invasive Approaches in Infections

44. Minimal Invasive Approaches in Spinal Tumors

Intro

Minimally  Invasive Spine Surgery

Publishers: Intertıp Yayınevi (Intertıp publishing house)

Copyright 2015, Turkey

Editors

Ali Arslantaş

Sedat Dalbayrak

Serkan Şimşek

Sedat Çağlı

Cumhur Kılınçer

Murat Coşar

A. Fahir Özer

ISBN: 978-605-5004-09-5

INTERTIP 2015 / TURKEY

To Our Family...

Authors

1. Acaroğlu Emre, MD

Hacettepe University, Faculty of Medicine, Department of Orthopedics, Ankara, Turkey

2. Açıkbaş Sabri Cem, MD

Akdeniz University, Faculty of Medicine, Department of Neurosurgery, Antalya, Turkey

3. Akalın Elif, MD

Dokuz Eylul University, Faculty of Medicine, Department of Physical Therapy and Rehabilitation, Izmir, Turkey

4. Akçalı Ömer, MD

Dokuz Eylul University, Faculty of Medicine, Department of Orthopedics, Izmir, Turkey

5. Altun Necdet, MD

Gazi University, Faculty of Medicine, Department of Orthopedics, Ankara, Turkey

6. Arslantaş Ali, MD

Osmangazi University, Faculty of Medicine, Department of Neurosurgery, Eskisehir, Turkey

7. Arslantaş Didem, MD

Osmangazi University, Faculty of Medicine, Department of Public Health, Eskisehir, Turkey

8. Attar Ayhan, MD

Ankara University, Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey

9. Aydın Hasan Emre, MD

Osmangazi University, Faculty of Medicine, Department of Neurosurgery, Eskisehir, Turkey

10. Başarır Murat, MD

Acıbadem Kozyatagı Hospital Neurosurgery Clinic, Istanbul, Turkey

11. Bozkurt Melih, MD

Ankara University, Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey

12. Çağlar Şükrü, MD

Ankara University, Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey

13. Çağlı Sedat, MD

Ege University, Faculty of Medicine, Department of Neurosurgery, Izmir, Turkey

14. Çakır Celal Özbek, MD

Malatya Park Hospital Neurosurgery Clinic, Malatya, Turkey

15. Caner Hakan, MD

Başkent University, Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey

16. Çaylı Süleyman R., MD

Inonu University, Faculty of Medicine, Department of Neurosurgery, Malatya, Turkey

17. Çırak Bayram, MD

Pamukkale University, Faculty of Medicine, Department of Neurosurgery, Denizli, Turkey

18. Coşar Murat, MD PhD

Canakkale 18 March University, Faculty of Medicine, Department of Neurosurgery, Canakkale, Turkey

19. Coşkun Erdal, MD

Pamukkale University, Faculty of Medicine, Department of Neurosurgery, Denizli, Turkey

20. Dalbayrak Sedat, MD

Neurospinal Academy, Tuzla Gisbir Hospital, Istanbul, Turkey

21. Doğu Beril, MD

Sisli Etfal Education And Research Hospital, Department of Physical Therapy and Rehabilitation, Istanbul, Turkey

22. Erkin Gülten, MD

Konya Education And Research Hospital, Department of Physical Therapy and Rehabilitation, Konya, Turkey

23. Fesli Ramazan, MD

Dıskapı Yıldırım Beyazıt Education And Research Hospital, Department of Neurosurgery, Ankara, Turkey

24. Güleç Sacit, MD

Osmangazi University, Department of Anesthesiology and Algology, Eskisehir, Turkey

25. Hancı Murat, MD

Istanbul Cerrahpasa University, Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey

26. Hepgüler Simin, MD

Ege University, Faculty of Medicine, Department of Physical Therapy and Rehabilitation, Izmir, Turkey

27. Işık Hasan Serdar, MD

Ordu University, Faculty of Medicine, Department of Neurosurgery, Ordu, Turkey

28. Kahraman Serdar, MD

Yeni Yuzyil University, Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey

29. Kaptanoğlu Erkan, MD

Yakın Dogu University, Faculty of Medicine, Department of Neurosurgery, Nicosia, TRNC

30. Kemerdere Rahşan, MD

Istanbul Cerrahpasa University, Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey

31. Kılınçer Cumhur, MD

Trakya University, Faculty of Medicine, Department of Neurosurgery, Edirne, Turkey

32. Koç R. Kemal, MD

Erciyes University, Faculty of Medicine, Department of Neurosurgery, Kayseri, Turkey

33. Kotil Kadir, MD

Istanbul Education And Research Hospital, Department of Neurosurgery, Istanbul, Turkey

34. Kuran Banu, MD

Sisli Etfal Education And Research Hospital, Department of Physical Therapy and Rehabilitation, Istanbul, Turkey

35. Naderi Sait, MD

Umraniye Education And Research Hospital, Department of Neurosurgery, Istanbul, Turkey

36. Öktenoğlu Tunç, MD

VKV American Hospital, Department of Neurosurgery, Istanbul, Turkey

37. Okutan Özerk, MD

Ordu University, Faculty of Medicine, Department of Neurosurgery, Ordu, Turkey

38. Öncü Jülide, MD

Sisli Etfal Education And Research Hospital, Department of Physical Therapy and Rehabilitation, Istanbul, Turkey

39. Özalay Metin, MD

Baskent University Adana Practice and Research Center, Faculty of Medicine, Department of Orthopedics, Adana, Turkey

40. Özbek Zühtü, MD

Osmangazi University, Faculty of Medicine, Department of Neurosurgery, Eskisehir, Turkey

41. Özdemir Mevci, MD

Pamukkale University, Faculty of Medicine, Department of Neurosurgery, Denizli, Turkey

42. Özer Ali Fahir, MD

Koc University, Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey

43. Öztürk Çağatay, MD

Istanbul Spine Center Florence Nightingale Hospital, İstanbul, Turkey

44. Özyalçın N.Süleyman, MD

Istanbul University, Faculty of Medicine, Department of Anesthesiology and Algology, Istanbul, Turkey

45. Palaoğlu Selçuk, MD

Hacettepe University, Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey

46. Sayın Murat, MD

Sakarya Ada Hospital, Departmen of Neurosurgery, Sakarya, Turkey

47. Şenel Alparslan, MD

Ondokuz Mayis University, Faculty of Medicine, Department of Neurosurgery, Samsun, Turkey

48. Şenköylü Alpaslan, MD

Gazi University, Faculty of Medicine, Department of Orthopedics, Ankara, Turkey

49. Şimşek Osman, MD

Trakya University, Faculty of Medicine, Department of Neurosurgery, Edirne, Turkey

50. Şimşek Serkan, MD

Dıskapı Yıldırım Beyazıt Education and Research Hospital, Department of Neurosurgery, Ankara, Turkey

51. Sönmez Erkin, MD

Başkent University, Faculty of Medicine Department of Neurosurgery, Ankara, Turkey

52. Temiz Cuneyt, MD

Celal Bayar University, Faculty of Medicine Department of Neurosurgery, Manisa, Turkey

53. Türkoğlu Erhan, MD

Duzce University, Faculty of Medicine Department of Neurosurgery, Duzce, Turkey

54. Uyar Meltem, MD

Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Izmir, Turkey

55. Yalnız Erol, MD

Trakya University, Faculty of Medicine, Department of Orthopedics, Edirne, Turkey

56. Yaman Onur, MD

Tepecik Education And Research Hospital, Department of Neurosurgery, Izmir, Turkey

57. Yegül İbrahim, MD

Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Izmir, Turkey

58. Zileli Mehmet, MD Ege University, Faculty of Medicine, Department of Neurosurgery, Izmir, Turkey

Preface

Turkish spine surgeons have been very productive for the last 20 years. Especially neurosurgeons have edited many textbooks on spine. However they were mostly in Turkish language and could not have international impact. This is one of the first English textbooks on spine written by Turkish authors and editors. The editors of this book are well known Tuskish neuro-spine surgeons who have been in administrative functions of Spine and Peripheral Nerve Section of the Turkish Neurosurgical Society.

The editors have done a great job. The book contains all aspects of minimally invasive spine surgery and discusses current problems. I congratulate them for their efforts to prepare this very comprehensive textbook.

Mehmet Zileli, M.D.

Professor of Neurosurgery

Past President of the Turkish Neurosurgical Society

Founding President of the Spine Section of the Turkish Neurosurgical Society

Honorary President of the Middle East Spine Society

Past President of the World Spinal Column Society

1. Minimal Invasive Spine Surgery and Historical Development

Definition

Micro-surgery is defined as a surgical procedure which is made with a small incision using other tools such as microscope or endoscope.⁸ Also referred as ìkey holeî surgery, this procedure requires serious preoperative planning although it appears simple.⁸ Selection of the patient, identification of the target level and efficiency of the superficial procedure required for the surgical procedure are important. The aim of improving treatment methods is to reach the anatomic tissue and perform the procedure with minimal trauma.⁶

Regarded as the pioneer of minimal invasive spinal surgery and defined as administration of chemopapain into the disc space, chemonucleosis was first performed in 1969. The aim is to lyse the nucleus pulposus using a chemical substance and to remove the compressive effects of the herniated disc fragment on the nerve root by activating the enzyme. The procedure is only a central nucleotomy and it does not target the pathological region.² Use of this method is forbidden due to the high risk of anaphylaxis, arachnoiditis and associated complications.⁵,¹⁰

History of the Microscopic and Endoscopic Methods

Recently, spinal surgical methods have improved and such changes enable less invasive procedures. First used in 1953, the microscope was used for intracranial vascular surgery and increased success in this field led to use of the microscope for spinal procedures.⁸ Pioneering surgeons such as Yaşargil, Caspar and Williams used the microscope in the spinal region in order to minimize surgery-emergent morbidity and they referred to it as ìlumbar micro-discectomyî.⁸,¹¹ Endoscopy was added to the use of microscope for lumbar disc surgery in ë70s and percutaneous discectomy was first performed by Williams, referred to as percutaneous endoscopic discectomy.¹⁰ Endoscopy derives from terms ìendoî and ìscopienî and they refer to direct visualization of interior structures in ancient Greek.³ Spinal surgeons improved endoscopic and tubular entry methods in ë90s and they can now enlarge the procedure area without injuring surrounding muscle fibers thanks to retractors.¹⁰ Endoscopic microdiscectomy was first performed by Foley and Smith in 1997.¹⁰ Such successes in the field of lumbar procedures were extended to cervical and thoracal regions within a short time.¹¹ This rapid advance of spinal surgical methods is chronologically demonstrated in Table 1.

Table 1:  Development of methods of spinal surgery in chronological order

Easily applicable laser coagulation methods recently emerged due to advancements and advertisements in the media; however, there is no retrospective controlled studies on those techniques, contrary to minimal invasive spinal surgery.¹⁰ Being developed in the light of chemonucleosis, this procedure aims to ensure coagulation of central nucleus pulposus. The procedure does not target the pathological region. Most spinal surgeons do not use laser methods since controlled studies are lacking.

Contrary to other procedures, the visualized area is narrow for spinal endoscopic methods. Use of endoscopy has a history of almost 200 years in gynecological and abdominal interventions and thus, it can be easily used within a large potential space. Narrow visualized field is the principal challenge for minimal invasive spinal surgery since the spinal cord does not have a large cavity.¹⁰ Despite working within a narrow and dark field, use of auxiliary devices such as microscope, fluoroscopy, intraoperative computerized tomography and neuro-monitoring made minimal invasive spinal surgery safer.¹⁰

Advantages and Complications of Minimal

Invasive Methods

Minimal invasive surgical methods offer several advantages such as shorter hospitalization period, less blood loss and less tissue damage as well as ability to spare normal anatomy and rapid healing resulting in earlier return to daily activities.¹¹ (Table 2) Studies indicate that complications such as recurrent disc herniations, incision and prolonged surgery are lower with minimal invasive methods.¹⁰ This method is associated with a small incision and accordingly, it is easily applied by most surgeons based on training seminars.¹⁰ In light of this fact, associated complications may be more frequent if the procedure is not performed by experienced spinal surgeons.⁸ The most remarkable disadvantage is major vessel injury which may occur intra-operatively. Adequate visual field cannot be ensured due to bleeding and controlling massive bleeding may be challenging.⁶ Therefore, being accustomed to the image on the two-dimensional monitor and learning endoscopic instrumentation will require time and experience.³

Use of minimal invasive surgical methods versus classical surgical modalities for spine disease is still debated despite all advances made in this field.⁵ The logic underlying the minimal invasive procedures is not different than that of classical methods. The aim of both approaches is to decompress the nerve root. The most significant advantage arising from minimal invasive surgery for candidates of lumbar microdiscectomy involve reduced exposure time to anesthesia, ability to choose local anesthesia, day surgery and early discharge.¹² Patient can be discharged within 24 hours and may return to work in a period of 2 to 6 weeks.² Another important consideration is related to decreased anatomic damage due to the small tissue incision enabled by use of microscope and small sized surgical tools. The surgeon is able to reach vertebra using a small incision, surrounding soft tissues are spared and thus, the patient experiences less pain in the postoperative period.⁷ Classical methods may lead to late complications such as spondylolisthesis depending on the impaired anatomy wince lamina, ligamentum flavum and medial facet removed.³ Based on those characteristics, it is clear that minimal invasive surgical methods reduce perioperative morbidity.⁹,⁵ Available clinical studies found that time for improvement of long-term leg pain is similar for classical discectomy and minimal invasive surgical methods. It is known that dural damage is more frequent with micro-invasive methods, however, no significant difference was found between the two approaches when all complications are evaluated.⁴ The complication rate of minimal invasive surgical procedure is 6 percent (Table 3).

Table 2: Advantages of minimal invasive surgery  for the patient

Table 3: Complications of minimal invasive surgery

Conclusion

Minimal invasive surgery experienced a rapid improvement throughout the last 4 decades. Considering the technological revolution and low treatment costs, success rate of minimal invasive spinal surgery has recently reached 80 percent. In 11 retrospective studies which were conducted within the last 3 decades, 3543 patients underwent microendoscopic surgery and it was found that the success rate was 74-100 % taking into consideration the study outcomes involving a postoperative period of 6 months.⁸ Therefore, it is superior to classical discectomy, which is the gold standard for lumbar disc herniations associated with radiculopathy. The increased success rate enabled the expansion of the intended use of those methods and they could even become the routine procedure for spinal surgery.⁸ The advances in the field of minimal invasive methods enabled the use of this approach for lumbar fusion, transforaminal lumbar interbody fusion, spinal tumor biopsies, vertebroplasty and kyphoplasty, in addition to lumbar microdiscectomy (Table 4).⁹

Table 4: Classification of Minimal Invasive  Surgery Procedures

Considering social advantages, some people prefer minimal invasive surgical methods due to cosmetic reasons which are principally based on the small skin incision.⁹ Moreover, in a study where obese subjects were evaluated, small incision and early mobilization secondary to short healing period made this procedure preferable to obese subjects.¹ Lack of general anesthesia requirement enables this treatment method to be easily chosen for subjects with systemic disease(s).

Considering the economic dimension, it was observed that minimal invasive procedures significantly reduced the treatment costs of hospitals.⁹ Use of easily applicable methods for treatment of spinal diseases, which cause significant labor loss, will compensate secondary to the shorter healing period.

References

Cole JS, Jacson TR: Minimally invasive lumbar discectomy in obese patients. Neurosurgery 61: 539-544, 2007

Deen GH, Fenton SD, Lamer TJ: Minimally invasive procedures for disorders of the lumbar spine. Mayo Clin Proc 78: 1249-1256, 2003

Gönül E, İzci Y: Principal Neuroendoscopy. Özer AF, Sasani M, Lumbar Endoscopic Discectomy, Ankara: Buluş Tasarım ve Matbaacılık, 2012: 287-299

Hormuzdiyar Hd, Stephen PJ, Lonni RS, Timothy FW, Daniel MS, Wolinsky JP, Gokaslan ZL, Bydon A: The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine 16: 452-462, 2012

Jeffrey H, Oppenheimer, Igor DC, Dennis E, Mc- Donnell: Minimally invasive spine technology and minimally invasive spine surgery: A historical review. Neurosurg Focus 27: E9, 2009

Korfalı E, Zileli M: Principal Neuroendoscopy. Özer AF, Sasani M, Spinal Minimal Invasive Methods, Ankara: Buluş Tasarım ve Matbaacılık, 2012: 1437-1452

Kornalis AP, Chadi T, Swetha S, Anderson DG: Minimal Invasive Exposure Techniques in the Spine Surgery. Current Opinion in Orthopaedics 1: 134-141, 2006

Mayer H. M: Minimal invasive Spine Surgery. Rulffes W, Technological Advances of Surgical Microscopes for Spine Surgery, Germany: Springer-Verlag Berlin Heidelberg, 2006: 9-11.

Ozgur B, Benzel E, Garfin S: Minimally Invasive Spine Surgery. Ozgur B, Scott C, Nguyen AD, Discectomy and laminectomy, New York: Springer Science+Business Media, 2009: 115-121

Paul JS: Minimally Invasive Spine Surgery: An Evolution in Progress. J Spinal Res Found 5: 26-31, 2010.

Samartzis D, Shen FH, Perz-Cruet MJ, Anderson DG: Minimally invasive Spine Surgery: A Historical Perspective. Orthop Clin N Am 38: 305-326, 2007

Yılmaz AA, Ökten F: Minimal Invasive Methods in the Spinal Surgery and the Anesthesia. Türkiye Klinikleri J Orthop & Traumatol-Special Topics 1: 16-21, 2008

2. What is Minimal Invasive Spinal Surgery and What is its Scope?

Development of minimal invasive spinal surgery

Most minimal invasive spinal surgery techniques have been developed to reduce the damage caused to the surrounding tissues. For example, the shift from laminectomy using microscope in disk surgery to laminotomy pioneered minimal invasive spinal surgery, and was first applied by Yaşargil.³,¹⁰ Currently, these techniques have been developed to the level of using minimal invasive methods even in fusion surgery.

Scope of minimal invasive spinal surgery

Perhaps calling this surgery 'Minimal approach surgery' instead of 'Minimal invasive surgery' is more accurate, because the small incision does not mean that the approach is small.

The general objectives of spinal surgery can be summarized as decompression, stabilization (fusion in general), correction of deformity and oncologic surgery. When doing this, safety and causing minimal damage to normal tissues must also be mentioned. It can also be said that there is a cosmetic concern in minimal invasive surgery. Objectives of minimal invasive surgery can be listed as follows:

Treating the pathology causing the least damage to the surrounding tissues.

Reducing the period of hospital stay.

To shorten the recovery-convalescence period.

To improve the outcome scores.

Good cosmetic results

Marketing

However, minimal invasive surgical techniques do not change the surgical indications. The objective of the operation does not change. You cannot make a minimal invasive surgery candidate from a patient who is not a candidate for open surgery.

We can list the tools used in minimal invasive spinal surgery as follows:

Endoscopes

Tubular retractors, expandable tubes

Percutaneous pedicular screw fixation

Mini ALIF approach

Bone grafting alternatives

Table 1: Some common minimal invasive procedures

Indications

All spinal surgeries can be performed using minimal invasive techniques. The required tools must be developed for this. However, it should be asked if this is necessary for all cases. There are indications that are compliant or noncompliant with this requirement. That is, minimal invasive spinal surgery has good indications and has indications that are not so good. There can be also in-between indications.

The overt indications can be listed as follows:

Lumbar disk hernia¹²

Single-level lumbar narrow canal

Cervical posterior microforaminotomy¹³

Cervical anterior foraminotomy, discectomy

Single-level lumbar fusion

The acceptable indications are as follows:

Decompression for 2-level lumbar stenosis

Lumbar fusion 2 lumbar levels

Short fixation in burst fractures for damage control purposes

Recurrent lumbar disc hernia

The emerging indications are as follows:

Deformity surgery

Fixation of the high-level thoracolumbar fractures

Intradural tumors

It is possible that minimal approach surgery can play a role in infections. Particularly when the basic objective is debridement and discharging an abscess, minimal approach surgery can be used for surgical infections. Percutaneous fixation can be performed. Stabilization can be performed for discitis for quick mobilization.

Minimal approach surgery can also have a place in spinal tumors. For example, vertebral support (vertebroplasty) can be performed to relieve the pain in cases without deficits or deformity. Percutaneous fixation can be performed for pain relief and stabilization in patients with shorter life expectation and without deficits. Hybrid applications including percutaneous fixation following corpectomy or radiotherapy can also be performed.

There are also areas where minimal invasive spinal surgery is not used yet. Its use in osteotomies, multilevel decompression and fusion procedures and big revision procedures is not possible.

There are also some techniques that are not performed any more. These include the biportal approach in lumbar transforaminal endoscopic discectomy and laparoscopic anterior lumbar interbody fusion (ALIF). Although AXIALIF was popular at first, it is not frequently used currently because of the high number of complications such as intestinal perforation and low rate of fusion.

The following questions must be answered when making the decision for indication:

a) To ask oneself if there is a minimal approach surgery for each case,

b) Will minimal approach be possible for a part of the intervention?

c) Will minimal approach surgery give the same result? Existence of such a method will not show that your decision is correct.

d) If you were the patient, which intervention would you prefer?

Surgery with a suitable level of invasiveness must be targeted when making the decision. Minimal invasive surgery must never be minimally effective surgery.

The main advantage of minimal invasive spinal surgeries is the absence or small amount of iatrogenic muscular damage, shorter periods of hospital stay, quick return to daily living activities and beter cosmetic results with small incisions.

Studies on iatrogenic muscular damage have shown histologically and histo-chemically that minimal invasive spinal surgery causes less damage, impairs the muscle enzymes (CPK-MM) less and causes less damage to muscles electrophysiologically.⁸,⁹ However, clear information on the reflection of these effects in clinical practice is lacking. That is, it has not been proven that minimal invasive spinal surgery does not reduce muscular strength and reduces the pain related to muscular damage.

Result

In general, the outcome measures for minimal invasive spinal surgery are the same as for open surgery in the long term.

In their study comparing open TLIF with the minimal invasive TLIF, Scheufler⁶ did not find any differences in the rate of recovery at month 16. However, Schwender⁷ examined TLIF in a prospective study, and reported in their evaluation 1 year later that Oswestry scores had improved more compared to open surgeries.

If minimal invasive surgery fails to provide results that are the same as or better than those obtained with open surgery, it can be said that the smallness of the incision has no importance. However, individual outcome scores instead of the literature must be considered as regards the results, because the individuals who developed the technique in general have created the literature. These pioneering studies tend to present the outcomes as better than they really are. Furthermore, these pioneering surgeons are master surgeons who perform operations in very large numbers. They select the patients well. The results obtained by these master surgeons may not be same as yours.

Zdeblic and Davis¹¹ examined a series of patients who underwent L4-5 ALIF with laparoscopic surgery. Laparoscopic surgery was performed on 25 patients out of 50, and mini-open surgery was performed on 25. Complication rate was found to be higher in the laparoscopic group, no differences were found between the techniques when the procedure was applied on one single level, and the laparoscopic procedure time was longer when the application involved two levels. The authors concluded that laparoscopic L4-5 ALIF had no advantages.

Complications

In general, minimal invasive surgery is not a surgery type with less complications. These methods are technically difficult with long learning periods. Therefore the complication rates can be greater during the learning process. For example, it has been reported that more dura and radix injuries are seen in endoscopic or tube-guided surgery at first. The recurrence rates of disk hernia are also higher at first.

The risk of injuring the nerve roots, dura mater and spinal ganglions is greater in lumbar tranforaminal endoscopic discectomy.

In addition, the minimal invasive surgical techniques are not very flexible. For example, when the percutaneous pedicle screws are placed by a posterolateral approach, erroneous placement and entry into the canal is very likely.

Complications of minimal invasive surgery can be examined in two groups:

a) The same complications as traditional open surgeries,

b) Complications related to the specific intervention. Iliopsoas trauma and hematoma in XLIF intervention (intrapsoas approach to lumbar spine), injury of the dorsal root in lumbar transforaminal endoscopic discectomy and related neuropathic pain, malposition of the screw related to loss of orientation in screw placement with tubular retractors, dura mater and root injury in percutaneous endoscopic discectomy and intestinal injury in AXIALIF can be listed among these.

In addition, the surgeon and patient can be exposed to over radiation because of the use of fluoroscopy in these interventions.²

Fourney et al.¹ reported in their study comparing open surgery with lumbar surgery performed with minimal invasive tubular retractor that these techniques did not reduce the complication rates. However, there are reports stating that infections are seen less with minimal invasive methods.⁴

Perez-Cruet et al⁵ made the following comment in their review on the complications in minimal invasive spinal surgery: Most of these interventions have long periods of learning. Mastering requires special training, cadaver workshops and working on animal laboratories. However, once mastered, these techniques provide significant reduction in complications, reduction of postoperative pain and earlier return to daily living activities.

Epilogue

In minimal invasive spinal surgery in general:

a) Recovery is quicker,

b) Period of hospital stay is shorter,

c) Outcomes at the end of year 1 are better or the same,

d) Complication rate is smaller with skilled hands.

Minimal invasive spinal surgery must be considered as a new tool to achieve the purpose of the operation. These techniques do not change the surgical indications. However, these must be as effective as the open techniques in your hands. Therefore, surgeons should analyze their own results carefully when shifting to a new technique.

The philosophy of minimal invasive surgery can be summarized as creating the least damage to the surrounding tissues, protecting normal tissue as much as possible, following the general purposes of surgery and obtaining results the same as or beter than open surgery in the long term.

References

Fourney DR, Dettori JR, Norvell DC, Dekutoski MB. Does minimal access tubular assisted spine surgery increase or decrease complications in spinal decompression or fusion? Spine 35:S57-S65, 2010

Giordano BD, Baumhauer JF, Morgan TL, Rechtine GR: Cervical spine imaging using standard C-arm fluoroscopy: patient and surgeon exposure to ionizing radiation. Spine 15: 1970-1976, 2008

Imhof HG, von Ammon K, Yasargil MG. Use of the microscope in surgery of lumbar disk hernia. Aktuelle Probl Chir Orthop. 44:15-20, 1994

O'Toole JE, Eichholz KM, Fessler RG. Surgical site infection rates after minimally invasive spinal surgery. J Neurosurg Spine 11:471-476, 2009

Perez-Cruet MJ, Fessler RG, Perin NI. Review: Complications of Minimally Invasive Spinal Surgery. Neurosurgery 51: 26-36, 2002

Scheufler KM. Technique and clinical results of minimally invasive reconstruction and stabilization of the thoracic and thoracolumbar spine with expandable cages and ventrolateral plate fixation. Neurosurgery 61(4):798-808, 2007

Schwender JD, Holly LT, Rouben DP, Foley KT. Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Tech 18 Suppl:S1-6, 2005

Styf JR, WillÈn J. The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine 23(3):354-358, 1998

Weber BR, Grob D, Dvork J, M¸ntener M. Posterior surgical approach to the lumbar spine and its effect on the multifidus muscle. Spine 1;22(15):1765-1772, 1997

Yasargil MG. Microsurgical operation of herniated lumbar disc. Adv Neurosurg 4:81, 1977

Zdeblick TA, David SM. A prospective comparison of surgical approach for anterior L4-L5 fusion: laparoscopic versus mini anterior lumbar interbody fusion. Spine 25(20):2682-7, 2000

Zileli M. Tube Guided Surgery for Lumbar Far-Lateral Disc Herniations. Türk Nöroşirürji Dergisi, 19- 3:192-195, 2009

Zileli M. Surgery of Cervical Spine: Posterior Techniques. Turkiye Klinikleri J Neurosurg-Special Topics 4(2):152-158, 2011

3. Imaging Methods in Minimally Invasive Spine Surgery

With the improvements in assisting imaging methods and the continual evolution of surgical instruments and ecarteur, the popularity of minimally invasive spinal surgery has increased in the recent. Basic X-ray, C armed scope, CT (computed tomography), MRI (magnetic resonance imaging), USG (ultrasonography) and navigation can be used for imaging during these attempts.

Spinal Navigation

Spinal navigation systems have been behind cranial navigation due to the inexistence of a stable reference point. It has become the main imaging method with software improvements that decreases the error rate. It is apparent that error rate will be lower in navigation systems for cranial anatomy because of deviation of anatomy with CSF drainage and calibration with real time scope. In recent years, software that will integrate a patientís MRI and CT images to systems during surgery has been developed. As a consequence, incision length can be decreased with this technique, instrument usage can be safer, and operation time can be shorter.⁷,⁹,¹⁸ If we assume that spinal surgery is the major operation in neurosurgery, these techniques that decrease medico-legal problems, error rates and operation time will make these methods more popular. (Figure 1a,b)

Figure 1: Screwing with navigation on (a) lumbar and (b) cervical

Robotic Systems

Together with the development of navigation systems, robotic systems have been introduced. CT based 3

dimensional planning provides decreased incision length and optimization of instrument placement. It also warns the surgeon of anatomical differences and decreases the complication rate. In addition, it quickens learning of percutaneous systems. Furthermore, it decreases the hospital stay length and cost. Also, one of its advantages is that it does not occupy a lot of space and X ray dosage is lowered for the surgical crew. (Figure 2)

Figure 2: Robotic screwing system added to spinal navigation

Computed Tomography

CT is mostly used during spinal biopsies and discographies during surgery. Robertson and Ball first did percutaneous spinal biopsies in 1935 without a scope.¹⁴ Siffert and Arkin ¹⁷ did spinal biopsy with conventional imaging. First biopsy with the assistance of scope was done in 1969, and with CT was done in 1981.¹,¹⁰ Using CT during surgery decreases the adjacent tissue and vein injury and provides safer pathological samples from the area needed. Three-dimensional images from CT pioneered diagnosis as well as surgical planning and have been a milestone for minimally invasive surgery. An important complication of biopsy, tumor plantation on the surgical line, is much lower with CT than with scope.²,⁸,⁹ Using CT during ablative attempts for pain (facet denervation, epidural blockage, SI injections) increases the strength and safety of the procedure.¹¹,¹⁵ However, this area is also passed on to invasive radiologists and algologists.

Spinal Magnetic Resonance Imaging

Important information about spinal fractures and timing of them is acquired from STIR (short tau inversion recovery), a new MRI technique that is used in the preoperative period, which suppresses fat. Furthermore, it provides information during vertebroplasty about the fracture line, which will be filled with cement on T2, weighted cross sections. MRI also gives detailed information about fluid injection or gadolinium use after discography. It gives sufficient support to minimally invasive surgery by providing detailed images and making it safer for the diagnosis and treatment of tumors or degenerative disc diseases.⁷,⁸,¹⁶

C-Armed Scope

Most minimally invasive interventions require scope guidance, for this purpose, this section is about scope utilization in detail. C-armed scope can reach the target anatomical region by using several images acquired from different angles. Rigid scopes used for gastrointestinal purposes are insufficient. Motorized scopes used by invasive neuroradiologists can maximize the image quality while minimizing error rate. Procedure time and exposed radiation can be decreased with these motorized systems and experienced staff. The device can store recurring procedures in its memory, and with the use of appropriate software operational steps can be shorter. However, the rooms, which have these devices are usually not convenient for routine surgeries.⁴,⁸,¹¹,¹⁵

Operation table should be permeable to beam and relatively narrow for C-armed scopeís motion. Material to keep patientís position stable should not block the image and C arm should be wide. Side of the C arm is not important. Sterile cover must be adjusted to allow scopeís motion be 90 degrees. Most C armed scopes have laser for guidance purposes.⁴,⁸

Beam Safety

In order to protect from the hazardous properties of radiation, preventive gloves, preventive lead scrubs and preventive thyroid materials must be used and taught. Most surgeons usually neglect these steps due to the weight of the material and its restricting features. However, the surgeon is not only putting himself at risk, but also affects other staff as well. The assisting personnel can expose surgeons to charges in the future. Equipment that will be used for C armed scope should have low scatter gram and pulse mode skill. By using approximately 4 pulse/s mode, radiation exposure can be decreased at least 80% with real time scope.⁴

Using Scope on other Areas

Using scope for minimally invasive approach es has improved surgical techniques and decreased surgical extent.

Scottie dog view provides appropriate target points for all lumbar injections (entry for transforaminal epidural, intralaminar epidural, intraarticular facet injections, medial branch injection, discography or intradisc procedures).¹¹,¹²,¹⁵,¹⁶,¹⁹ It is obtained by rotating the scope 20-30o. More rotation is needed for lower lumbar facet injections. (Figure 3)

Figure 3: Scottie dog view obtained by rotating scope by 20-30 o

Epidural anatomy is shown with epidurography, and it also prevents medication from escaping to thecal sac or veins. Patient can be in prone, sitting or lateral decubitus position. C armed scope is rotated to lateral and caudal by 20 and 30o, respectively from the midline. Needle is guided to the laminaís upper margin and then interlaminar space. There is a resistance while passing the ligamentum flavum, and negative pressure is apparent in the epidural space. Contrast material is easily passed into the epidural space.¹¹,¹⁵,¹⁹ (Figure 4) Epidurography is done with non-ionic contrast agent, which is proven safe for myelography. Contralateral oblique view is the safest for showing needle passing from lamina to space.

                                      Figure 4: Epidurography (a) position (b) inserting the needle (c) contrast agent injection

Transforaminal epidural injection is done when the patient is in prone position. Lateral angle is more than in the interlaminar technique. Usually there is a 30-45o angle from the midline while mildly rotating to caudal position. Needle