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Beckers Spine Review: Biggest Challenges to MIS Spine Care Today

Beckers Spine Review has a weekly series they call Ask Spine Surgeons, whereby they interview spine surgeons across the United States about various things affecting spine care. Our very own Dr. Michael Gordon was asked to participate to weigh-in on the challenges facing Minimally Invasive Spine surgeons today.

Question: What are the biggest challenges to MIS spine care today?

Michael Gordon, MD. Spine Surgeon at Newport Orthopedic Institute:
Becoming overwhelmed by the promise of Minimally Invasive Spine (MIS) Surgery in the face of the realities of the spinal pathology being treated. We must not over-promise and under deliver, and we must remember proper patient selection is paramount.

Most MIS surgeries for disc herniation, spinal stenosis and lumbar instability patterns have as a goal nerve decompression and spinal stabilization. Indications for surgery must balance invasiveness of intervention with the magnitude of underlying pathology treated. In an effort to minimize soft tissue trauma by using a minimally invasive technique, a surgeon may compromise outcome because of the limitations of MIS surgery. There is always the threat that, in a desire to perform a minimal-access procedure, the surgeon can be blinded to the risks of under-decompression, failure to accomplish a fusion due to underlying inadequate bone surface preparation or failure to achieve good sagittal balance in the cervical or lumbar spine. MIS techniques, which are very reliable in the treatment of one- or two-level pathology, may fail when confronted by factors such as poor bone quality or excessive deformity.

Managing patient expectations with realities of surgery can also be difficult. [Typically] one or two levels are easily done MIS, but what about this hypothetical patient? Picture a 73-year-old obese (BMI 36), diabetic, osteopenic woman with mild smoking-related chronic obstructive pulmonary disease and an old myocardial infarction. She has severe lumbar spinal stenosis with a coronal and sagittal deformity at L2 to S1 measuring 35 degrees. She expects, based on advertising she has seen, that an MIS surgery can be done with combined decompression and fusion with segmental fixation and percutaneous screws as well as anterior column support with MIS/TLIF or XLIF at five levels. An open procedure in many hands, although more "invasive," can be done more quickly and effectively than a multilevel MIS case.

Which is a greater surgical risk to this patient: an eight-hour MIS case of L2 to pelvis decompression and fusion with multiple small incisions, or a five-hour multilevel open "360?" Don't forget the radiation exposure which can easily top 10 minutes in a multilevel case.

Read the full article at Bechers Spine Review site here.