Minimally invasive spinal surgery is becoming increasingly popular with both surgeons and patients, but some surgeons believe that the evidence base in spinal surgery is poor and therefore, at present, minimally invasive procedures do not have a place in the spinal world. D Greg Anderson, orthopaedic surgeon, The Rothman Institute; professor, Department of Orthopaedics, Thomas Jefferson University College of Medicine in Philadelphia, USA, is chairing a hands-on course on minimally invasive surgery at the 26th annual meeting of the North American Spine Society (NASS), 2–5 November, Chicago. In this quick-fire interview, he talks to Spinal News International about why minimally invasive surgery does have a place in the spinal world.
What is your response to spinal surgeons who claim that at the moment, there is not enough evidence to support the use of minimally invasive procedures in spinal surgery?
There is a growing body of scientific literature that supports the use of minimally invasive procedures, particularly in the lumbar spine, for selected patients. At present, the literature shows that there are clear advantages such as a diminished risk of heavy bleeding and a reduced rate of surgical site infection with minimally invasive approaches compared with traditional open surgery. Also, several studies show that minimally invasive surgery is associated with reduced pain, decreased usage of narcotic medications and shorter hospitalisation. Longer term outcomes appear to be comparable between minimally invasive and traditional open surgery in the areas of lumbar decompression and lumbar fusion.
Aside from a perceived lack of evidence, are there any other reasons why some surgeons are reluctant to use minimally invasive techniques?
A barrier for some surgeons is the need to learn something new. Some surgeons find it easier to continue doing what is familiar and comfortable, even if it may have disadvantages for their patients. As young surgeons learn minimally invasive techniques during their residency and fellowship training programmes, there will be less need to adopt new skills during the active stage of a surgeon’s practice and this issue will be reduced.
What are the key skills needed to become proficient in minimally invasive surgery?
There is not a single skill, but rather a family of skills that are necessary to become a competent minimally invasive spinal surgeon. These include competence with new types of technology and the ability to recognise the relevant spinal anatomy when only a small region of the spine is visualised. The surgeon must also learn to use tactile senses along with visualisation for some aspects of the procedure. In addition, the surgeon must gain a three-dimensional awareness of the spinal anatomy to understand operative trajectories. Finally, the surgeon must become proficient with the use of fluoroscopy and interpretation of fluoroscopic images.
Do you think that there will ever be a point where open spinal surgery is consigned to the history books and minimally invasive surgery becomes the norm?
I do not believe that minimally invasive surgery will ever supplant traditional spinal approaches because there is a wide spectrum of cases, and certain cases will require a more generous exposure to be completed in the safest and most efficient fashion. The goal is not to eliminate open surgery, but to use the best approach for each patient’s situation.