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Minimally Invasive Spine Surgery (MISS): Future of the Spine Surgery

Spine surgery involves three basic surgeries such as discectomy, decompression and spinal fusion surgery. Discectomy and Decompression surgery relieves pressure put on spinal nerves by removing portions of bone or a herniated disk. The basic idea in Spinal fusion surgery is to take away the painful abnormal movement between spine vertebras by fusing them into a single, solid bone. Spine surgery is traditionally done as "open surgery," meaning the area being operated on is opened with a long incision with significant retraction of the back muscles to allow the surgeon to view and access the anatomy. In recent years, however, technological advances have allowed more back and neck conditions to be treated through small portals avoiding significant damage to the muscles surrounding the spine. In most cases, MISS results in less pain after surgery and a faster recovery.

Procedure

MISS fusions and decompression procedures (such as discectomy and laminectomy) are performed with special tools called tubular retractors. During the procedure, a small incision is made and the tubular retractor is inserted through the skin and soft tissues down to the spinal column. This creates a tunnel to the small area where the problem exists in the spine. The tubular retractor holds the muscles open and is kept in place throughout the procedure. The surgeon accesses the spine using small instruments that fit through the center of the tubular retractor. Any bone or disk material that is removed exits through the retractor, and any devices necessary for fusion such as screws and rods are inserted through the retractor. Some surgeries require more than one retractor

Commonly Performed MISS Procedures

MISS Discectomy-A herniated disk in the lower back that pinches a nerve may cause severe leg pain, numbness, or weakness. To surgical lyrelieve these symptoms, the disk is removed. This procedure is called a discectomy. For the surgery, the patient is positioned face-down and a small incision (< 1 in.) is made over the location of the herniated disk. The surgeon inserts the retractor and removes a small amount of the lamina bone. This provides the surgeon with a view of the spinal nerve and the disk. The surgeon carefully retracts the nerve, removes the damaged disk, and replaces it with bone graft material.
MISS Decompression (Laminotomy)- Indicated in spinal stenosis condition where due to hypertrophy of the ligaments and facet joints the space of the neural canal is compromised. Similar to discectomy with the help of tubular retractors hypertrophied ligament and bone removed to decompress the nerves.
MISS Spinal Fusion- Common procedures performed are MIS Transforaminal lumbar Interbody fusion (MIS TLIF) and MIS Lateral Lumbar Interbody fusion (MIS LLIF). In an MIS TLIF, the patient is positioned face-down and the surgeon places one retractor on either side of the spine. This approach prevents disruption of the midline ligaments and bone. Using the two retractors, the surgeon can remove the lamina and the disk, place the bone graft in to the disk space, and place screws or rods to provide additional support. In MIS LLIF, patient positioned on one side and small incision is made over the lateral abdomen to insert tubular retractors which pass through retroperitoneal area to reach the spine and similarly disc is removed with insertion of the Interbody spacers.
Pros of MISS
Less pain and rapid recovery
Decreased risk of infection
Minimal blood loss
Back muscles are spared to their function

Cons of MISS
Significant learning curve for the surgeon Difficult to perform in multiple levels Significant radiation exposure to patient and surgeon. Most patients who choose MISS vs traditional surgery enjoy earlier return to routine activity with less pain. This means patient can get back to their lifestyle quickly and safely after minimally invasive spine surgery.

Article By
Dr Rahul Chaudhari MBBS MS ECFMG (USA)

Clinical Fellow- Spine/Scoliosis Surgery (USA)

Consultant Spine/Scoliosis Surgeon, Pune

What is Arthritis ?

Arthritis is a common term used by people which essentially means nothing but inflammation in and around the joint

Osteoarthritis also knows as OA, is a type of arthritis which develops with age causing wearing out of the joint and its structural components. Osteoarthritis is very rampant in India especially in old age population . It affects joint that help to weight bear of our human body such as knee, hips and spine.

Let us try to understand how it occurs in the simplest language and shortest way….

We need to know what is cartilage before we start talking about OA Cartilage is a protective layer which covers the end of bones that meet at the joint and avoids direct rubbing of bony ends over each other. It also acts like a shock absorber reducing the stresses over the bony ends.

Osteoarthritis affects the cartilage and makes it harder and stiffer making it less effective in working as a shock absorber. This hard and stiff cartilage is more prone to breakage as well and eventually gives up in some areas of joint causing erosion of the cartilage that is nothing but damage of the cartilage exposing the underlying bone which it was protecting.

Now these exposed underlying bones rub against each other and become cause of pain in every movement that involves these joints. Also because of this there is increased stretching and tensioning of the muscles, tendons and ligaments causing additional pain and discomfort. So this cartilage affection is the main culprit of causing osteoarthritis. Few factors that cause or fasten the procedure of development of osteoarthritis are obesity, overuse of joints, lifestyle and so on.

SIGNS AND SYMPTOMS OF OSTEOARTHRITIS AND INVESTIGATIONS

So as we discussed that osteoarthritis affects weight bearing joints such as knees, hips and spine.

Typical symptoms of osteoarthritis are as follows

PAIN – many patients have continuous pain in their joints due to OA, but most of them have pain during walking or starting to walk after prolonged sitting. Most of the time the pain is there while taking every step while walking.
STIFFNESS – joint stiffness is nothing but inability to move the joint as it was previously freely movable. In other words the range of movements of the joints are decreased.
.DEFORMITY – prolonged untreated OA starts deforming the joints causing deformities. There are various deformities such as bowing knees which could be inwards or outwards or forward bending.

4.GAIT- painful gait or waddling gait is very common. Many many patients have stooping posture due to pain.

INVSTIGATIONS

RADIOGRAPH ( X-RAYS)- are the basic investigations for diagnosis of OA

MRI might be needed for diagnosis in so

CONSERVATIVE (NON SURGICAL) TREATMENT OPTIONS

1.LIFESTYLE MODIFICATIONS

These include regular EXERCISES

Exercises help to build and improve strength in the muscles around the joints which helps in lowering impact on joints.

Also exercises improve the range of movements of the joints which would lowewr the chances of stiffness of joint

Next important lifestyle modification is WEIGHT REDUCTION.

Reduction in weight reduces stresses on the weight bearing joints and reduce the chances of causing OA

If you are diabetic, CONTROL OF BLOOD SUGAR is very much important to alleviate pain.

2.MEDICATIONS

There are several kinds of medications such as NSAIDS for control of pain of OA, but these medications should not be taken unsupervised and without doctors advice.

3.PHYSIOTHERAPY

IFT, TENS, Muscle strengthening exercises, Hot or cold compresses may help relieve the pain due to OA

4.SUPPORTIVE DEVICES

Braces (hinged, compartment offloading ), knee caps , crutches or canes as per your doctors advice may help you

5.INJECTIONS

Injection of hyaluronic acid directly in the joint by your doctor can help in lubrication of the joint and reduce the inflammation in and around the joint helping in pain relief.

SURGICAL TREATMENTS

1.ARTHROSCOPY

Arthroscopy procedures are used to wash out the inflammatory substances in the joint and clear out the wear and tear debris. Also depending on the cartilage damage, repair procedures are also available.

2.HIGH TIBIAL OSTEOTOMY

This is a procedure which helps in offloading the affected compartment of your knee joint and prolonging the life of your knee,

This is a surgical procedure with excellent results if done right. There are multiple ways to perform this surgery, your orthopedic joint specialist is the best person to suggest you about the same.

3.UNICONDYLAR / TOTAL KNEE REPLACEMENT / TOTAL HIP REPLACEMENT

Arthroplasty or joint replacement surgery is replacing the damaged joint with an artificial one. With the latest technology, nowadays we are replacing the damaged portion of joints with precision and accuracy.

After joint replacement surgery, patients are able to walk immediately and resume daily routine activities with no or minimal pain.

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