Alternatives to Minimally invasive spinal surgery procedures
Ross Hauser, MD
Danielle R. Steilen-Matias, MMS, PA-C
Why do people go for minimally invasive spine surgery?
Many people get a great benefit from spinal surgery, including benefits from minimally invasive spinal surgery procedures. We usually do not see these people in our office. We see the people who had the surgery and did not get the hoped-for benefits. We see the people who had the surgery and are trying to avoid secondary surgery. We see the people who had surgery on one segment of their spine and choose not to have it on another segment.
For some people, the reward of surgery is in the promise. You have had back pain for some time. You did the physical therapy, the painkillers, the anti-inflammatories, possibly the epidural and cortisone injections. The back pain is still there and your surgeon(s) are recommending surgery. Your surgical team may discuss various surgical options but the one that may have interested you the most is the minimally invasive spine surgery option. The idea is that somehow this is a “smaller surgery.” But is it really? Is it less risky?
When we talk about surgery in our articles, we like to bring in the surgeons for their options. Let’s hear what they have to say.
Is Minimally invasive spine surgery really less complicated, less risky, less painful?
Doctors at the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, came to these conclusions in the journal Clinical Spine Surgery (April 2018).(1)
“Minimally invasive spine surgery has increased in popularity due to proposed advantages in the perioperative and immediate postoperative periods.”
Comment: There is an understanding among patients that in the period just before the surgery and in the recovery after the procedure there are advantages to having minimally invasive spine surgery.
The Rush researchers discovered that the 3 most important criteria for patients when choosing between open (traditional spinal surgery) and Minimally invasive spine surgery were:
- long-term outcomes,
- surgeon’s recommendation,
- and complication risk.
When compared with Minimally invasive spine surgery, the majority of patients thought that:
- Traditional open surgery would be more painful (83.8%) than Minimally invasive spine surgery
- Traditional open surgery would have an increased complication risk (78.5%), than Minimally invasive spine surgery.
- Traditional open surgery would have increased recovery time (89.3%), than Minimally invasive spine surgery.
- Traditional open surgery would have increased costs (68.1%), over Minimally invasive spine surgery.
- Traditional open surgery would require heavier sedation (62.6%) than Minimally invasive spine surgery.
- If required to have spine surgery in the future, the majority of both patient groups would prefer a minimally invasive approach (80.0%).
Long-term opioids use
A September 2019 (2) study from NYU Langone Orthopedic Hospital and the NY Spine Institute – NYU Medical Center does suggest that patients undergoing minimally invasive surgery transforaminal lumbar interbody fusion required fewer inpatient opioids and had a decreased incidence of opioid dependence at 3-month follow-up. Further, patients with preoperative opioid use undergoing minimally invasive surgery versus open transforaminal lumbar interbody fusion are less likely to require long-term opioids.
A March 2020 study published in the journal World Neurosurgery (3) reviewed the medical charts of 294 patients (mean age 62 years, 48% male) who had traditional fusion and minimally invasive surgery. These are the combined numbers they published:
- Patients younger than 65 years trended toward more opioid use before surgery and significantly higher opioid use after surgery
- Depression trended toward increasing opioid use after surgery.
- Fusions of 4 or more levels were associated with overall greater opioid use after surgery.
- A higher rate of opioid use before and after surgery is associated with worse European Quality of Life 5 level scores after surgery and worse Oswestry Disability Index scores after surgery
- Overall, opioid use is associated with worse functional outcomes and may serve as a marker of disease progression.
Causes of Chronic Post-Surgical Spinal Pain and why another surgery is being recommended
In this video, Ross Hauser, MD describes the 5 main reasons that back surgery failed to help the patient’s condition.
- The surgery did not address the actual cause of the patient’s pain. The diagnosis is wrong. A primary cause of “missed” low back pain is an injury to the Sacroiliac Joint. If your MRI showed disc degenerative disease and you had the discs operated on but the sacroiliac joint was not addressed, the pain will continue after the surgery.
- The surgery made the lower back MORE unstable. Minimally invasive Foraminotomy, Laminectomy, Microdiscectomy, disc surgery, all have to remove parts of the bone in the spine.
- The “missed secondary problem.” The surgery may have successfully addressed what was considered your primary problem, but, you really had two problems. This could be a multi-segmental problem that was not discovered until after the first surgery.
- Too much sitting after surgery, possibly too much bed rest.
- Rarer, scar tissue pinches on the nerves.
But is the understanding that Minimally invasive spine surgery is less complicated, less risky, less painful, accurate? Toronto Western Hospital, University of Toronto surgeons questions this.
This is research from the Journal of Neurosurgery, Spine.(4)
The doctors in this study compared to research and outcome studies surrounding a minimally invasive fusion surgery with a traditional open lumbar fusion surgery.
Here is what they found:
- Minimally invasive fusion surgery got you out of the hospital a half-day soon.
- 3.5 day stay for traditional open surgery vs. 2.9 days stay for minimally invasive (About a three-day stay)
- The actual time in surgery under general anesthesia was about the same.
- There was no significant difference in surgical adverse events (complications) between the two procedures.
- No difference in nonunion or re-operation rates was observed.
So where was the benefit?
- Slightly better disability scores at 24 months were observed in the minimally invasive fusion surgery patients.
- There was less chance of “adverse medical effects.” The surgery itself causing problems, such as surgical errors or post-surgical complications.
The conclusion does question the evidence that minimally invasive surgery is better than traditional surgery: “The quality of the current comparative evidence is low to very low, with significant inherent bias.”
But is the understanding that Minimally invasive spine surgery is less complicated, less risky, less painful, accurate? New York University Langone Medical Center Study questions this.
Researchers at New York University Langone Medical Center (5) warn about the growth and popularity of minimally invasive surgery (MIS) procedures. They say that the procedures are easily marketable to patients as less invasive with smaller incisions, minimally invasive surgery is often perceived as superior to traditional open spine surgery. The NYU researchers put this to the test.
A systematic review of randomized controlled trials involving minimally invasive surgery versus open spine surgery was performed.
- For cervical disc herniation, minimally invasive surgery provided no difference in overall function, arm pain relief, or long-term neck pain.
- In lumbar disc herniation, minimally invasive surgery was inferior in providing leg/low back pain relief, rehospitalization rates, quality of life improvement, and exposed the surgeon to >10 times more radiation (as the procedure requires imaging) in return for a shorter hospital stay and less surgical site infection.
- In posterior lumbar fusion, minimally invasive surgery transforaminal lumbar interbody fusion (TLIF) had significantly reduced 2-year societal cost, fewer medical complications, reduced time to return to work, and improved short-term Oswestry Disability Index scores at the cost of higher revision rates, higher readmission rates, and more than twice the amount of intraoperative fluoroscopy.
- The highest levels of evidence do not support minimally invasive surgery over open surgery for cervical or lumbar disc herniation. However, minimally invasive surgery transforaminal lumbar interbody fusion demonstrates advantages along with higher revision/readmission rates.
- Regardless of patient indication, MIS exposes the surgeon to significantly more radiation; it is unclear how this impacts patients. These results should optimize informed decision-making regarding minimally invasive surgery versus open spine surgery, particularly in the current advertising climate greatly favoring minimally invasive surgery.
But is the understanding that Minimally invasive spine surgery is less complicated, less risky, less painful, accurate? A study in the British Journal of Neurosurgery questions this.
In research from August 2017 appearing in the British Journal of Neurosurgery, surgeons said this:
“Though different techniques have been successfully employed in the treatment of recurrent lumbar disc herniation, the one which should be considered most ideal has remained a controversy, (minimally invasive surgical techniques).”
“In view of the currently available data and evidence, minimally invasive techniques for revision of recurrent disc herniation do not really appear to be superior to the conventional open surgical approaches and vice-versa. Spinal fusion should not be undertaken in all recurrences but should only be considered as an option for revision when spinal instability, spinal deformity or associated radiculopathy is present.”(6)
Various causes and frequency of reoperations following lumbar microendoscopic discectomy for disc herniation and microendoscopic decompression for spinal stenosis
An August 2019 study from Japan’s Funabashi Orthopedic Hospital and Tokyo Medical University published in the medical journal Spine (7) examined various causes and frequency of reoperations following lumbar microendoscopic discectomy for disc herniation and microendoscopic decompression for spinal stenosis.
It should be pointed out that of the 394 patients in this study, ALL, had surgery from the same physician at that physician’s various experience rate.
Here are the study findings in highlights:
- The 5-year reoperation rate for all patients combined was 12.4% (49 of 394 had to have another surgery).
- The main causes for reoperations were recurrence of disc herniation and increase of postoperative spondylolisthesis and/or instability;
- Two of the nine cases were caused by excessive decompression (too much material was removed and this in itself caused spinal instability).
- The other causes for reoperations were postoperative epidural hematoma (localized bleeding), insufficient decompression, and residual segmental scoliosis; two segmental scoliosis cases did not provide relief from sciatica, and therefore L4/5 transforaminal interbody fusions were performed.
This research concludes: “Postoperative epidural hematoma and excessive or insufficient decompression were often observed in the initial series of patients as the causes for reoperations. We think that it is important to be aware of and prevent such potential problems in an initial series of patients, as there are limitations to any surgical indications for the use of microendoscopic decompression for degenerative segmental scoliosis because of original traction and/or kinking of nerve roots.”
In other words, surgery does not help or is warranted for everyone. No medical procedure is including those offered in our clinics. There has to be a realistic outlook on how any treatment may help you.
This view can be supported by statements like this published in the European Spine Journal (8) February 2020: “Recurrent lumbar disc herniation is the most common complication after discectomy. Due to the altered anatomy with the presence of scar tissue, the surgical revision of already operated patients could be a surgical challenge.”
Any spinal surgery can be complicated, no one questions that.
There are times when spinal surgery is necessary. Those times should be when all available non-surgical options have been exhausted. The reason is simple, even minimally invasive surgery can become complicated.
Spinal decompression is indicated in the presence of a progressive neurological deficit such as loss of muscle strength and the ability to walk or use an extremity. A microdiscectomy involves removing part of a disc, generally because of a herniation pressing on a nerve.
Laminotomy is the removal of all or part of the lamina, the flattened or arched part of the vertebral arch. Complete laminectomy or bilateral laminectomy means the removal of the spinous process and the entire lamina on each side of it. Hemilaminectomy or unilateral laminectomy means the removal of the lamina on one side of the spinous process only. When the opening to the nerve root is enlarged, this is called a foraminotomy. For the right indications, spinal surgery can resolve symptoms.
Minimally Invasive Corpectomy
A Corpectomy typically removes a vertebra and the disc above and below it. It is usually reserved for more advanced cases of spinal degeneration. Following the removal of the vertebra and discs, a spinal fusion component of the surgery will replace the missing parts of the spine. When someone is in a violent car accident or has a spinal tumor, this may be the best option. When the surgery is elective as in treating cervical or lumbar stenosis, patients are made away that complications can occur. This includes paralysis and nerve damage.
These are related articles that may assist you in your research as they describe the components of fusion surgery necessary after a corpectomy
- Anterior Cervical Discectomy and Fusion | Does this surgery cause more cervical spine instability and deformity?
- Atlantoaxial instability | Cervical Fusion or Prolotherapy PRP Stem Cell treatment options
- The evidence for non-surgical cervical radiculopathy treatments
Minimally Invasive Discectomy
When your surgeon(s) feel that your problem is not complicated enough to warrant a corpectomy a discectomy will be recommended. A discectomy is the removal of a portion or whole disc that has become herniated. This is one of the more popular minimally invasive spinal surgeries. It is performed under general anesthesia. We have a very extensive article on the various types of discectomy and surgical options as well as non-surgical options. Please see Prolotherapy non-surgical treatment of a bulging or herniated disc.
Minimally Invasive Laminectomy
A laminectomy is a surgical procedure to relieve “pinched nerves.” The procedure removes bone from the spinal vertebrae to take the pressure off the affected nerves. This can be an effective procedure for many people. Our article will examine what happens when the laminectomy procedure is not as successful as the doctor and patient hoped for and examines the resulting Post-laminectomy syndrome and what treatments can be offered for it. Please see Post-laminectomy syndrome.
Minimally Invasive Lumbar Fusion
This is a description of a “Minimally Invasive” Lumbar Fusion.
- A surgeon will “fuse,” the vertebrae of the spine to prevent excessive movement that may cause herniation in the future. The “fuse” or graft are strips of bone, typically taken from your pelvic bone or a cadaver. Synthetic grafts are also available.
- To hold the graft in place, the surgeon will drill screws, rods, plates, and cages into your spine.
While Minimally Invasive Lumbar Fusion can be beneficial to many people, we typically see the patients for whom surgery is not yet indicated, the patient does not want surgery, or the patient had surgery with a less than hoped for a successful outcome. These problems are covered in our articles highlighted here:
- Non-surgical treatment options for lumbar spinal stenosis
- Prolotherapy and non-surgical treatment of lumbar radiculopathy
“Less facetectomy is better.” Minimally invasive spinal surgery should be more minimal to prevent failed back surgery syndrome
In August 2019 surgeons from leading Chinese university hospitals examined the risks of failed back surgery as it related to the facetectomy procedure. This research was published in the journal BioMed Central musculoskeletal disorders (9)
- Percutaneous transforaminal endoscopic discectomy (PTED) is widely used for the treatment of lumbar disc herniation.
- Facetectomy (removal of vertebrae facet joint bone) in PTED is necessary for accessing the intraspinal region and for decompressing the exiting nerve roots in patients who suffer from hypertrophy of the facet joints. (A herniated disc).
- However, this may increase morbidity (the chances or risk) of failed back surgery syndrome.
- “Less facetectomy is better because it may reduce the risk of biomechanical deterioration and consequently, that of FBSS.”
Dangers of injuring spinal ligaments in spinal surgery
Doctors at the Osaka City University Graduate School of Medicine, (10) Japan acknowledge that spinal ligament damage is possible in spinal surgery because the posterior spinal bony prominences (parts of the vertebral structure) are commonly used as landmarks during posterior spinal surgery; however, the exact relationship of these structures with ligamentum flavum borders and attachments has not been clarified.
- Surgeons, they say need to design safe and adequate lumbar spinal decompression surgeries with the idea of not damaging the ligamentum flavum.
- Trying conservative care DOES NOT cause failed decompression surgery
Many surgeons suggest that patients should not consider conservative care prior to surgery as it may have an impact on their surgical success. Doctors at the University of Bern in Switzerland have disproved this.(10)
“The incidence of lumbar spinal stenosis continues to rise, with both conservative and surgical management representing options for its treatment. The timing of surgery for lumbar spinal stenosis varies from shortly after the onset of symptoms to several months or years after conservative treatment.
The aim of this study was to investigate the association between the duration of pre-operative conservative treatment and the ultimate outcome following surgical interventions for lumbar spinal stenosis.
Cases of lumbar spinal stenosis with a documented duration of conservative treatment, undergoing spinal decompression with at least one post-operative patient assessment between 3 and 30 months, were included in the study.
“The duration of pre-operative conservative treatment was not associated with the ultimate outcome of decompression surgery.”
Iatrogenic spondylolisthesis following decompression surgery
Iatrogenic spondylolisthesis is an acquired spondylolisthesis and a well-recognized complication after posterior decompression or fusion surgery, occurring in 3.7%–20 % of cases.(7)
- Spondylolisthesis describes the forward slippage of a vertebra onto another. In decompression, removing too much bone can lead to post-operative lumbar instability and then to spondylolisthesis. Patients suffering from iatrogenic spondylolisthesis often complain of increased back pain and have new or deteriorating sciatic symptoms with time.
As documented in the medical journal Neurosurgical Focus in a paper entitled Iatrogenic spondylolisthesis following laminectomy for degenerative lumbar stenosis: a systematic review and current concepts, instability following lumbar decompression is a common occurrence.(12)
Comprehensive Prolotherapy to the stabilizing posterior ligaments is very effective at resolving this.
Lumbar decompression surgery can reduce symptoms and problems for patients when it is done to correct problems of progressive neurological deficit. However, when done for the wrong reasons, such as ligament laxity in the spine or pelvis, instability and symptoms can worsen. In most instances, it is appropriate for a person to seek out a consultation with a Prolotherapist before undergoing surgery. A Prolotherapist can let the person know what the chances are that the condition and its associated symptoms will be helped by Prolotherapy. Receiving Prolotherapy first will not in any way impede or hamper a person’s response to surgery later.
A Prolotherapist will help remind a person about some questions to ask a surgeon when getting a consultation:
- What does the surgeon feel is causing the pain?
- Is the surgery that is proposed a decompression or a fusion? Which levels of the spine are going to be decompressed or fused?
- What chances does the surgeon feel that the surgery will affect the adjacent joints and cause them to deteriorate later on? When would this cause symptoms?
- More importantly, what is the likelihood of long-term pain relief with surgery?
- How much pain relief can be expected with the surgery and when?
- Are there any long-term restrictions in activities after the surgery?
Minimally invasive spinal surgery procedures are still the same complicated spinal procedures. The difference is getting to the spine. In open surgery the incision is large, the muscles have to be retracted, there is significant blood loss. In Minimally invasive spinal surgery procedures, the incision is smaller, the blood loss is less, the muscle damage is reduced. But it is still a complicated spinal operation performed under general anesthesia and carries the same risks.
Minimally invasive spinal surgery can be effective for many people. In our article, we only seek to present a non-surgical option. Non-surgical of course can be considered the most minimally invasive.
The Spinal ligament repair injection treatment option Prolotherapy
In this video, Danielle R. Steilen-Matias, MMS, PA-C explains and demonstrates a Prolotherapy treatment for the lumbar spine.
Video Summary and Learning Points
- Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
- Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone.
- We treat the whole low back area to include the sacroiliac or SI joint. In this video, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
- I’ve marked with a black crayon all down the midline of this patient’s back and then I have a horizontal line drawn where her pain stops. This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
- It’s important to note that this particular patient is actually not sedated in any way so even though it is a lot of shots and a lot of injections through the skin which can be painful, patients tend to tolerate it really well the whole procedure goes relatively quickly
- At 2:20 I’m just making sure that I get the sacroiliac or SI ligaments as well as the iliolumbar ligament to help strengthen the low back.
- After treatment we want the patient to take it easy for about 4 days.
- Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.
Published Caring Medical research:
Citing our own Caring Medical published research (13) in which we followed 145 patients who had suffered from back pain on average of nearly five years, we examined not only the physical aspect of Prolotherapy but the mental aspect of treatment as well.
- In our study, 55 patients were told by their medical doctor(s) that there were no other treatment options for their pain, and a subset of 26 patients were told by their doctor(s) that surgery was their only option.
- In these 145 low backs,
- pain levels decreased from 5.6 to 2.7 after Prolotherapy;
- 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression, and overall disability
- 75% percent were able to completely stop taking pain medications.
If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is pain resolution.
If this article has helped you understand the role of Minimally invasive spinal surgery procedures and you would like to explore options to avoid surgery, get help and information from our specialists
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