Minimally Invasive, Endoscopic, and Laser Spine Surgery: Facts & Fiction

The trend in spine surgery has moved toward minimally invasive procedures. Minimally invasive spine surgery (MIS) involves surgical treatment of the spine through small incisions with minimal disruption of the surrounding muscle tissue.

The benefits of minimally invasive spine surgery include:

Small incisions and minimal scar tissue formation
Less damage to surrounding muscle and soft tissues
Decreased blood loss
Decreased pain and reduced need for pain medication
Quicker recovery and faster return to regular activities
Shorter hospital stays
Many procedures can be performed as outpatient surgery
Decreased risk of postoperative infection

“Open” Surgery and Minimally Invasive Surgery

Surgical procedures of the spine are often referred to as either an “open” procedure or minimally invasive. An open procedure involves making a skin incision and retracting (moving aside) any tissues overlying the anatomy that is to be worked on so that the surgeon can directly view the desired anatomy. The surgeon will view the anatomy either with the naked eye, magnifying telescopic eyeglasses called loupes, or a magnifying microscope. Traditionally, open procedures have required larger incisions and more muscle tissue distraction than minimally invasive surgery.

Minimally invasive surgical techniques utilize specialized instruments, which allow a surgical procedure to be done through smaller incisions with much less tissue disruption. One of these specialized instruments is called a tubular retractor, which is a series of gradually expanding tubes that gently and progressively dilate and separate muscles and soft tissues to expose the desired anatomy. Using specialized tools, surgery is performed through the tube.

Percutaneous Surgery

Percutaneous is a term that literally means “through the skin." Percutaneous surgery involves procedures that are performed through tiny incisions or punctures in the skin without the surgeon having a direct view of the anatomy that he or she is working on. Since the surgeon cannot see the instruments beneath the skin, the surgeon has to use a portable x-ray machine (fluoroscope) or other image-guidance technology to see where the surgical instruments are located within the body.

There are several physicians and facilities that now offer Percutaneous Disc Decompression procedures for treatment of lumbar disc herniations. These facilities often claim that these procedures provide all the benefits of traditional surgery with none of the risks.

Percutaneous disc decompression involves placing a long needle into the disc and passing some type of instrument through the needle to remove small channels of disc material from within the disc. The instrument may be a mechanical device, laser or other tool. The theory behind this treatment is that by removing disc material from within the disc, pressure on the outer wall is relieved, reducing the symptoms caused by the disc bulge.

Although the concept of treating herniated discs with these procedures is attractive, the results have not been as good as what was hoped. Percutaneous disc decompression techniques do not allow for direct visualization of the disc herniation, nerve root, or other anatomy. Because of this, it is very difficult for the surgeon to selectively remove the portion of disc that is directly pressing on the nerve without injuring the nerve.

Therefore, percutaneous techniques are non-selective, meaning that disc material is removed from within the disc, but the disc protrusion or herniation itself is often not necessarily removed directly from the nerve. Also, percutaneous discectomy is only indicated for small, contained herniations, which will typically respond to non-surgical treatment with therapy, medications, and epidural steroid injections. Because these results of percutaneous discectomy are less satisfactory than those achieved with other techniques, these procedures have largely fallen out of favor.

Percutaneous disc decompression procedures also go by the names:

Dekompressor Discectomy
Nucleotome Discectomy
LASE procedure
Percutaneous Laser Disc Decompression
Percutaneous Laser Discoplasty
Percutaneous Disc Nucleoplasty
Plasma Disc Decompression

Endoscopic and Endoscopically-Assisted Spine Surgery

An endoscope is a very thin fiber-optic video camera, which can be used to see internal portions of the body. The camera sends the images to a monitor similar to a television. The endoscope is made with built-in magnification and a light source. Surgery is performed by passing instruments through the endoscope to remove disc material or bone spurs. The major advantage of the endoscope is that it allows for the procedure to be done through a very small incision with minimal tissue damage, while allowing direct visualization of the desired anatomy via the camera.

There are different types of endoscopes. Endoscopes that are used to view the abdominal cavity are often called laparoscopes, and when used to view the inside of a joint, they are called arthroscopes. The term “arthroscopic surgery” has been used to describe various techniques of minimally invasive spine surgery, but technically, “arthroscopic surgery” should only be used to describe procedures within a joint, such as knees or shoulders. Most surgeons use the term endoscope to describe the camera used for spine surgery, others have used the term “discoscope” since the camera is commonly inserted into the spinal disc.

Endoscopes used for spine surgery are typically the diameter of a standard pencil (5-7mm). The endoscope is inserted into the body through a small “keyhole” incision, just large enough for the endoscope to fit through. When this technique is used, the procedure is considered to be true endoscopic surgery.

The endoscope can also be inserted through an open incision or through a tubular retractor in order to improve visualization with greater magnification of anatomic structures. This technique is called “endoscopically- assisted” surgery and is often done through slightly larger incisions (14-18mm) than true endoscopic surgery.

Laser Spine Surgery

A laser is a device that produces a form of light energy. Surgical lasers are typically used to remove (ablate) unwanted or abnormal tissue. As the affected tissues absorb the laser, light is converted to heat. As the tissue is heated, it vaporizes, a process known as ablation.

The term “Laser Spine Surgery” has become very popular on the internet and in magazine ads in recent years. The idea of having a surgeon “zap” you with a laser to cure your back pain sounds great. You may have had back pain for many years and tried many treatment options that have failed, so when an advertisement in a magazine or on the internet promotes that they can cure your pain with laser surgery, and have you back to playing golf the next day, it is tempting to want to believe it.

Many people buy into the marketing hype offered by many laser spine centers because of what I consider the “LASIK surgery effect." There’s a good chance that you know at least one person who has gone from having terrible vision and being totally dependent on glasses or contacts to having perfect vision after having their eyes t reated with a quick, outpatient laser procedure called LASIK surgery. If it works so well for the eyes, why can’t it cure back pain and sciatica too, right?

Unfortunately, it’s not that simple. The spine is a complex structure consisting of bones, discs, joints, nerves and muscles. Often, for patients with chronic back pain, it is very difficult to determine which of theses structures is the cause of pain, and in many cases, the pain is caused by multiple structures.The laser is not a “magic wand” that can reverse arthritis, heal degenerated discs, or cure all back pain. The laser is merely a tool that can be used to perform specific surgical techniques (listed below) that may (or may not) help with back and leg pain. Like any other tool, the laser has its benefits and its limitations.

In reality, the term “Laser Spine Sugery” does not describe one specific technique.

In spine surgery, there are three different procedures that the laser can be used for. A “laser spine surgery” may involve one, two or all three of the following techniques:

1. Laser Facet Joint Nerve Ablation (Rhizotomy)
Destruction (ablation) of the small nerves that supply the facet joints in attempt to reduce back pain from arthritic facet joints

2. Laser Disc Decompression
Removal (ablation) of disc material to relieve nerve compression causing leg pain

3. Laser Annuloplasty
Treatment of tears in the disc wall (annulus) in order to reduce back pain

Laser Spine Surgery Myths and Facts:

Myth: Laser spine surgery means that I don’t have to have an incision.

Fact: A laser is like any other surgical tool. In order for it to be used, it has to be placed into the appropriate area of the body through an incision. The laser instrument can be inserted through a very large open incision (3- inches or more), through a minimally invasive tubular retractor (14-18mm), through an endoscope (8mm), or percutaneously (3mm) with x-ray guidance, and in all of these cases the surgeon may call this “laser spine surgery.”

Myth: Laser surgery can cure spine arthritis and remove bone spurs causing stenosis.

Fact: Spinal arthritis is a condition that cannot be cured and it cannot be “lasered away”. Spinal arthritis is the wearing away of the cartilage surface that lines the facet joints, and once the cartilage wears away it will not grow back. These arthritic changes can lead to inflammation and back pain. Arthritis also causes thickening of the facet joints and ligaments and the formation of bone spurs, all of which result in stenosis (narrowing of the spinal canal) and pressure on the spinal nerves, leading to leg pain. One goal of spine surgery is not to cure the arthritis, but to remove the overgrown tissues causing the pressure on the spinal nerves. The laser that is used in spine surgery cannot cut bone. The bone spurs that cause spinal stenosis must be removed with small drills and/or cutting instruments. When a laser is used in spine surgery it is used to perform facet joint nerve ablation in an attempt to reduce back pain from arthritic facet joints. This technique involves using the energy from the laser to vaporize (ablate) the small nerve endings that supply the facet joints, essentially disrupting the pathway the pain signals use to get to the brain. Facet joint nerve ablation can also be performed without a laser with a technique called radiofrequency nerve ablation (RFNA).

Myth: Laser surgery is always better than surgery without a laser.

Fact: Although it is advantageous to use the most minimally-invasive techniques when possible, not all spinal conditions can be safely or appropriately treated with a laser, and using a laser does not always provide advantages. Disc material can be ablated with a laser, however it is often easier and quicker to remove the disc material with other tools, which can often be placed into the disc through just as small of an incision as a laser.

There are some surgeons who will do ninety percent of an operation with these other instruments, and then put the laser in for sixty seconds so that they can call the operation “laser surgery” for marketing purposes.

As with all types of surgery, success should never be guaranteed, and there are always risks. If a surgeon is making a technique sound too good to be true, you should be cautious. Some laser spine centers have received negative press recently regarding patient outcomes.

References and Articles

Summary

Minimally invasive surgery is emerging as an alternative, reliable method of treatment for a variety of spinal disorders. Like "building a ship in a bottle", there is a steep learning curve for surgeons learning to do these procedures. Although the recovery is often faster, the complication rate during surgery can be greater and the results not as predictable when the surgery is performed by surgeons who have not become totally skilled at these newer techniques. Minimally invasive surgery is certainly "the wave of the future" for many spinal procedures and will continue to develop as new, safe techniques continue to evolve. Not every patient, however, is a candidate for minimally invasive spinal surgery. To see if you are a candidate for this type of surgery contact our office for a second opinion.