Issue link: https://beckershealthcare.uberflip.com/i/1412045
72 ORTHOPEDICS MIS spine technology: Which trends are fads, and what is here to stay? 7 surgeons weigh in By Alan Condon O ver the last 30 years, minimally invasive technology has developed rapidly in spine surgery, with many technologies demonstrating significant clini- cal advantages, but others promising more than they could deliver and largely falling by the wayside. Seven spine surgeons discuss which tech- nologies are here to stay and which could be a flash in the pan. Question: Which minimally invasive technology trends are a fad and which are here to stay? Peter Derman, MD. Texas Back Institute (Plano): I anticipate that motion preserva- tion via disc replacement and minimally invasive and endoscopic decompressions will increasingly be utilized. For this to happen, training in these techniques must become more widespread; we must continue to produce high-quality evidence support- ing their use; and the reimbursement system must change to reflect the value generated by these operations compared to fusion. Continued innovation with development of arthroplasty devices that can be used in the setting of deformity and instability will ulti- mately help even more patients avoid fusion. I believe that the recent explosion in the use of interspinous and interlaminar spac- ers will subside just as it has in the past. I am skeptical that the long-term data will demonstrate meaningful benefit. Further- more, the argument that these devices are useful in patients who are too old or frail for a direct decompression is flawed — advanced surgical techniques allow us to perform laminectomies via comparable (or smaller) incisions with minimal blood loss. General anesthesia may not even be necessary if endoscopic techniques are employed, and patients can go home the same day. Why insert a kyphosis-inducing implant when a nondestabilizing direct decompression is an option? Joseph Lee, MD. Rothman Orthopaedics (Philadelphia): Minimally invasive surgery has continued to evolve in the last 30 years. However, the goals of minimally invasive spine surgery remain constant: nerve de- compression and spinal stability. Advances in navigation, robotics and augmented reality will continue to evolve together and allow surgeons to perform minimally invasive surgery safely and efficiently. e next frontier will be merging information from MRI and CTs to allow robots to assist in exposure, neural decompression and disc space preparation. Advances in interbody technology such as surface modification and multiplanar expansion capabilities facilitate achievement of fusion and sagittal plane correction. e traditional lateral MIS approach remains a successful surgical tech- nique for a variety of degenerative spinal conditions. e recent introduction of the single-position prone lateral technique has been successful, with its proposed advantag- es of superior OR efficiency, better sagittal correction and ability to incorporate naviga- tion/robotics. Endoscopic spine surgery, or "ultra-minimally invasive surgery," has become more popular in the last few years, but it has yet to be determined if this tech- nique provides superior clinical outcomes compared to traditional minimally invasive techniques. James Mok, MD. NorthShore Orthopae- dic & Spine Institute (Skokie and Des Plaines, Ill.): Here to stay are expandable interbody cages, which facilitate restora- tion of disc height, maximize footprint, and minimize the amount of trialing and energy of insertion. ese attributes further enable the minimally invasive surgeon to achieve the goals of interbody fusion. e continuing advances in cage designs make this a minimally invasive technology with staying power. On the other hand, prone lateral interbody fusion, a variant of the established MIS lateral retroperitoneal interbody fusion, might prove to be a fad. It is performed in the prone position, and although an interesting concept, several problems may preclude widespread adoption. While there is only a single major value proposition — the time savings in repositioning (the "flip") — the prone position has several potential drawbacks, including gravity dragging retroperitoneal fat and other so tissues into the field of view, making disc space prep and implant insertion challenging. But the major concern is safety. It is easier to consistently maintain a safe working angle (vertical) with the patient in the lateral decubitus position than the prone position (horizontal). is is critical considering the adjacent struc- tures such as the great vessels. e effect of gravity on the lumbar plexus — considered the structure most at risk in the lateral ap- proach for interbody fusion — is yet to be defined. Surgeons must carefully weigh the benefit of saving time against these safety considerations when evaluating prone lateral interbody fusion. Ali H. Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Minimally invasive surgery is fast becom- ing the norm across all specialties. How- ever, the concept of MIS can be confusing for many patients. In traditional spine ap- plications, MIS refers to the use of smaller incisions or multiple stab incisions to replace large open incisions and operations. is minimizes blood loss, anesthetic time and complications. Any MIS and related technologies that achieve these endpoints will be adopted, modified and improved upon, and are here to stay. e MIS trends, however, that are likely to be transient are those which have been used in spine surgery in the past and have been abandoned by surgeons, only to be repackaged and reapplied by other special- ists in traditionally nonsurgical fields. Prime examples of this are spinous process distrac- tion devices for the treatment of lumbar stenosis, posterior sacroiliac fusion using allogra dowels, and needle/shaving devices used for ligamentum flavum removal as a replacement for traditional laminectomies. Procedures which allow us to take advantage of the body's natural corridors and orifices are here to stay. ose operations that can be done more safely, effectively, efficiently and reproducibly through small incisions will also be the ones that we continue to utilize. Lastly, advances in medical device design will also streamline surgery and make it less invasive. Hooman Melamed, MD. Hoag Orthope- dic Institute Surgery Center - Marina del Rey (Calif.): e field of endoscopic spine surgery, which I would consider is ultra- minimally invasive, is going to become the preferred and a better alternative choice for patients who not only require decompres- sion, but even more importantly, save many patients from having fusion done, where, with the power of endoscopy, one can perform a very thorough extraforaminal de-