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10 Minimally Invasive vs. Open Spine Surgery "Unquestionably, spine surgery is heading to a less invasive surgical technique," says Kern Singh, MD, Co-Founder of the Minimally Invasive Spine Institute at Rush in Chicago. "Patients are becoming much more educated about the surgi- cal options available and are placing a premium on return-to-work and func- tion. Five years ago minimally invasive spine surgery was only done in a few centers; now it's exploded. Younger surgeons are learning the technique earlier in their career and advancing the field in a logarithmic fashion." Imaging technology also plays a role in minimally invasive surgery develop- ment. "The complexity and learning curve required for MIS surgery will less- en as more reliable imaging technology is developed that will aide safe guid- ance of tools and implants to desired anatomic locations," says Alexander Vaccaro, MD, of Rothman Institute in Philadelphia. "The learning curve now involves mastering how to work through a tubular corridor with instruments that are elongated where one must master the ability to effect movement of the proximal end of the instrument over a greater distance." Neurosurveillance technology can also help prevent neural injury when sur- geons access the spine, which is important when using indirect methods to visualize spinal anatomy. "Surgeries will become less invasive over time as long as safety can be en- sured," says Dr. Vaccaro. "These techniques are welcomed in revision proce- dures when open dissection can be technically difficult and associated with greater soft tissue morbidity. If one has to decompress the neural elements in the setting of significant scarring from previous surgeries, open techniques may be more reliable if superb visualization with MIS methods cannot be achieved." Minimally invasive techniques also open the door for spine surgeons to perform cases in the outpatient ambulatory surgery center setting. A select group of surgeons is already performing such cases. "Eighty percent or more of my cases are now done with a minimally invasive technique," says Richard Kube, MD, Founder of Prairie Spine & Pain Institute in Peoria, Ill. "That's a huge difference from the 20 percent it was five years ago. My practice is migrating that way and with the ability to do minimally invasive procedures, a lot of spine can be done in the ASC. Typically ASCs are cheaper and provide greater value with fewer complications and higher patient satisfaction rates. I think that's the reason we will see even more of these procedures performed this way in the future." However, open spine surgery isn't going away any time soon. "I think there will always be a role for traditional open approaches as well as minimally invasive spine cases," says Zachary A. Smith, MD, of Northwestern Memorial Hospital in Chicago. "I think the role for minimally invasive sur- gery will continue to expand and I think at a certain point as more surgeons become comfortable with it, it will be less of a novelty. It will be the regular way we do things. But there will always be indications for open surgery, like revision cases or larger tumor cases. There will also be cases that demand a hybrid of the two techniques." n Minimally Invasive vs. Open Spine Surgery: Where the Field is Headed (continued from cover) "We've definitely shown reduced blood loss, infection rate, less narcotic use and shorter hospital stays with these procedures," says Dr. Hart. "With Axi- aLIF, the fact that you don't violate any of the muscular or ligamentus struc- tures of the spine to get to your target is a huge benefit. That's what appeals to me — you have the natural access corridor to get to the disc without damag- ing the patient's anatomy." Cost reduction Reducing hospital stays will go a long way in lowering the cost of care. "I think the costs for spine surgery are outrageous — most spine surgeons are aware of this — but patients aren't," says Dr. Ali. "The percentage of costs as- sociated with the hospital stay makes up the majority of overall costs for the procedure. If we can decrease the length of stay we can decrease the financial burden." Smith et al compared the outcomes and charge data for 202 patients who underwent either an open approach to lumbar interbody fusion or mini- mally invasive interbody fusion (single-level direct lateral or a two-level com- bination of direct lateral and pre-sacral approach). The researchers found a lower level of complications in the minimally invasive group along with a 10 percent and 13.6 percent reduction in charges respectively compared to the open approach. 3 Despite the potential for lower-cost care, minimally invasive spine surgery still has several challenges as a field. Payers — government and private — looking to cut costs have tightened indications for covering spinal proce- dures. Cost pressures and the medical device excise tax have also lowered the amount of money available for device companies to fund new innovations. "There is going to be less money to develop new and better products," says Dr. Ali. "That's going to be one of the challenges that has to be overcome by surgeons and industry together. There has to be a team effort to support and drive innovation to improve techniques and minimize the scope of surgery." Future potential Despite the financial challenges, Dr. Ali still sees immense opportunity for development in the spine field. "In general that's what I love about the spine field — it's not static," he says. "In spine surgery, we've seen revolutionary changes. I'm excited about the scope of possibilities in spine, many of which we haven't even realized yet." Combining minimally invasive procedures with computer navigation has potential for improving procedures in the future. "So far, most of the spinal navigation systems have been at best ridiculously expensive and clunky to use," says Dr. Hart. "But we are starting to see some real progress with that. Registration and reference tracking has been the problem in the past because the whole point is to make as few and as small of incisions as possible; but the reference tracker requires a separate incision over the spine or iliac crest, which defeats the purpose. There are companies trying to develop techniques for navigation without the incisions in the fu- ture." n References: 1. Parker, S.L., Mendenhall, S.K., Shau, D.N., Zuckerman, S.L., Godil, S.S., Cheng, J.S., McGirt, M.J. (2013 Jan). Minimally Invasive versus Open Transforami- nal Lumbar Interbody Fusion for Degenerative Spondylolisthesis: Compara- tive Effectiveness and Cost-Utility Analysis. World Neurosurg. pii: S1878- 8750(13)00102-2. doi: 10.1016/j.wneu.2013.01.041. 2. Whang, P.G., Sasso, R.C., Patel, V.V., Ali, R.M., Fischgrund, J.S. (2013 Dec). Comparison of Axial and Anterior Interbody Fusions of the L5-S1 Segment: A Retrospective Cohort Analysis. Journal of Spinal Disorders and Techniques, 26 (8), 437-443. 3. Smith, W.D., Christian, G., Serrano, S., Malone, K.T. (2012). A comparison of perioperative charges and outcome between open and mini-open approaches for anterior lumbar discectomy and fusion. Journal of Clinical Neuroscience, 19, 673-680.