Becker's Spine Review

64 Executive Roundtable The Role of the Surgical Microscope in Modern MIS Spine By Megan Wood M astering microsurgical techniques proves essential for spine sur- geons performing minimally inva- sive spinal surgery. The following four spine surgeons provide insight into their acquain- tances with the surgical microscope. Question: How did you start using the mi- croscope for OSS? K.D. Riew, MD, Colum- bia Orthopedics, New York City: After I finished my fellowship, I spent two weeks with John McCulloch who taught me how to use the mi- croscope. Initially, I only used it for part of the decompression. As I got more comfortable with it, I used it more frequently and now I use it for every- thing that I do. Michael Mayer, MD, PhD, Schön Klinik München Harlaching, München, Germany: I started using the surgi- cal microscope from the beginning of my surgi- cal career. Since I am a board-certified neuro- surgeon, as well as an orthopedic surgeon, the surgical microscope has always been an essential tool for spine surgery. Roger Härtl, MD, New York City Presbyterian Hospital – Weill Cornell Medicine: I'm a neuro- surgeon by training, so during our residency, we were exposed to the mi- croscope early on. It be- came an obvious tool that we would use for cranial surgery and also for spinal surgery. Mohd Hisam Muhamad Ariffin, MBBS, UKM Specialist Centre, Kuala Lumpur, Malaysia: My first experience with the mi- croscope was actually for hand surgery mi- cro-vascular work as an orthopedic surgeon. It was during a combined ortho and neuro spinal cord tumor surgery; my neurosurgery friend introduced me to using the micro- scope for spine surgery and from that mo- ment the loupe, which is "the first love," was forgotten. Q: Why did you start using the micro- scope for surgery? MM: The advantages of the surgical mi- croscope are obvious: it provides light and magnification even in deep surgical fields and through small approaches and still en- ables the surgeon to have a 3D view of the surgical field. If you look through a surgical approach which is smaller than the distance of your naked eyes, you can only have a 2D view, such as with an endoscope. RH: Because you can visualize especially neuro structures, much better. And you have 3D visualization of the anatomy, with typical- ly excellent illumination and I think it allows you to perform surgery in a limited space much safer and much more efficiently. MHA: The physical benefit for a surgeon is obvious that I can now operate in a more physiologic posture, meaning that I can main- tain my neck and also my lower back in the normal lordosis and this helps reduce the strain on my neck and as the binocular tubes are tiltable and adjustable according to your posture. The ability to stand in more physio- logical and ergonomic posture has allowed me to do more surgery and more important- ly, will also help me grow old protecting my own spine. The clinical benefit is tremendous and I think the most important, is that it allows me to see very clearly at the depth of the surgical field, especially in minimally invasive spine surgery where the access is very small. The ability to see at the depth is possible as modern sur- gical microscopes tailored for spine surgery have a longer focal distance along with the co- axial and homogenous illumination, akin like seeing light at the end of a tunnel. The longer optics, and hence a longer working length, is also important as we use long instruments during surgery and we don't want our instru- ments to keep knocking on our microscope. The surgical microscope also allows better depth perception, which is the main advan- tage over an endoscope as we are dealing with very delicate structures here and mistakes are not tolerated. KDR: It gives unparalleled visualization of the cervical field. Q: What advantages do you see in using a microscope for your surgeries? a. Patient RH: The advantages for the patients are that surgeries can be performed with a very max- imum focus on the actual pathology. We can magnify the pathology and surrounding ana- tomical structures and we can really maximize our ability to effectively treat the pathology without affecting surrounding healthy tissues. MHA: For the patients, the microsurgical technique has allowed them to have a small- er and cosmetically pleasing incision, re- duced blood loss and hence, less pain and reduction in analgesic and opioid consump- tion. They actually have shorter hospital stays nowadays, for example a minimally in- vasive transformational interbody fusion will only need to stay for one night and daycare surgery for simple microdiscectomy is now a possibility. My patients also actually go back to their activities and work faster, and this improves their well-being and also will take away the fear associated with spine surgery. KDR: The more thorough a decompression we can do, the better it is for the patient. MM: Less invasiveness, with less tissue trau- ma, less blood loss, shorter OR times, less complications, shorter hospitalization and rehabilitation times. b. Practice KDR: The better your patients do, the better it is for your practice. RH: I think it can impact the practice because you eliminate certain downsides of surgery with conventional, open surgery without a microscope. For example, posture-related issues for the surgeon — bending forward, neck pain — occupational disadvantages from standing there for hours in awkward posi- tions. That is all eliminated from using the mi- Sponsored by: Dr. K.D. Riew Dr. Michael Mayer Dr. Roger Härtl Mohd Hisam Muhamad

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