While spine robots are still widely considered to be in the infancy stages, endoscopy surgery has been around for far longer. Recent years have seen more device companies develop spine robots to rival legacy platforms on the market and interest in endoscopic spine surgery has spiked because of its potential efficiency and cost-effective status in the outpatient setting.
Twelve spine surgeons discuss innovative developments in minimally invasive spine surgery and what most excites them for the future,
Question: What area of minimally invasive spine surgery most excites you? Why?
Nitin Bhatia, MD. UCI Health (Orange, Calif.): Minimally invasive spine surgery has been an exciting relatively recent development. The goal of MISS is to minimize trauma to surrounding tissues while still achieving the goals of more traditional “open” spine surgery, and the past 10 years have shown dramatic improvement in both the technology and surgical skills required to make MISS successful and reproducible. One of the areas in MISS which most excites me is robotics. While still in its infancy for spine surgery, robotic surgery has allowed less invasive surgery in numerous fields including prostate surgery, GI surgery and total joint replacement. With today's newer generation of robots combined with our improvement of MISS techniques, the combination of minimally invasive robotic-assisted spine surgery is extraordinarily exciting.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: There is a vast world in the endoscopic spine opening up in the minimally invasive spine surgery field. As the tools improve and limits are pushed, I think we will be able to get more degenerative spine cases done through an endoscope. Once you get over the anatomical challenges and up the learning curve, it is really a great option for many patients. As an alternative to big open cases or even tubular surgery it is a great technique. The challenge is the capital purchase of the equipment. Prices will be driven down as the bigger box companies get into this space, and the market will drive the cost down, but I still think the purchases will be over the $50,000 to $60,000 range even at its least expensive.
Saad Chaudhary, MD. Mount Sinai Health System (New York City): Minimally invasive surgical solutions have never been more in demand and accepted in spine care. The two areas piquing my interest include the advances and adaptation of robotics and endoscopy.
One of the largest challenges in adapting MIS techniques for spine surgery has been the high-dose radiation exposure required to execute a reliable and durable less invasive option. Now, with the advent of high-fidelity robotic platforms, the radiation exposure to the surgical team and patients can be significantly minimized, while delivering a highly accurate and successful surgical solution. This robotic technology will allow for a wider adaptation of less invasive surgical solutions across the country.
Endoscopy is another tool in the MIS procedural spectrum that can enhance the delivery of spine care. This technique can be utilized for various spine pathologies, but maybe especially useful in delivering care to certain challenging patients with high morbidity. Endoscopic techniques may also be utilized to perform decompression surgeries without general anesthesia and that may increase our ability to help certain older, higher risk patients.
John Wainwright, MD. WMC Health (Valhalla, N.Y.): Historically, the only difference between minimally invasive spine surgery and traditional open surgery was the substation of less traumatic retractors and tissue handling techniques. MISS has evolved from minimal incision, to tubular access, and now to ultra-minimally invasive surgery with endoscopic spine surgery. Recent advancements in the technology have brought endoscopic spine surgery to the forefront of MISS. For nearly all indications, there is an endoscopic solution that can address the pathology and relieve the patients pain. Endoscopic approaches allow surgeons to achieve four major goals, which are minimizing incisions, muscle dissection, and post-operative pain while achieving equivalent, or in some cases, better decompression of nerves and the spinal cord. Endoscopic spine surgery has similar to better results than traditional open or other MISS techniques. In many cases since the pathology is being directly addressed, there is a lower risk for persistent and/or recurrent symptoms requiring repeat surgery.
Additionally, because of faster recovery times, most endoscopic procedures can be performed in the ambulatory surgery setting, which frees up valuable hospital OR space in a healthcare system already strained by maximal utilization. Navigation will allow these endoscopic surgeries to be performed with less radiation exposure to the patient and potentially more importantly to the surgeon and OR staff. Additionally, upcoming augmented reality technologies that allow for simultaneous viewing of the endoscope video feed and navigation display while maintaining line of site with the surgical field will allow surgeons to perform these surgeries with greater speed, confidence and safety. The major downside to endoscopic spine surgery is the substantial learning curve. However, navigation and AR technologies can help flatten this curve and hopefully will lead to broader adoption of these techniques.
Albert Wong, MD. DOCS Health (Los Angeles): Integration of image-guided, robotic navigation with augmented reality will enable us to push the limits of minimally invasive spine surgery. Cutting-edge technology provides surgeons the ability to optimize the surgical plan before surgery even starts. This ensures consistent, successful outcomes with minimal unexpected intraoperative complications.
Jose Canseco, MD, PhD. Rothman Orthopaedic Institute (Philadelphia): Endoscopic spine surgery. The promise of minimal incisions with maximal outcomes is encouraging. I see it being used easily for decompressions and discectomies in today's spine practice. However, as it stands currently, the endoscopic fusion research literature is not there to justify utilizing these techniques for patients necessitating a spinal fusion. I am enthusiastic about the research and clinical prospects that come with developing innovative technology adjuncts to endoscopic spine procedures that can safely enhance bony fusion – the potential for helping patients with minimal tissue disruption is a surgeon's dream. We are not there yet, but we will get there, and that's very exciting!
Peter Derman, MD. Texas Back Institute (Plano): In a field typically characterized by incremental advances, endoscopic spine surgery represents a total paradigm shift in how we approach spinal pathology. Utilizing a camera eliminates the need for larger incisions and the associated damage to supporting soft tissues about the spine, resulting in extremely rapid patient recovery. In many cases, existing osseous windows can be exploited so that no bone removal is necessary, reducing concern for post-operative instability, fracture, or facet arthropathy. This also allows for isolated decompression in many cases that would otherwise necessitate fusion.
While endoscopic concepts have been around for decades, the optics, displays, and instrumentation have advanced to where they now allow for spectacular visualization and safe, reproducible outcomes. The field continues to progress as we develop new techniques and progressively expand its applications. Adoption will continue to increase among spine surgeons as it reaches a critical mass in training institutions and patients increasingly (and appropriately) demand it.
Arakal Rajesh, MD. Texas Back Institute (Plano): The ability to merge navigation technologies with better direct visualization (arthroscope or microscope) will naturally yield a better ability to target pathology and treat it focally. I expect this is create a generational shift in surgical management options.
Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): With the aging demographic and better access to healthcare, more patients than ever before are being diagnosed with lumbar spinal stenosis. The area of minimally invasive spine surgery that most excites me is tubular decompression surgery for the lumbar spine. Traditional surgical methods required surgeries to be done at hospitals with overnight stays. I am encouraged to see a movement towards tubular minimally invasive lumbar decompressions including laminectomies and microdiscectomies at ambulatory surgery centers. Often, several levels of the spine accessed through one small incision. This forward progress has many improved outcome measures including decreased operative times, decreased blood loss, decreases costs from having shorter or no length of stay overnight, quicker recovery and return to work, and overall better patient satisfaction.
Issada Thongtrangan, MD. Spine Surgeon at Microspine (Scottsdale, Ariz.): I am most excited about endoscopic spine surgery for decompression and assistance with fusion. I can also do a full-endoscopic fusion surgery. This technology can bring the minimally invasive to another level. In addition, with the ASC-friendly navigation system, I can target Kambin’s triangle a bit easier and safer in certain challenging anatomies.
Jeremy Smith, MD. Hoag Orthopedic Institute (Irvine, Calif.): Minimally invasive spine surgery in my hands has lessened blood loss, length of stay and time to recovery. What excites me is the evolving field and improved ability to achieve more complex goals while still preserving the principles of MIS.The days of large open surgery are fewer and the ability to perform these surgeries on an outpatient basis has become more of a reality.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Our newest partner is a highly trained master in the MIS spectrum of surgical approaches. A new era abounds with youth and recent trained expertise. By far, the microdissection for synovial cyst decompression/removal because of the tissue sparing approach and the shared eventual outcome. This continues to be a satisfying procedure for patient and provider alike.