The Truth About Minimally Invasive Surgery

There is some diversity in opinion about minimally invasive surgery (known as MIS). Either surgeons claim to do it or say it isn’t important. For the doctors who claim to perform these procedures, some of these surgeons truly do MIS, however most do not. MIS has several meanings to different surgeons. As a patient/consumer you must learn what type of surgery your surgeon is performing, what type of training they had to make the claims that they do regarding the procedures they may offer you. Your surgeon should be able to provide you with outcome data, success rate and complications rate. As a patient you should be thoroughly educated on the different types of spinal surgery available.

Minimally invasive refers to the approach with an incision which is typically between 15 and 21mm. Micro endoscopic refers to a dilating portal system in which the surgical instruments, cameras and implants (if necessary) are inserted. These tools are very small and require very skilled hands. MIS procedures require either a microscope or endoscope, tubular retractor and advanced intraoperative imaging. True MIS is usually an outpatient procedure, does not require blood transfusion, and is associated with a short recovery time and less post operative pain. MIS surgeons have advanced training with these procedures, and whose practice usually is predominantly MIS.

As times change and technology advances, older more invasive spinal procedures will soon be a relic of the past. Minimally invasive spinal surgery will soon become the norm just as other procedure such as laproscopic gall bladder surgery have become. However, for most physicians it is easier to do what is learned during their residency than take the time and effort of learning newer techniques. Unfortunately, what was taught even 10 years ago may now be obsolete having been replaced by more advanced technology.

Spine Q&A

What are common causes of back pain? There are many cause of back pain. One of the most common causes of back pain is degeneration of the spinal joints or discs. Muscle strain is another cause. Other medical conditions need to be considered such as vascular or kidney problems.

I am a nonsmoker in excellent physical condition. I recently started having irritating, nagging low back pain during the day. I am OK in the evening but sometimes I am awakened by the pain. A hot shower generally relieves my back spasms. What should I do? A few days (1-2) of rest and anti-inflammatory medications are the first steps in the treatment of uncomplicated low back pain. Comfortable resting positions include lying on the side with the knees bent or on the back with the knees bent, perhaps using a pillow for support. Ice applied to the back for 20 minutes three to four times a day may be helpful. Anti-inflammatory medications have side effects and patients should carefully read the package material or consult their doctor if taking any medications for longer than a few days. Generally, symptoms will improve and the patient will gain a gradual resumption of normal activity. Other treatments might include a short course of chiropractic treatment or acupuncture, oral steroid medication, stronger pain medication, muscle relaxant medication, or the use of a transcutaneous electrical nerve stimulator (TENS unit). A short (3 – 4 week) course of physical therapy may be prescribed. A single best treatment for low back pain has yet to be. Most episodes of low back pain will resolve with little need for long term treatment.

What are the risks of spine surgery ? Risks associated with spinal procedures include infection, spinal fluid leak, nerve injury, bleeding, failure to fuse, implant failure or the need to re-operate. The risks depend upon the specific surgery being performed, the health of the patient involved, and the training and experience of the spine specialist performing the surgery. You can minimize the risks by seeking out surgeons with advanced training and who dedicate their practice to spinal surgery.

When is surgery necessary for patients with spine problems? Surgery is only necessary when a patient has progressive motor weakness or bladder incontinence. The majority of time surgery is performed to improve a patient's quality of life by increasing activity level and decreasing pain. In this situation, surgery should only be considered after a trial of non-surgical treatment has failed.

Is my shoulder and arm pain caused by a problem in my neck? Pain that occurs as a result of a cervical spine problem usually radiates in a line extending distally from the neck or shoulder girdle into the arm and toward the hand/fingers. It usually has a specific distribution in the arm rather than feeling like "whole arm" pain. Such radicular pain can also often be accompanied by numbness or tingling in a similar distribution, in contrast numbness does not commonly occur as a result of problems in the extremities, unless it involves a peripheral nerve entrapment or irritation. It can be very difficult to differentiate cervical radiculopathy (radiating pain, numbness or weakness) from extremity problems, even for the well-trained physician. Your physician will rely on subtle aspects of your history and subjective findings, physical exam findings, x-rays and sometimes more sophisticated imaging. An injection of local anesthetic and steroids into your shoulder may be necessary as a final means of differentiating between a shoulder problem (such as subacromial impingement, rotator cuff problems or shoulder arthritis) and cervical radiculopathy.

How do disc injuries cause back pain? Disc injuries cause disruption of the normal disc structure. This can lead to mechanical back pain. Also, chemicals which are irritating to the nerves and can cause pain can leak from an injured disc.

What are common symptoms I should be aware of? There are many symptoms that can be addressed at the Northeast Ohio Spine Center. Here are a few common ones: • pain running down your arms or legs • pain that lasts 3 weeks or more; • pain that interferers with your everyday activities • loss of feeling in legs or arms • if you are dragging an arm or foot • if you've lost bladder or bowel control If you're experiencing any of these, contact your family doctor or the Northeast Ohio Spine Center at 330.966.9328.

What is lumbar instability? Instability has been defined in multiple ways, and there is still some controversy over what it involves. Most agree that lumbar instability involves the abnormal motion between two vertebral bodies caused by either an increase in range of motion in a normal plane or motion caused by the translation of the vertebrae in a plane that it should not occur. This can produce an impingement of the neural elements and pain. This pain is usually associated with normal activities and relieved by bed rest.

My doctor told me that I have arthritis of my spine and that I should learn to live with the pain. Is this true? It may or may not be true. It depends on the severity of the pain, how much it limits your life, how active you are, and your general health. Generally there is a way to decrease pain in most patients and that may ultimately require surgery, but more often it doesn't.

Will fusing my spine cause damage to adjacent areas? Usually, the damage to adjacent areas is minimal. A fusion does result in more stress on the unfused levels above and below the fusion. So, if those levels are predisposed to have a problem, it is possible that a fusion may accelerate this problem. As a result, if a fusion is not needed, it is best not to do one; however, if it is clearly indicated, the worries about the affect on the adjacent area should not be a reason not to perform the fusion.

How quickly can I expect to recover from surgery? Recovery from surgery occurs in stages. With most modern surgical techniques patients are able to ambulate on the day of surgery. This allows for discharge within 24 hrs for an uncomplicated disc excision. When a fusion is performed the recovery takes longer. The fusion takes months to consolidate, however functional recovery can progress much more quickly depending on the surgical approach and use of instrumentation. The use of minimally invasive approaches such as the endoscopic technique can allow for discharge from the hospital within 24 - 48 hrs. Return of function requires tissue healing as well as physical reconditioning.

Why do some surgeons approach the spine from the back and others through the abdomen? A lot of that has to do with the patient's symptoms. If the patient is complaining of a radiculopathy or a pinched nerve where they have pain from the spine and into the legs and has an associated neurological deficit: if they have weakness in one of their legs if they have a loss of sensation, if they have a change in their reflexes, those patients need a nerve root decompression. That can be most commonly and most easily performed from the back. Fusions can be achieved either from the front or the back, so a lot of it depends on the patient's radiographic findings and their symptoms.

Will the epidural steroid injection correct my back or neck disorder? The epidural steroid injection will not correct a structural abnormality in your back or neck. It may, however, reduce the pain and swelling associated with your disorder.

Are there any complications associated with an epidural steroid injection? The epidural steroid injection has a long history of safe use. There is only a 1- percent chance that you will suffer from a brief headache after receiving an epidural steroid injection. Also, whenever skin is punctured, there is a slight chance it may become infected, resulting in redness, swelling, tenderness, or warmth at the injection site. If you experience a headache or develop an infection at the injection site, immediately notify your physician.

For the past six years, I have been suffering with on and off low back pain. This pain goes down to my knee and sometimes into my lower leg. It seems to be worsening. It increases when I walk as little as one block. Leaning on a shopping cart enables me to walk farther. I have been taking over-the-counter pain medications but do not feel it is helping. Can you suggest something that would relieve my pain? By your history, you appear to be suffering from lumbar spinal stenosis. This would have to be confirmed by physical exam, and the proper imaging studies. Initial treatment of spinal stenosis usually is non-surgical and focuses on flexion exercises and a non-steroidal anti-inflammatory drugs. Flexion exercises tend to "open" the spinal canal and the NSAID's reduce arthritic inflammation. When these measures fail, an injection into the spine of a long acting cortisone derivative anti-inflammatory drug, called an epidural steroid injection, is often undertaken. The injection is attractive because it is a outpatient procedure. However, there is tremendous variability in response, with some patients having no improvement whatsoever and others achieving good pain relief for a protracted interval of time. When more conservative measures fail, consideration is given to surgery which is the most definitive solution but also the most invasive.

I am 35 and am in excellent health. Six months ago I started having severe cramps in my right leg and back, which kept me in bed for two weeks. Eventually the cramps disappeared but I was left with constant numbness and tingling in my right calf and foot. X-rays confirmed a problem with my sciatic nerve. Can you tell me what to do to relieve the constant ache and numbness in my calf and foot? Also, my lower back has been weak and I am unable to resume a regular exercise program. It appears as though you have had these symptoms in your right leg for many months. It is good that the cramping type of pain has eased but worrisome that there is numbness and tingling as a residual. X-rays are actually unable to confirm a problem with the nerve and usually an MRI scan or some other type of sophisticated imaging is required in order to confirm this diagnosis. Usually the back and leg symptoms can be resolved with time, medications and physical therapy. You should be able to return to your regular exercise program and eventually ease your right leg symptoms. You may require an MRI scan before treatment.

If I have a fusion does that mean I will never be able to bend? Most likely if you has a fusion, you will not be able to detect any difference in your motion. When a surgeon is recommending a fusion, you are usually dealing with a spinal motion segment that is not normal. And there's usually not a lot of motion at that segment, so even if the surgeon were to remove all motion from that diseased segment there are several other segments in the spine that compensate.

Is a bulging disc normal? Degenerative changes in the spine can be associated with bulging discs. The degenerative changes are considered normal aging process changes. Bulging discs in this situation could be considered normal. Degenerative disc changes are caused by loss of water and metabolic changes, which translate into a decrease in the disc space with prominent ligaments or annulus. A bulging disc is considered abnormal when it is associated with pain.

My mother was diagnosed with breast cancer many years ago. She had a mastectomy and we thought she was cured. A few months ago, she started complaining of back pain. She saw her doctor, and he found that her cancer had spread to her spine. Is there anything that can be done? There are many treatment options for your mother's spinal metastases These may include radiation and medical therapy and, occasionally, surgical treatment. Most importantly, she should be able to obtain excellent pain relief and a good quality of life.

I fractured my lower back when I was in a car wreck 3 years ago. I was operated on and had steel rods put in my back. I now suffer daily pain in my back with severe spasms that sometimes goes down into my legs. My doctor tells me that my fusion did not take, a pseudarthosis. What is this and is there anything that could be done? If the fusion did not heal completely, we call this a non-union or pseudarthosis. This may be the source of your pain. After this diagnosis is made with imaging studies, the spine could be restabilized and result in some relief of your symptoms. Occasionally, the types of symptoms you describe are present even with a solid fusion and stabilization. Pain management, physical conditioning, back-stabilization exercises and avoidance of may provide you the best chances of improvement.