MIS: Minimally invasive spine surgery
Spinal nerves innervate muscles, skin, and internal organs, sending efferent and receiving sensory signals from these organs.
Compression of spinal nerves due to a ruptured or herniated spinal disc can lead to pain, numbness, weakness, or even paralysis.
Spinal nerve decompression surgery is typically considered the final option. In this article, Dr. Tewajetsada Paruang, a surgeon specializing in neurological spine surgery at MedPark Hospital, elaborates on the minimally invasive spine surgery approach and provides insight into this technique.
Untreated spinal cord diseases may lead to paralysis
Pain, numbness, and weakness in the neck, upper, and lower extremities originate from the cervical and lower back spinal nerves. Cervical spinal nerve issues can cause neck pain radiating to arms or hands, while pain originating from the lower back can lead to back pain radiating to the legs or feet.
“Numbness due to nerve problems in the neck affects the arms and hands, while in the lower back affects the thighs, calves, and feet. The weakness usually comes late before paralysis sets in. The patient can barely grasp objects and walk with an abnormal gait. Prolonged sitting, standing, or lifting can sometimes bring on the pain. Sciatica or lower back pain is common with pain radiating to the legs, aggravated when walking or standing for too long, and radiating to the calves.”
The causes of sciatica pain, numbness, radiating pain, and weakness are spinal stenosis, spondylolisthesis, infection, and spondylitis. However, the leading cause is a ruptured or herniated spinal disc encroaching on spinal nerves. When it comes to treatment, surgery is the last option that surgeons will consider.
“Treatment starts with medications and physical therapy. 70-80% of the cases are manageable with these alone. However, in severe cases of spinal nerve compression associated with muscle weakness, as well as those whose conditions do not improve after medications and physical therapy, surgery may be necessary.”
Minimally invasive spine surgery: A novel and beneficial alternative for patients
Spine surgery advancement, including technical approaches and medical instrumentation, has continually evolved to enhance the efficacy of surgery, benefitting both physicians and patients. Specialist surgeons, particularly neurosurgeons, have increasingly touched upon MIS and endoscopes.
“Minimally invasive surgeries are successful in more than 90% of cases. Many may be familiar with the term endoscopic surgery. This technique involves making a small 6-7 millimeters incision, through which the surgeon inserts an endoscope and surgical instruments to perform surgery. It's a marvelous technique.”
A keyhole MIS surgery includes not only endoscopic surgery but also small and large incision microsurgeries. Additional instruments needed, apart from endoscopes or microscopes, are tubular retractors and microsurgery tools.
“Endoscopic MIS: the camera is installed at the tip of a tubular retractor. The size of the retractor may be 1 centimeter bigger or smaller than that of the endoscope, depending on the surgical field. After inserting the endoscope, it will display a 4K video on a screen, showing abnormalities, lesions, and pathological changes. The endoscope can transmit an oblique 360-degree field of view. It will be like entering to work in a tunnel.”
Endoscope or microscope: Which is better?
When comparing an endoscope with a microscope for MIS, an endoscope displays images with greater clarity and precision. A microscope is external to a patient, streaming video of the magnified view of the surgical site, while an endoscope is positioned close to the lesions. Which type of scope is suitable depends on the patient's preference and the surgeon's discretions.
“If MIS is feasible and appropriate, I will consider it first. If the patient chooses an endoscopic surgery, I will go along, except when there is a contraindication such as anatomical problems or complexity of diseases like cancerous tumors. In this case, I will proceed to MIS with a microscope or other instruments.”
“MIS is usually performed in patients with cancer, spinal tumors, marked spondylolisthesis, or severe spinal disc herniation. We wanted our patients to achieve rapid recovery. Also, elderly patients with complicated comorbidities, heart diseases, and kidney diseases should avoid major surgery; MIS can markedly reduce potential risks.”
Nevertheless, precision MIS requires ancillary technological support. MedPark has a navigation system for generating 3D virtual anatomical images to identify the location needing a tissue excision. Furthermore, neuromonitoring equipment used to assess nerve function during surgery assists in identifying problematic nerves. If a nerve is in proximity and potentially at risk of injury, it will sound an alarm. It also displays the nerve function in the form of a real-time graph. After the problematic nerve is relieved of the pressure, the neuromonitoring equipment will display the status.
“Good techniques and high-precision instruments lead to better efficacious treatment outcomes, minimized injuries, less muscle bruising around the incision, less blood loss, fewer complications, and risks. Patients can recover rapidly, resume walking one day after surgery, and return home in a few days.”
MIS requires experience, a good team, and instruments
Minimally invasive surgery is an innovative surgical technique that requires extra learning and skill development over a specific period. Compared to developed countries, the number of surgeons adopting this technique in Thailand is far fewer.
“In Germany, where I did my fellowship, or in Europe, most physicians are trained and perform this surgery skillfully. We are early on our learning curve as it is quite new to Thailand. Nevertheless, this technique is becoming more common as we pass on our knowledge and skills in this technique to other physicians through annual training. A steady stream of physicians have been participating in academic sessions and training as assistant surgeons.”
Despite considerable online information regarding minimally invasive spine surgery, the detail and complexity of this surgery vary from case to case and are not the same for everyone. Because of this, Dr. Tewajetsada said it is advisable to consult with a doctor.
“The information you receive regarding treatment may not apply to you, which can lead to a lost opportunity to get the right treatment. I recommend consulting a doctor for the most suitable and effective treatment.”
