Minimally invasive procedure – an alternative to traditional back pain surgery

How many people have back surgery every year?
Dr. Taylor: In the United States, back surgery is performed on 200,000 to 300,000 people per year. What’s really gone up in the past year is the amount of fusions people are doing. It used to be a small number of people who would have it. It used to be a discectomy or a laminectomy, which is a smaller operation, and the amount of fusions were relatively low. Over the past year or so, that amount has just increased, so now we’re doing approximately about 100,000 fusions per year just in the United States alone.

Why are so many people getting back surgery each year?
Dr. Taylor: People want their back pain to get better. For example, the 80-year-old who comes into my office who no longer can play golf says in 2005, he wants to go out and play golf again. People who have degenerations in their back or arthritis are now refusing to live with it. They don’t want the back pain, and they want to get better. And the fusions really take care of back pain. The other operations we talk about are more likely when people talk about herniated discs. As our population ages, degenerations of the spine become more and more, and older people are just so much more active than they used to be.

What has been the standard surgery for people who had significant damage to their backs?
Dr. Taylor: Let’s say for someone who was looking to have a fusion, he would have had a non-instrumented fusion. For this, he’d have a fusion where doctors would’ve just taken bone from his hip, laid it over the bone in the back, and then they would’ve put him in a brace. He would’ve been in bed for the next six weeks. That has then changed over the past 10 or 11 years, where we started putting instrumentation in rather than bone from the hip. We’re starting to use metal, titanium and implants in the spine to increase the rate of fusion, and to get people back into their normal activities much more quickly. With that increase in the instrumentation in fusion, we then need bigger surgeries and more operations, and it becomes more complicated and more expensive for everybody at the same time.

Now, what is the next advance?
Dr. Taylor: The new advance is minimally invasive surgery for the spine. As some people know, minimally invasive surgery, or endoscopic surgery as it’s commonly called, has been available for many different specialties, but it’s only been available for the spine recently. Fusions are larger operations that doctors normally had to do open. So, the patient would come into the hospital and need a fusion operation or a laminectomy and a fusion and instrumentation, and they were looking at a five- to seven-day stay in the hospital, one to two units of blood transfusion, a day in the ICU, and then six to eight weeks before they were back to their more normal activities. The minimally invasive surgery is the latest advance which is made in other parts of medicine, but is late to the spine. It is just now really starting off.

Why do you think it has taken so long to develop a minimally invasive procedure for the spine?
Dr. Taylor: The cavity to do endoscopic surgery is what everybody looks for, so you have to create a space. When doctors do endoscopic surgery in the abdomen, they put gas or CO2 into the abdominal space, and would then be able to operate off a TV screen into that space. If someone’s operating arthroscopically in the chest, they would use the lung as the space. They would retract the lung out of the way, which would become your space. With spine surgery, we had a difficult time creating that space because the nerves and the bones are so delicate in that location that you can’t put CO2 or gas in that environment or you’ll cause damage to the nervous system. So we didn’t have the ability to create that space to work in, and the other thing that happened is that the technology really hadn’t caught up with the instrumentation on what people wanted. Our idea now is that we’re using specialized retractors and specialized equipment to create that space that we need to work in to do a minimally invasive procedure.

How are you able to work your way around the nerves?
Dr. Taylor: It has worked its way around the nerves. There are two parts to the spine. One is the bony anatomy, which we think about as causing problems, and the second one obviously is the nervous system or central nervous system. When you’re operating in that space, the nervous system is completely unforgiving. You can cause significant damage to it very quickly. Most of the symptoms that people have are because of compression or pressure on the nervous system that we want to use, so the instrumentation has to be lending itself to creating that sort of space and not putting any extra pressure on the nervous system, which we’re trying to avoid.

What is the standard back surgery like? How difficult is it for the surgeon and for the patient?
Dr. Taylor: The standard back surgery would have been an incision of about 15 centimeters and maybe eight to 10 inches long for a single, one-level fusion. It would’ve involved stripping all the muscles away on the spine to get good exposure to the spine, so you would need exposure where you would remove all the muscles along the back. It would be a lot of operative time and compression and a lot of pain for the patient because of all that work that needed to be done. That translated to a lot of time in the operating room, significant blood loss, which then translates into a longer time in the hospital and more complications. An older patient just can’t tolerate that. As we’re operating on older and older people and doing bigger and bigger operations, we’ve run into more complications.

What is the pain like with the standard surgery?
Dr. Taylor: The pain is quite severe in standard surgery. Most people would be on a morphine drip, so after surgery, they would be on IV narcotics. Ten being the worst pain you can imagine, and one being a nagging ache, they would rate the pain an eight to nine. They talk about the pain being an eight to 10 for a number of weeks. They would be on significant long-term narcotic medications to control that pain, which obviously, then, inhibited their recovery and made things a little more difficult.

What is the minimally invasive surgery like? What are the differences between the standard and the minimally invasive procedures?
Dr. Taylor: Number one is that the surgery has been made much easier for the patient. Now, the incision is one to three centimeters long, which is just enough to get the retractor into that space. It’s really localized now, specifically with fluoroscopy. We don’t look visually to try to find things, but we locate them on X-rays. Then we can put instrumentation, the retractor, into that space by localizing with X-rays. The length of surgery has gotten shorter because we don’t have to do the large dissection to remove all the muscles and expose everything. The blood loss has been by a tenth, so there is no longer a need for blood transfusions. Also, since the pain is much less, the narcotic rate has gone way down. People are out of the hospital in one to two days in lots of situations, and they’re recovering much faster and back to their normal activities quickly. I operated on a lady today who was 79 and her family doctor had told her, “You’re 79 years old, you can’t have any surgery,” which is just not the case anymore. With a minimally invasive surgery, which is shorter, faster, with a small incision, less healing time, and less blood loss, she’s able to have a rather large surgery very successfully.

Does the minimally invasive surgery cut down on infections that can result from the large incision?
Dr. Taylor: It absolutely does. We don’t quite know what that is, now if someone were to do surgery on just the average person with an inserted metal instrumentation, the infection rate is somewhere between 2 percent to 6 percent, which means every 100 times you do it, you’re going to have four or five people. Infection in the spine is a very big problem because you’d have to take out the metal instrumentation and do another surgery. You’re stuck redoing everything. The infection rate has dropped astronomically in the minimally invasive procedures. Number one is because you don’t have the huge muscle bisection the space is much smaller and more controlled that you’re working in, so the patient is not as sick. They’re not bedridden for as long, they don’t require a catheter for as long, the drains come out sooner, everything moves more quickly, which is what you want to try to avoid for risk of infection. Also, the amount of devitalized tissue is much smaller. When we’re cutting away the muscle and the spine for a long operation, we’re devitalizing and destroying those tissues. The amount of tissue that is devitalized is very small in a minimally invasive procedure, so you don’t have the opportunity for infection in those tissues.

If the rate of infection is up to six people out of 100 in standard surgery, how would it relate with minimally invasive surgery?
Dr. Taylor: There isn’t a number yet, because people don’t really know. I can tell you we’re putting together groups of numbers at the moment. I’m at about 200 minimally invasive procedures, and I have not had an infection yet. Now, I’m certainly going to have one, because the average clean infection for any procedure is about 1 percent. Re-do spine operations and instrumentation go up a lot from there. Around the country what people are reporting is that the infection rate is much lower. My feeling is it will probably be around 1 percent, which is about a half to a third of what it would be in an open operation, which is a big deal. People want to get fixed and then want to go home and go back to their normal activities, and if you have a complication, it makes it much more difficult to do that.

How has the use of the minimally invasive procedure changed the way you do things?
Dr. Taylor: Number one, it’s made me more willing to operate on people with a larger set of morbidities or co-morbidities, like an older patient with more complications and problems. Even 20 to 30 years ago in neurosurgery, people would say, “Well, anyone over the age of 65 can’t have neurosurgery because they’re too old.” That just doesn’t hold anymore. People are now having surgery up into their 80s and very easily. So, it allows me to operate on people much more safely. Number two, it’s changed in the sense that instead of feeling every time I see the person like I have to take care of every single problem he has, I can do things to make sure someone’s going to get better. Now, I can do an operation and the patient can be in and out of the hospital very quickly and back to normal activities. Lots of times they don’t need that other procedure, which we might’ve done because the X-ray looks bad or something looks abnormal, but we’re not sure. It’s allowed me to tailor the operation. I can have patients in to do one thing, and if it doesn’t work, I can try something else.

What do you think the biggest advantage is for patients?
Dr. Taylor: Number one, nobody wants a blood transfusion anymore. If you tell them they don’t need a blood transfusion, and they see someone else who says, “Well, you have to donate two units of blood beforehand, or you might need a blood transfusion,” that makes a big difference. The other thing that’s really good is that lately people have been rushed out of the hospital. For example, it’s not uncommon to hear about people having “drive-thru” deliveries. Insurance companies want people out of the hospital quickly, so doctors are pushed to get people out of the hospital quickly. Even if it doesn’t get the person out of the hospital any quicker, you’re discharging people when they’re ready. When they leave they are ready to go home and get back to activities. Very rarely are we sending people to rehab for some prolonged recovery. The other thing is that when you’re doing surgery, you’re always going to have some kind of complication, and the rate of those complications is much less for this surgery. The unhappy or unsatisfied person who has a problem from the surgery or something else goes way down.

Who’s a good candidate for this?
Dr. Taylor: Anyone’s a good candidate. Younger people want it because it’s more cosmetically appealing. They want something which is less destructive and less invasive, and older people want it because they recover quicker. People who are still in their 30s, 40s, and 50s want to get back to work, get back to their activities, and don’t want to be in the hospital for a long time. So, 90 percent of what I do now is minimally invasive. There’s a minimally invasive procedure for everybody, for just about every problem that you can think of with spine surgery.

Is there anybody who would not qualify?
Dr. Taylor: I think what we’re seeing right now is that re-do operations are always more difficult. I think they’re even more difficult with minimally invasive surgery. They certainly can be done, but the re-do operation, which is open, is hard. I think it’s probably a little bit harder with minimally invasive surgery because your tissue plains are less, and you really require anatomy which you can visualize with minimally invasive surgery. We’re also just starting to think about doing scoliosis in a minimally invasive way. Scoliosis is a big problem with spine patients, and that’s going to be the next step for minimally invasive surgery. Then the thing after that is when those artificial discs are starting to happen. It’s a big operation to put an artificial disc in, so the next step is going to be minimally invasive approaches for the placement of artificial discs.

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