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Minimally invasive surgery not always maximally beneficial to patients

ByScott D. Boden, MD

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The professional, industry and public debate rages on regarding minimally invasive spine surgery. But what exactly is minimally invasive surgery? Typically the term refers to the size of the incision or the replacement of a traditional incision with multiple smaller incisions or ports and occasionally further accentuated by the use of a laser — an absolute magnet for patients trying to avoid traditional spine surgery. Many prefer the term minimal access surgery because it may more appropriately reflect the “minimal” part of the term is related to the approach taken to reach the spine rather than the actual extent of spine surgery being performed.

Scott D. Boden

Twenty years ago, less invasive spine surgery typically referred to procedures that used an operating microscope for lumbar discectomies, which afforded a slightly smaller skin incision. Multiple prospective, randomized clinical trials have failed to show any consistently demonstrable benefit of the microscope or the smaller skin incision. More recently, tubular retractors have allowed even smaller skin incisions with purportedly less muscle trauma, but again, prospective, randomized trials have failed to document a clear benefit in terms of patient outcomes, and may have even shown a slightly higher reoperation rate — perhaps due to suboptimal visualization. Today, even a traditional open lumbar microdiscectomy is routinely performed as an outpatient surgery.

Costs should be offset

Anterior lumbar interbody fusions enjoyed a brief dance with laparoscopic approaches only to be replaced by a less invasive version of the traditional approach due to the design of more efficient retractors. Newer less invasive direct lateral and transforaminal approaches to achieve interbody fusion are still being studied and being compared to traditional interbody fusion approaches. One thing is clear: most of the minimal access approaches involve expensive disposables supplied by the device manufacturers that add significant cost to the intraoperative portion of the procedure. Whether these costs can be offset by shorter lengths of stay or other savings remains to be seen.

Percutaneous insertion of pedicle screws and rods in cases where the primary surgery was accomplished through an anterior or lateral approach may represent a reasonable application of minimally invasive spine surgery, but the learning curve is steep and manufacturers often charge more for the hardware associated with less invasive surgical approaches. At least in the short term, these less invasive approaches are beneficial to the companies that produce and distribute the disposables that facilitate surgical access and/or nerve monitoring.

Some outcomes still unproven

Another potential beneficiary of minimally invasive surgery may be the surgeons who choose to aggressively market themselves because of the promise of less invasive surgery. The “L words” (laser and less invasive) always sound better to patients, but often those procedures can be more expensive and not deliver outcomes that are proven to be better.

As we transition from a volume-based health care economy to a value-based health care economy, minimally invasive surgery has a great opportunity to play a major role. Its challenge will be to provide comparable or better outcomes at a lower overall cost — not an increased cost. While those sound like simple goals, neither has been consistently achieved to date. The Cover Story in this issue of Spine Surgery Today features opinions from experts who have developed and used minimally invasive techniques, as well as those who have stopped using them. Both points of view are important to hear as the public debate about minimally invasive spine surgery continues.