How Has Minimally Invasive Spine Surgery Advanced?

Major clinical advances are helping minimally invasive spine surgery get patients back on their feet faster — and with much less pain.

Traditionally, open spine surgery for decompression or stabilization required incisions that could be half-a-foot or even a foot long. The procedures involved a lot of soft tissue dissection, which could lead to significant postoperative pain, deconditioning, wound complications and infections. Recovery could take months. 

“While patients often did very well with open surgery, their initial recovery could be painful,” says Ram Kiran Alluri, MD, an orthopedic spine surgeon with the USC Spine Center and USC Orthopaedic Surgery, part of Keck Medicine of USC. 

Minimally invasive spine surgery (MISS) can achieve the same results as traditional open surgery — but through much smaller incisions the size of an adult thumbnail, about 18 millimeters or less. 

Patients experience a number of benefits from MISS. Rather than having to stay in the hospital for days, they can go home the same day as the procedure. They have much lower infection rates. And with much less pain, they have minimal opioid requirements. 

“We get these patients back on their feet a lot quicker and with a lot less postoperative pain,” Alluri says. 

Advances in minimally invasive spine surgery 

While MISS has been available for about 30 years, it has become more common in the past 15 years, driven by advances in surgery and instrumentation. 

During MISS for decompression, surgeons use an advanced instrument called a tubular retractor: a tube-shaped tool that surgeons insert to create a tunnel to a specific area of the spine. About 16 to 22 millimeters wide, the tube gently moves aside the muscle and soft tissue. Surgeons then place small tools through the tunnel to work on the spine, while using a microscope to help guide the surgery. 

The challenge of MISS for fusion surgery is placing instrumentation into the spine without the visualization offered by traditional open surgery.  

With MISS for fusion, the technological advances include both navigation and robotics. Surgeons use a CT scan to help them navigate the safe placement of the instrumentation, such as a cage or screw. Surgeons also can use a robot called a shared-control device that uses a CT scan to guide the placement of the instrumentation, while the surgeons control the drill and screw and place them through a rigid robotic arm. 

These improvements in MISS “allow us to treat pathology with less collateral damage,” he says. “We can get to the offending lesion through a very small incision, and that leads to patients having less pain, fewer complications and fewer infections. So, patients can get back to their lives the same day or the next day, as opposed to several months later.” 

Endoscopy represents another breakthrough in MISS. While arthroscopic surgery is more common for the shoulder or knee, endoscopy for the spine has become more popular in about the past five years. 

By using a camera to visualize the procedure, endoscopy allows surgeons to treat some spine problems through incredibly small incisions of 5-7 millimeters, or about one-third the length of other MISS incisions. With smaller, less-invasive incisions, endoscopy can lead to even quicker recoveries.  

Today, about 80% of Alluri’s patients undergo MISS, which all USC Spine Center spine surgeons offer. The remainder of Alluri’s patients receive traditional open surgery, often for spinal deformities or multilevel fusions.  

“Most patients with standard degenerative pathology affecting one or two levels are good candidates for a minimally invasive approach,” he says. 

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Novid Parsi

Novid Parsi is a freelance writer for Keck Medicine of USC

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