January 12, 2016

Minimally Invasive Spine Surgery: Does the Evidence Support Its Use?

MIS appears to improve perioperative outcomes, but more studies are needed

15-NEU-2535-Steinmetz-650×450

By Michael P. Steinmetz, MD

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

A large majority of patients who visit a spine surgeon are seeking a minimally invasive surgery (MIS) option. This approach to treating common spine disease has gained traction with patients due in large part to print and television advertising. One such consumer ad features attractive models, one of whom is sporting a small Band-Aid on her back with the caption: “Guess which one of these people had spine surgery today?”

In general, many types of surgeries have become minimally invasive. For example, most abdominal procedures have been replaced by outpatient laparoscopic options, including robot-assisted surgery. These same techniques have made their way into spine surgery —yet it remains unclear how effective they are or could be.

Defining minimally invasive spine surgery

15-NEU-2535-Steinmetz-Inset-1

The surgeon begins working through the minimally invasive retractor in order to remove a herniated disk in the lumbar spine.

MIS of the spine must first be defined; if not, essentially any operation performed through a small incision would be classified as minimally invasive. Technically speaking, in the spine, MIS involves making a small incision and a corridor through the muscle. This corridor is created by minimally dilating the muscle fibers en route to the spine.

This is in contrast to conventional surgery, which involves “stripping” the muscle from its attachment to the bone. The latter may be associated with more blood loss and certainly greater trauma to the bone.

With this definition in place, the only true difference between MIS and conventional surgery is the approach

The most commonly performed minimally invasive spine surgeries include lumbar microdiskectomy, laminectomy and transforaminal lumbar interbody fusion (TLIF). In the cervical spine, minimally invasive foraminotomy is also done frequently.

Potential for improved perioperative outcomes

Spine surgeons have been employing a minimally invasive approach to surgery since the 1980s. Unfortunately, we are only now collecting enough data to analyze the effectiveness of MIS for the spine.

Advertisement
15-NEU-2535-Steinmetz-Inset-2

After placing a retractor through the skin, the surgeon begins working through a 2.5 cm incision toward an eventual lumbar fusion with screws and rods.

It appears, albeit with early and low-quality evidence, that the vast majority of minimally invasive spine surgeries result in improved perioperative outcomes — specifically less blood loss, less pain immediately following the procedure and shorter hospital stays. However, long-term outcomes have not shown any advantages for MIS of the spine

Proponents of MIS tout the differences in perioperative outcomes as clear advantages, while opponents claim that the differences are not practical in “real life” and that analysis of long-term outcome data is necessary before we draw conclusions.

Studies have clearly shown that patients after MIS surgery have less pain and lose less blood during surgery. However, less pain may be 10 out of 100 on a pain scale versus 15. The difference between the numbers may be significant; however, these same patients’ pain may be practically the same.

Short-term advantages aside, research today has moved toward understanding the cost-effectiveness of minimally invasive spine surgery. If long-term benefits are not shown, then the early or perioperative benefits must decrease the cost of the entire healthcare episode. The evidence is extremely limited. Some early studies clearly have demonstrated cost-effectiveness, while others have not.

15-NEU-2535-Steinmetz-Inset-3

Intraoperative fluoroscopic image. A minimally invasive tubular retractor has been placed through the skin in the lumbar spine.

Mounting evidence of benefits, but more research is needed

Surgery as a whole is becoming more and more minimally invasive. Spine is no different. There are clear advantages and disadvantages to MIS of the spine. Minimally invasive spine surgery costs more, often takes longer to perform and exposes the patient to greater amounts of radiation due to more extensive intraoperative imaging. On the other hand, the incision is smaller, and the patient loses less blood, may have less pain and spends fewer days in the hospital.

MIS is appropriate for specific patients with specific pathologies, since one size never fits all. The decision to perform MIS or not largely rests in the pathology or the reason surgery is to be performed.

Advertisement

Evidence continues to mount demonstrating perioperative benefits of MIS over conventional spine surgery. We eagerly await the results of further outcome and cost-effectiveness studies.

Dr. Steinmetz is Co-Director of the Center for Spine Health in Cleveland Clinic’s Neurological Institute.

Related Articles

20-NEU-1915483 Navigated TMS to guide management of refractory epilepsy_CQD_650x450
August 10, 2020
How Navigated Transcranial Magnetic Stimulation Is Advancing Epilepsy Care

A noninvasive approach to map eloquent areas before surgery

17-CCC-4475-Telehealth-650×450
June 25, 2020
Behind the Scenes in Telehealth Amid COVID-19: Physicians Help Shape the Narrative of Patient Care During the Pandemic

Physician reimbursement policy experts join forces with IT and coders to enable digital transformation

minority-stroke-program-650×450
April 21, 2020
Tailoring Stroke Treatment and Prevention to Populations Who Need It Most

Minority Stroke Program focuses on outreach to racial and ethnic minority communities

botulinum toxin injection for pediatric migraine
December 10, 2019
Botulinum Toxin Injections Are Bringing Relief for Intractable Pediatric Migraine

Excellent response seen with ongoing use in patients as young as 11

19-NEU-5592-AltinayTransgenderPsychiatry-650×450
November 11, 2019
Caring for Transgender Adults: Essentials for Behavioral Health Providers

Q&A with a psychiatrist in Cleveland Clinic’s Transgender Surgery and Medicine Program

19-NEU-5594_back-on-trek-650×450
October 31, 2019
Multidisciplinary Chronic Back Pain Program Identifies – and Addresses – Risk Factors for Noncompletion

Time constraints, language barriers, substance misuse, mood disorders targeted for improvements

19-NEU-3981-pediatric-epilepsy-650×450
October 18, 2019
Charting a Course for the Future of Pediatric Epilepsy Care

Project draws $1.6M to leverage telemedicine to create medical home, ease transition to adult care

19-NEU-3809-Willis-MS-SuicideSigns-650×450
June 26, 2019
Suicide in Patients with Multiple Sclerosis: Guidance on Red Flags and Prevention

Comorbid depression is only one of the likely warning signs

Ad