Minimally invasive techniques have limitations in spinal deformity correction

When comparing open spinal surgery with minimally invasive procedures for spinal deformity correction, open surgery can have better long-term outcomes.

As health care providers, it’s essential to stay aware of the evolving surgical techniques and technologies in spine surgery. In a presentation by John R. Dimar II, M.D., spine surgeon with Norton Leatherman Spine, several questions were raised regarding the widespread promotion of minimally invasive techniques and their applicability in complex cases.

Dr. Dimar cautioned against the blanket adoption of minimally invasive procedures, especially in cases of significant pediatric and spinal deformities. While these techniques often are marketed as the new standard, Dr. Dimar stressed the importance of recognizing the limitations inherent in such approaches.

One key point is the reality of outcomes, particularly in cases of severe spinal curvature. Dr. Dimar highlighted that many studies showcasing the success of minimally invasive techniques often focus on less-severe degenerative curves, which may not accurately represent the challenges posed by more complex deformities involving severe spinal curvature or too much positive forward balance. The increased use of minimally invasive transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) procedures, for example, has been associated with a concerning rate of nonunion or a lack of inadequate release of the nerves, requiring revision surgeries.

Beyond the clinical implications, according to Dr. Dimar, there are the risks to the patient and physician associated with prolonged exposure to radiation during fluoroscopy-guided procedures. While lead protection is standard practice, the cumulative radiation exposure over a health care provider’s career involves potential long-term health risks.

In response to these challenges, Dr. Dimar advocated for a judicious approach to spine surgery, emphasizing the need for well-tailored interventions based on the specific needs of each patient. He has promoted the concept of the mini open anterior interbody fusions (anterior lumbar interbody fusion and oblique lumbar interbody fusion) and posterior interbody fusion (TLIF and midline lumbar interbody fusion) techniques, as a viable alternative to the various minimally invasive and lateral lumbar interbody fusion (LLIF)-based procedures, due to more favorable deformity correction, improved fusion success, better decompressions and improved long-term outcomes.

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In conclusion, health care providers should evaluate critically the evidence supporting minimally invasive spine surgery and prioritize patient safety and long-term outcomes when treating adult spinal deformity. While these MIS techniques do have their place in certain clinical scenarios, they should not be portrayed as a universal remedy for all spinal pathologies, especially those requiring more extensive correction.

Open surgery vs. minimally invasive surgery

When comparing open spinal surgery with minimally invasive procedures for spinal deformity correction, open surgery generally is believed by many spine surgeons to have better correction and higher fusion rates. This is often attributed to better visualization of the spine during open procedures, allowing for better correction of the deformity. Open procedures allow for a wide variety of osteotomies that facilitate the restoration of flexibility, subsequent superior correction of the deformity, more precise placement of instrumentation, and a significantly improved environment for bone grafting and fusion.

In contrast, minimally invasive techniques may have limitations in addressing complex spinal deformities, due to restricted access and visibility. While minimally invasive surgery offers advantages such as reduced blood loss, shorter hospital stays and faster recovery times, the trade-off can be a higher likelihood of needing additional surgeries due to inadequate decompression, loss of correction and worse fusion success. It is important for patients to discuss these factors with their health care providers to determine the most suitable approach for their specific condition. To determine the most suitable surgical technique based on the patient’s specific condition and needs, patients should consult with a surgeon specializing in all pediatric and adult spinal deformity conditions.

Considerations for adults with scoliosis

Although the treatment of deformity in the pediatric population requires special considerations, most techniques are similar to those employed in adults. Untreated pediatric deformity often will progress during adulthood due to degenerative changes in the spine, or a deformity simply may develop spontaneously, due to spinal degeneration. Consequently, as adults age, spinal deformity frequently causes increased back pain, stiffness, nerve compression and weakness, and difficulty maintaining standing balance. As the spine undergoes these degenerative changes — which often predictably accelerate with age — they frequently result in a significant reduction in a person’s activities of daily living and their quality of life.

Adults with scoliosis may experience three serious issues with their spinal deformities as they age; loss of standing balance, incapacitating back pain, especially in the lumbar (lower back) region; and spinal stenosis that results in the compression of the spinal cord and nerves, resulting in radiating pain, numbness or weakness in the legs. This nerve compression further can contribute to difficulties in walking or performing daily activities.

These three progressive symptomatic conditions that develop with aging in adults with preexisting pediatric scoliosis and degenerative scoliosis may require surgery to stabilize their spinal deformity, balance their spine in an upright position, relieve their back pain and most important — improve their nerve compression. For adult deformity and scoliosis, options include an open spinal fusion surgery, which is considered by most spine specialists as most effective for severe deformities. The surgery often involves aligning the spine with modern instrumentation, followed by fusing the vertebrae together to stabilize and align the spine for the long term. Additionally, severe deformities may require the spinal vertebrae to be cut, using highly specialized techniques to more effectively realign the spine, or anterior surgery to mobilize the vertebra, place realignment cages and enhance fusion success.

It is important for all patients to take the time to select a center that has an experienced surgical team, all available modern equipment, a skilled spinal nursing staff and facilities to enhance their recovery. There have recently been numerous transformational changes in adult spinal deformity surgery to meet these ends, including modern instrumentation, spinal cord monitoring, fusion-enhancement biologics, precision guidance machines to place the screws and rods, comprehensive spinal outcomes and registries, and enhanced protocols to speed recovery. Patients should inquire whether the spine center that they are considering has these state-of-the-art features to ensure their successful surgical outcome.

The surgical goals for patients with adult degenerative scoliosis is to correct spinal deformities, alleviate back pain, improve overall spinal alignment and function, relieve neurologic pain, and improve their quality of life. Patients should request a referral to an experienced spine surgeon, with expertise in the treatment of adult deformity, to evaluate their spinal deformity. The surgeon can evaluate whether or not surgical treatment is appropriate, based on the severity of their condition and overall health, and the individual needs of the patient. The patient also should consider choosing a nationally recognized spine center with state-of-the-art facilities and rapid recovery regimes to ensure improved outcomes, such as Norton Leatherman Spine.

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