Minimally Invasive Spinal Surgery: An Overview
Guest: Dr. John Glaser – Orthopedic Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. John Glaser, who is Professor of Orthopedic Surgery here, at the Medical University of South Carolina, and one of our experts in spine surgery. Dr. Glaser, in all areas of surgery, there’s so much interest these days in the less invasive or minimally invasive techniques in surgery. Has that been important in spine surgery as well?
Dr. John Glaser: Yes. Spine surgery is one of the areas where many of these techniques have come into play in recent years and are being accepted throughout the spine surgery world.
Dr. Linda Austin: What are some examples of less invasive approaches in spine surgery? What sorts of procedures are you doing, these days, that way?
Dr. John Glaser: One of the most common ones that we do, it’s actually the most common operation spine surgeons do, is a discectomy for disc herniations, or slipped discs. The technique, now, that I and many other people perform is called a microdiscectomy. In years gone by, we would make a much larger incision, expose a great deal of the spine, strip away a great deal of muscle and then take away a fair amount of bone to see the nerve where the disc problem was, retract the nerve, and pull the disc out.
What many of us are doing now is making a much smaller incision. We often will have an x-ray machine in the operating room to help us localize the incision. We detach a small amount of muscle or we, now, have some newer systems where, rather than detaching, we can dilate through the muscle, allowing us to see in without detaching the muscle from the bone. Once we get in, we can move an operating microscope in, other people will use some techniques similar to jewelers’ loops, where they magnify the field, and we can work through a much smaller, less bloody, field, causing a lot less pain and allowing for a faster recovery, and getting the same effect of decompressing the nerve and taking out the slipped part of the disc.
Dr. Linda Austin: So, I gather, this is a procedure that you would do when there has been a severely herniated disc, is that correct, causing a lot of pain? You mentioned in an earlier podcast that, often, you’d first try conservative treatment, such as bed rest and exercise, and so forth. But this is something you do when that doesn’t work?
Dr. John Glaser: That’s right. It’s not common that we have to get someone to the operating room quickly for a disc herniation. For a majority of people, their main problem is pain. And although pain is very uncomfortable, it’s not an emergency. And sometimes, with nonoperative treatment, we can get them over the episode without surgery. So, in most people, the time to operate is when nonsurgical measures have not helped.
Dr. Linda Austin: And so, these are situations, then, when you can schedule the surgery? It’s not done emergently?
Dr. John Glaser: That’s right.
Dr. Linda Austin: How long is the recovery from this surgery?
Dr. John Glaser: Most people go home that day or the next day. I generally tell them to limit their activity for a few weeks. I like to let the dust settle on things for awhile. I think that when nerve roots are angry, from a disc herniation, they tend to stay angry even though you’ve taken the piece of disc out. I tell people it’s like living with their in-laws. The bite might be over, but the next thing they say set’s you off all over again. But, many people are able to get up on their feet within a few days. If they have a sedentary job, I let them go back when they feel up to it, which is usually between two and six weeks. If they have a physically demanding job, I wait a little longer and work on some rehabilitation.
Dr. Linda Austin: Now, help me to understand a little bit better, anatomically, what’s going on. You remove the disc, right? So then, you have the two vertebral bodies just stacked up, on top of each other? Is that right?
Dr. John Glaser: Not exactly. We do our best to remove as little as we can and still allow for decompression of the nerve root. So, a large majority of the disc is still there. We just take the herniated piece out.
Dr. Linda Austin: I see. That makes more sense.
Dr. John Glaser: If you were to remove the entire disc, you would have a collapse of the disc space. And, if you don’t perform another procedure, such as a spine fusion, it would lead to arthritic, degenerative, painful problems.
Dr. Linda Austin: But, a spine fusion cannot be done with minimally invasive technique? Is that right? That requires a bigger operation?
Dr. John Glaser: Actually, it can, depending on the situation. We now have technology that allows us to place, for instance, bone graft, or some other bone substitutes, into the disc space through a slightly larger incision, but not much. So, minimally invasive technology has actually come into the spine fusion field as well.
Dr. Linda Austin: What do you envision as the future of less invasive techniques in spine surgery?
Dr. John Glaser: Well, I believe that the thrust is going to be for smaller and smaller incisions, more things done through a percutaneous, or through the skin, approach. And the challenge will be to allow us to continue to be able to access what we need to do, to see what we need to see, and still be able to do our surgeries, such as a microdiscectomy or a fusion, through as little an incision as possible with as little pain, discomfort and blood loss.
Dr. Linda Austin: I think that’s important to underline. There may be folks who are thinking, well, gee, you know, I keep my shirt on and I’m not a very vain person, I don’t really what care about the size of the incision or scar. But it sounds, from what you’re saying, as if there are medical reasons why you want to keep the incision site as small as possible.
Dr. John Glaser: There are some medical reasons, such as scarring in the area and the greater blood loss. There are times when I appreciate the people, though, that say they keep their shirt on and don’t mind a larger incision, because there are still many things that are, technically, quite challenging, and it does make life a lot easier to be able to make a little bigger incision and to see what you need to see.
Dr. Linda Austin: So, it’s a question of visualizing and really getting good access to the site? And I’m sure you would never want to compromise that for the sake of esthetics.
Dr. John Glaser: That’s right. It doesn’t do much good if the incision is smaller but the surgery didn’t work.
Dr. Linda Austin: Exactly. Dr. Glaser, thank you so much.
Dr. John Glaser: Thank you.
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