Progressnotes - October/November 2012
- About MUSC Health
Traditionally, correcting problems with the spine has necessitated open back surgery, requiring a large incision (5-6 inches or longer), muscle dissection, and retraction to expose the spine. Surgeons had full access and visualization of the spine, but at the cost of significant tissue trauma and long recovery times. Many of the spinal procedures once done via open surgery are now being performed, with comparable outcomes, using minimally invasive surgical (MIS) techniques that require smaller incisions, resulting in less blood loss and disruption of muscle tissue. In addition to speeding recovery times, these techniques are associated with less scarring and a reduced risk of infection or wound breakdown.
Bruce M. Frankel, M.D., Professor of Neurological Surgery and Radiation Oncology in the Departments of Neurosciences and Radiation Oncology at MUSC, has helped pioneer the application of these MIS techniques, now almost commonplace for the surgical treatment of degenerative disk conditions, to the treatment of patients with metastatic spinal tumors or with traumatic fractures to their thoracolumbar spine.
Dr. Frankel specializes in MIS techniques for the spine. Instead of exposing the spine to gain visualization and access, Dr. Frankel opens a limited portal, through which the exact spinal region of interest can be visualized with the aid of a microscope and through which specialized surgical instruments can be passed to perform the procedure. He makes a small incision off the midline of the back, much smaller than that which would be required for open surgery, and establishes a channel to the spine not by dissecting muscle but by dilating it. Once access to the appropriate region of the spine has been achieved using fluoroscopic guidance, an 18- to 24-mm port is inserted. The posterior approach minimizes complications by avoiding the transabdominal region and the chest.
The more rapid recovery times made possible by MIS techniques are particularly critical for cancer patients with tumors that have metastasized to the spine. These tumors can put pressure on the spine, leading to extreme pain as well as loss of mobility and neurological function. Surgery is one palliative option in these patients, helping to relieve some of these symptoms by removing or debulking the tumor. However, many of these patients are in the last months of their lives, and physicians and patients alike have had to weigh the benefits that could be gained through surgery (lessened pain, better ambulation) against the long recovery times required after open surgery. The availability of an MIS option tips that balance, because the same gains can be achieved with dramatically shortened recovery times. New approaches to minimally invasive spine surgery are being pioneered at MUSC to positively affect the outcomes of patients with complicated conditions involving the spine.
In a series of 72 patients with metastatic spinal tumors at MUSC, those treated using MIS techniques had shorter hospital stays, as well as decreased blood loss and wound breakdown, and the quality of their lives increased, in part due to decreased pain and better ambulation (data unpublished but presented at national meetings). The surgery does not prolong survival, but it could affect it indirectly by making it possible for patients to restart chemotherapy or radiotherapy sooner and to stay ambulatory, staving off immobility-associated complications.
This same MIS technique can be used to stabilize the spine or fuse vertebrae in patients who have sustained thoracolumbar fractures, which are caused by high-velocity accidents like car crashes. Such fractures can result in severe pain, spinal instability, as well as lack of mobility and neurological function. In a cohort of 61 patients (MIS technique, n=45; open, n=16), those undergoing an MIS technique vs open surgery lost less blood (mean: 518 mL vs 1800 mL), had shorter hospital stays (6.5 vs 20.2 days), and had fewer complications (hardware failure: 6.6% vs 12.8%; wound infection: 3.3% vs 6.4%; data unpublished but presented at national meetings).
MUSC specializes in tissue-sparing minimally invasive surgery for the brain and spine. For example, MUSC is the first in the state to offer transforaminal endoscopic microdiscectomy for herniated disk repair. This repair, which adopts a unique approach through the intervertebral foramen (the opening formed by a neural arch through the spinal cord), requires only an 8-mm incision and has a far shorter recovery time than more traditional discectomies.