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The Evolution of Minimally Invasive Spine Surgery

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The Evolution of Minimally Invasive Spine Surgery LITERATURE REVIEW J Neurosurg Spine 30:149–158, 2019 The evolution of minimally invasive spine surgery JNSPG 75th Anniversary Invited Review Article Jang W. Yoon, MD, MSc, and Michael Y. Wang, MD Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida The field of minimally invasive spine surgery (MISS) has rapidly evolved over the past 3 decades. This review follows the evolution of techniques and principles that have led to significant advances in the field. While still representing only a subset of spine surgeries, MISS’s goals of reducing soft-tissue trauma and mitigating the morbidity of surgery are being realized, translating into more rapid recovery, lower infection rates, and higher cost savings. Future advances in technol- ogy and techniques can be anticipated. https://thejns.org/doi/abs/10.3171/2018.11.SPINE181215 KEYWORDS minimally invasive; cost; economic; spine; percutaneous; XLIF; TLIF; endoscopic HE field of spinal surgery has advanced significantly • A product? over the past half century. Along with the prolifera- • A surgical approach? tion of techniques and technologies in general, there • A marketing ploy? Thas been a concomitant movement to reduce the morbidity • A surgical philosophy? of surgery. Minimally invasive surgical (MIS) approaches • A systems-based approach for minimizing the overall have thus been popularized, with its core principles being impact of surgery? the following: 1) to minimize the collateral damage, 2) to In this review we retrace the history and evolution of preserve the normal anatomy, and 3) to reduce the overall MISS and attempt to highlight the major breakthroughs stress to the patient, all while achieving the same surgical in the field. goals as open surgery. The roots in minimally invasive spine surgery (MISS) are based primarily on technique modifications. The Wil- MISS for Neural Decompression liams microdiscectomy, described in 1978, revolutionized One of the principal goals and indications for spinal MISS by starting the evolution of lumbar discectomy from surgery is decompression of the neural elements. As such, an open surgery through a 6-inch incision to a microsurgi- MISS has its roots here. Unlike open spine surgical proce- cal approach through as small an opening as possible.68 dures where the surgeon has the luxury of wide exposure The Wiltse approach, described in 1968, was revolution- to identify anatomy as well as multiple trajectories for tis- ary insomuch as the dissection in the spine was achieved sue manipulation, an MIS approach by definition is more between muscular planes, as opposed to through the soft- restrictive. The compromise between finding a surgical tissue envelope or the subperiosteal plane.69 Subsequent corridor that provides a large enough window to perform developments have heavily leveraged new technologies, decompression while being minimally disruptive has been including enhanced retraction, fixation, biologics, visual- a perpetual challenge in MISS. ization, monitoring, and navigation, further disrupting the landscape (Fig. 1). Microdiscectomy However, it is instructive to first pose the question of The concept of microscopic discectomy introduced by “What is minimally invasive spine surgery?” Is it: Williams68 was the precursor to the modern microdiscec- • A technique? tomy in use today. Reducing soft-tissue dissection result- • A technology? ed in less postoperative back pain for patients; using the ABBREVIATIONS MIS = minimally invasive surgical; MISS = minimally invasive spine surgery; TLIF = transforaminal lumbar interbody fusion. SUBMITTED October 1, 2018. ACCEPTED November 1, 2018. INCLUDE WHEN CITING DOI: 10.3171/2018.11.SPINE181215. ©AANS 2019, except where prohibited by US copyright law J Neurosurg Spine Volume 30 • February 2019 149 Unauthenticated | Downloaded 09/23/21 04:24 PM UTC Yoon and Wang FIG. 1. The Journal of Neurosurgery: Spine has been a conduit for disseminating innovative technological breakthroughs in MISS. This is a list of cover art in the journal from 2001 to 2017 that highlighted techniques in MISS. Copyright American Association of Neurological Surgeons (Figs. from 2001, 2002, 2009, 2010, 2011, 2012 [upper and lower figures], 2013 [left figure], and 2016 [right figure]); Andre Nozokou (2013 [right figure]); Roger Härtl (2015); Roberto Suazo (2016 [left figure]); and Akihito Minamide (2017). Published with permission. Figure is available in color online only. operating microscope allowed narrowing of the surgical of the spine without cutting any muscle. Wiltse continued corridor with enhanced illumination and magnified visu- to apply this principle of muscle-sparing technique to per- alization. Smaller surgical tools with gentler manipulation form far-lateral discectomy, insertion of pedicle screws, of dura and nerve roots soon followed, which lowered sur- and ipsi-contralateral decompression in lumbar spine.70 gical complications such as durotomy, nerve root injury, While not advocating for a small incision, Wiltse laid the and discitis.31 This paradigm shift continued with the ap- groundwork and philosophical basis for MISS. plication of tubular retractor technology and endoscopic surgery described below. The Transforaminal Route The transforaminal corridor to the lumbar spine is fre- Muscle-Sparing Approaches quently used by surgeons, interventional radiologists, and The need for paraspinal muscle dissection to gain pain physicians. This corridor is bound by the existing surgical access frustrated spinal surgeons and patients nerve root superiorly, superior endplate of caudal verte- alike. The effects of extensive subperiosteal stripping and bral body inferiorly, and facet joint root medially. First prolonged retraction of the soft-tissue envelope are sig- described by Parviz Kambin (Fig. 2A) in 1973, the trans- nificant. Ischemic necrosis of the paraspinal muscles and foraminal access has been the workhorse for tackling a va- chronic back pain can be seen in patients who undergo riety of pathologies that affect the lumbar spine. Initially spinal surgery. Wiltse (Fig. 2B) and his colleagues inno- he began to experiment with percutaneous posterolateral vated a unique approach that involved muscle splitting as access to the spine to treat herniated discs at L3–4 and opposed to subperiosteal stripping to achieve the same ex- L4–5. Kambin described his surgical technique in detail, posure.69 The procedure involved “longitudinal separation making an incision 8 to 9 cm off the midline and inserting of the sacrospinalis group between the multifidus and lon- a cannula with a converging angle of 35° to gain access to gissimus” to bluntly gain access to the posterior elements the disc space. This approach was aided by fluoroscopy, 150 J Neurosurg Spine Volume 30 • February 2019 Unauthenticated | Downloaded 09/23/21 04:24 PM UTC Yoon and Wang FIG. 2. Prominent figures in MIS spine surgery. A: Parviz Kambin (source: https://upload.wikimedia.org/wikipedia/commons/8/8a/ Dr._Parviz_Kambin.jpg). B: Leon L. Wiltse (source: http://www.burtonreport.com/wp-content/uploads/2016/01/Wiltse200.gif). C: Luiz Pimenta (source: https://www.lateralaccess.org/assets/headshots/150 × 225-Luiz-Pimenta.jpg). D: Kevin T. Foley (source: http://www.truevisionsys.com/testimonials-neuro.html). E: Richard G. Fessler (source: https://www.nref.org/en/Ways-to-Give/ Honor-Your-Mentor-Funds/Richard-G-Fessler-Fund). F: Anthony T. Yeung (source: https://www.sciatica.com/doctors/anthony-t- yeung-m-d/). G: Gun Choi (source: http://wooridul-ph.com/templates//inc/images/about/img_Dr.jpg). Copyright Jds319 (panel A, license type: CC BY-SA 4.0 [https://creativecommons.org/licenses/by-sa/4.0/]); Charles V. Burton (panel B); Society of Lateral Access Surgery (panel C); TrueVision Systems, Inc., 2018 (panel D); Neurosurgery Research & Education Foundation (panel E); Anthony T. Yeung (panel F); and Wooridul Hospital (panel G). Published with permission. Figure is available in color online only. which in and of itself was unusual during that era, and nerve root retractors could be applied in a similar manner was the predecessor to modern techniques that are depen- to open surgery. An early predecessor to this was Faubert dent on technology (as opposed to direct visualization) for and Caspar’s report of a “percutaneous” microdiscectomy localization. By passing the cannula into the interverte- at the L4–5 level through a paramedian approach.14 bral disc, herniated disc fragments were delivered into the In 1999, Foley (Fig. 2D) and Smith reported their ex- working cannula, through which disc fragments were as- perience of microendoscopic discectomy for far-lateral pirated by applying negative pressure. He concluded that disc herniation in 11 consecutive patients using a tubu- complications such as “postoperative bleeding, perineural lar retractor and disposable endoscope. They described scar formation, and reherniation through the posterior fen- docking the initial dilator at “the junction of the cephalad estration” that are often associated with midline laminec- transverse process and the pars,” and through a 16-mm- tomy and discectomy are avoided through his approach. diameter tubular retractor, decompression of the exiting Kambin continued to treat lumbar disc pathology through nerve root was performed by removing the superior ar- a transforaminal corridor, and would later publish his re- ticular process with a Kerrison rongeur and high-speed sults regarding 100 patients with an 87% success rate with drill.17 While
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