Sr. Consultant - Brain & Spine Surgery
Cell: 09823170977
shailesh_kelkar@hotmail.com
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Minimal Invasive Spine Surgery
Minimal invasive spinal surgery (MISS) was first performed in the 1980s, but has recently seen rapid advances. Technology has enabled spine surgeons to expand patient selection and treat an evolving array of spinal disorders, such as degenerative disc disease, herniated disc, fractures, tumors, infections etc using newr and minimal invasive approaches.
Spinal Surgery – Burden of Past Experiences

In the past century and last 1-2 decades in particular, science has been evolving with rapidity beyond imagination. All gadgets related to Information technology, including mobile phones, telecommunication, internet and and what not has been remarkable. Medical science has kept pace with this evolutionary pattern. With the introduction of Neuroimaging , CT Scans, MRI scans ,introduction of Microscopes , Drilling systems the Spinal Surgery has become more precise and predictable.

Having said that, which is one side of the coin or story. As a clinician, one has to answer a whole gamet of questions which are legitimate and at times logical by the patient regarding the disease process and its management. It so happened that one middle aged gentleman walked into the outdoor department with severe backache, tingling sensation in limbs and difficulty in standing and walking following lifting of heavy object. He was evaluated clinically and suspected to have slip disc. His MRI was done which confirmed the suspicion, images showing a large disc, which had prolapsed and was pressing over exiting nerves. Having diagnosed the case, the gentleman was advised surgical intervention with excision of disc by minimal access surgery either microscopic assisted or endoscopically.

At this point the discussion ensured with relatives, particularly from senior generation stepped in, All the medical opinion right from traction, strict rest, diathermy to some weired options like bone cutting, some baba planting a kick on the back, panch karma benefitting the patient were discussed logically and scientifically and come down to a conclusion that patient was left with surgical options only. One of the senior person among the relatives started to share about his confrontation with this type of surgery two decades back. He told about the bad experience which his patient had then. The patient could not stand on his feet after surgery and was still leading a bedridden life. His anxious face showed the signs of old memories trying to suggest that these surgeries are not worth taking the risk. At that moment the surgeons convincing power were being put to test. The challenge was to take the whole story through the present day perspective of surgical understanding. Surgeon once gain began explanations, without discrediting the valuable contribution of Surgeons of previous generation and talked about the better understanding of anatomy along with functioning and biomechanics of spine .To add to it the vast inputs from radiology in the form of MRI adding to the precision and last but not the least the evolved surgical skill of the present day surgeon to tackle the problem were put across the table. Finally relatives were convinced , patient underwent surgery , a microdiscectomy (MISS) was done and the pressure over the nerve was released. Patient had good surgical outcome and none of the problems discussed before surgery were to be faced. In. Short, it was a smooth sailing surgical exercise. All Spinal surgeons of present generation have to face this type of dialogue in there practice and try to change the outlook of the patient and relatives towards spinal surgery. Old memories die hard. But I am more convinced that spinal surgeons of today are well equipped in terms of skill, precision and decision making to deliver excellent results and once for all change the perception of people towards spinal problems and spinal surgery over a period of time.

Minimal invasive spinal surgery (MISS) : What is it all about?
It is interesting to know the background of the development of minimal invasive surgery. One potential drawback of traditional low back surgery is the damage that occurs due to the long incision. Sometimes disruption of natural spinal anatomy is necessary to facilitate decompression of pinched nerves and the placement of screws and devices to stabilize the spine. This may lead to lengthy hospital stays , prolonged pain and recovery periods, significant operative blood loss, and risk of post –op infection.MISS developed to rectify the longstanding problems of conventional spinal surgery.
Why Minimal Invasive Surgery?
Minimal invasive spinal surgery(MISS) has been developed with the aim of reducing approach related morbidity or 'collateral damage' to surrounding tissues whilst obtaining the same clinical outcomes of traditional open procedures.
Minimal Invasive Spine Surgery have been used for various surgeries like:
a. Micro-discectomy
b.Endoscopic Discectomies
c. Interbody fusion
d. Thoracoscopic Spine Surgery
e. Pedicle screw fixation
f. Biopsy

Microdiscectomy :surgery for a herniated lumbar disc is traditionally performed through a two-inch incision. The muscle is peeled off of the surrounding bone to access the disc space. The use of microscope allowed better illumination and magnification as well as a relatively smaller incision.

Endoscopic discectomy:The overall goal of this technique is quite similar to that of an open microdiscectomy. The endoscopic discectomy procedure is performed through a small tube placed through a small puncture in the skin. A specialized micro video camera, or a microscope and specialized lighting, is used to visualize the nerves and disc. Removal of disc material is performed with specialized micro instruments. The benefit of this procedure lies in the reduction of local trauma. Specifically, this means that none of the muscles, ligaments, or other soft tissue structures have been cut or disrupted in anyway. This translates into very little pain after surgery and a greatly enhanced rate of recovery. Many patients can return to work in just a few days.

The benefits of MISS include:
1. Reduced blood loss
2. Reduced post-operative incisional pain
3. Minimised respiratory difficulties
4. Improved mobilization
5. Early discharge from hospital
6. Enhanced rehabilitation and early return to activities and work.

These advantages afford a clear reduction in direct and indirect health care costs when employing MISS or MASS techniques.

Balanced Decision Making!!!

In spinal surgery, apparently every surgical decision has to be a balanced one. Surgical planning could be for Minimal invasive surgery(MISS) or otherwise but the outcome depends on the fact how judiciously decisions are taken. This reminds me of a story which can simulate a similar situation and try to simplify and convey my thoughts.

Imagine if a bird made of wax is made to fly over the sea (water) on a bright sunny day , and the bird has to cross over the long stretch of water to reach the land on the other end safely . The wax bird will have to fly at an optimum height over the water level. If, the bird flies at a low height over the water it may fall in the water because of its own weight and drown and if it flies at extreme height, it may melt as the heat will melt the wax .So, the moral of the story is if someone wants to achieve his goals in life he needs to optimize his thinking, deeds over a prolonged period of life in a disciplined manner.

The same logic applies to decision making in spinal surgery. Treating surgeon has to find the balance in decision making. This can involve timing of surgery, approach to the particular pathology , understanding about the outcome. Any over-enthusiastic or sub-optimal surgical intervention will result in disappointment to the patient. Hence I suggest that there should be clarity in the minds of treating surgeon, patient and the relatives as to what are the expectations out of the proposed treatment, which could be either medical or surgical. This rational approach will significantly reduce unrealistic expectations and frustrations of patients. This will reduce distrust and in turn reduce medico-legal hassles . The newer concepts will reduce financial burden of the society and will also improve doctor-patient relationship and make approach to life more realistic.