The Concept of Optimally Invasive Spine Surgery

Minimally Invasive Spine Surgery is no longer the new buzz, but the accepted norm.  The newer spine surgeons try to be minimally invasive in their approaches to the spine. With improvement in instrumentation and visualization techniques – the incisions have decreased in size. It is a much welcome step in the advancement of spine surgery and spine patients also are actively seeking minimally invasive spine surgeons for their care.  The scientific literature and studies have partially confirmed marginal superiority of these techniques with regards to early return to work and anatomy preservation. There are many patients who come to our clinic asking for minimally invasive surgery. I more than often have told them that I will be doing optimally invasive spine surgery– as the MIS surgery with limited access to pathology may not do complete justice to the entire extent and grade of pathology. It is important to individualize treatment options to various types, extents

and grades of pathologies. Sticking to limited, mastered traits of ‘seeing though the key hole’ may limit treatment options we can provide. Instead of assessing the patients to see if he fits your approach, it is important to be able to tailor your approach for the patient’s current pathology, which may even include doing open surgery.  It is also important to be at ease, to open and see the bigger picture when in need. If you have the above ability, you can be called as optimally invasive spine surgeon. 

In the quest of being called as minimally invasive surgeons there has been a neglect to learn the principles and techniques of open surgeries. We do come across instances where even well versed laparoscopic general surgeons find it uncomfortable and out of place to do laparotomy even if they have to . As has happened to our general surgery colleagues, with time and flow they got so well verse with the laparoscopic procedures that they feel uncomfortable and out of place while opening the abdomen -even if they have to. I call this phenomenon as a tendency of seeing through a keyhole. It is critically important to understand that the justice to the pathology should be done to assure good outcomes.  If pathology is extensive sometimes an open approach can take care of this extensive pathology in a quicker and better way. Surgeon should be able to know when to open the door to have a complete view. It is important to remember that the limitations “squeezing the entire spectrum through a key hole”.

Minimally invasiveness now has engrained in all modern-era spine surgeons but at the same time they have to keep in mind that they have to titrate this invasiveness with the pathology.  An incomplete surgery in spite of being less invasive, does not provide comparable good outcomes (essential thing to call it MIS surgery).  As compared to multiple staged smaller surgeries one stage open surgery may be optimally invasive. Patients insisting on MIS procedures also need to be educated about the limitations of key hole surgeries and the rationale in your decision to individualize and optimize for better outcome

Dr. Amit Bhandarkar and  Dr. R. Barani