Minimally invasive spinal surgery

In this article surgeons discuss pros and cons of  minimally invasive spinal surgery versus traditional open surgery. The article concludes with a discussion of non-surgical regenerative medicine procedures versus surgery.

Researchers at New York University Langone Medical Center warn about the growth and popularity of minimally invasive surgery (MIS) procedures. They say that the procedures are easily marketable to patients as less invasive with smaller incisions, minimally invasive surgery is often perceived as superior to traditional open spine surgery. The NYU researchers put this to the test.

A systematic review of randomized controlled trials involving minimally invasive surgery versus open spine surgery was performed.

  • For cervical disc herniation, minimally invasive surgery provided no difference in overall function, arm pain relief, or long-term neck pain.
  • In lumbar disc herniation, minimally invasive surgery was inferior in providing leg/low back pain relief, rehospitalization rates, quality of life improvement, and exposed the surgeon to >10 times more radiation (as the procedure requires imaging) in return for shorter hospital stay and less surgical site infection.
  • In posterior lumbar fusion, minimally invasive surgery transforaminal lumbar interbody fusion (TLIF) had significantly reduced 2-year societal cost, fewer medical complications, reduced time to return to work, and improved short-term Oswestry Disability Index scores at the cost of higher revision rates, higher readmission rates, and more than twice the amount of intraoperative fluoroscopy.
  • The highest levels of evidence do not support minimally invasive surgery over open surgery for cervical or lumbar disc herniation. However, minimally invasive surgery transforaminal lumbar interbody fusion  demonstrates advantages along with higher revision/readmission rates.
  • Regardless of patient indication, MIS exposes the surgeon to significantly more radiation; it is unclear how this impacts patients. These results should optimize informed decision-making regarding minimally invasive surgery versus open spine surgery, particularly in the current advertising climate greatly favoring minimally invasive surgery.1

In regard to minimally invasive cervical spine surgery, doctors writing in the Journal of neurosurgical sciences also examined minimally invasive surgery versus traditional surgery. They write that degenerative disorders of the cervical spine requiring surgical intervention have become increasingly more common over the past decade.

Traditionally, open surgical approaches have been the mainstay of surgical treatment. More commonly, minimally invasive techniques are being developed with the intent to decrease surgical morbidity and iatrogenic spinal instability. Iatrogenic is a term used to describe a worsening condition caused by surgery.

A multitude of studies demonstrating the significant incidence and impact of axial neck pain following open posterior spine surgery have led to a wave of research and development of techniques aimed at minimizing posterior cervical paraspinal disruption while achieving appropriate neurological decompression and/or spinal fixation.

  • The currently available literature supports the use of minimally invasive posterior cervical laminoforaminotomy for the treatment of single-level radiculopathy.
  • The literature suggests that fluoroscopically-assisted percutaneous cervical lateral mass screw fixation appears to be a technically feasible, safe and minimally invasive technique.
  • Based on the currently available literature it appears that the DTRAX® expandable cage system is an effective minimally invasive posterior cervical technique for the treatment of single-level cervical radiculopathy.
  • While several MIS approaches already exist, there is a need for advanced and improved techniques for use in posterior cervical surgery.2

In Germany however, doctors, while discussing the positives of minimally invasive spine surgery also discussed the common thread to all surgeries. The surgical risk.

Minimally invasive spine procedures, such as minimally invasive transforaminal interbody fusion seems to be a valid alternative to open spinal surgery. Both methods yield good clinical results with similar improvements of Oswestry Disability Index (ODI) and pain scores on follow-up.

There seems to be no significant differences in clinical outcome and fusion rates on comparison.

The most pronounced benefits of minimally invasive transforaminal interbody fusion are a significant reduction of blood loss, shorter lengths of hospital stay and lower surgical site infection rates.

On the downside, minimally invasive transforaminal interbody fusion seems to be associated with significantly higher intraoperative radiation doses, a shallow learning curve, at least in the beginning, longer operating times and potentially more frequent implant failures/cage displacements and revision surgeries.3


Should a patient have disc surgery?

In a new study, doctors at the University of Salzburg presented these findings on the surgical and conservative care of herniated disc.

According to these doctors, when should a patient have disc surgery?

  • When conservative treatment did not improve clinical symptoms.
  • When progressive or persisting neurological deficits, as well as for persisting pain which alters the quality of the patient`s life.


The German researchers suggest that surgery should be the LAST CHOICE, and that all conservative treatment methods must be FIRST exhausted.1

It is important to note that the above paper from spinal surgeons recommended strongly, that surgery be the last choice, BUT, treatments of any kind should not be delayed.

First choice of back pain treatment related to herniated disc

Let’s look at the first choice of herniated disc treatment through the eyes of a Canadian research team who reviewed the current concepts and clinical guidelines for the management of low back pain to assess their quality of care.

In this February 2017 study, doctors and researchers found according to high-quality guidelines:

  • All patients with acute or chronic low back pain should receive:
    • education,
    • reassurance,
    • and instruction on self-management options;
  • Patients with acute low back pain should be encouraged to return to activity and may benefit from:
    • paracetamol,
    • nonsteroidal anti-inflammatory drugs (NSAIDs),
    • or spinal manipulation;
  • Patient with chronic low back pain may include:
    • exercise,
    • paracetamol or NSAIDs,
    • manual therapy,
    • acupuncture,
    • and multimodal rehabilitation (combined physical and psychological treatment); and
  • Patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation.

This new study found some of these guidelines to still be in practice but outdated, specifically the use of paracetamol for acute low back pain and other herniated disc symptoms.

The other problem they found was the recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments., were guidelines targeted to nonspecific low back pain.5

If you are reading this article, there is very good chance you were not helped by the herniated disc treatment guidelines, you have been recommended to herniated disc surgery, and you are exploring alternatives.

Prolotherapy a non-surgical option to spinal surgery

Prolotherapy treats low back pain by addressing the root cause of pain: ligament laxity.  Very few cases of low back pain actually stem from a herniated disc. Rather, the herniated disc is proof that ligament laxity exists. Prolotherapy is an injection technique that induces a mild inflammation to stimulate the body’s immune system to heal the injured area. When compared to Prolotherapy, percutaneous disc decompression raises some red flags in the case of low back pain:

In the Journal of Prolotherapy , study results of 145 patients who experienced low back pain an average of 58 months, who were treated on average with four sessions of dextrose (12.5%) Prolotherapy, quarterly, at a charity clinic.

The patients were contacted on average 12 months after their last Prolotherapy session.In these patients:

  • pain levels decreased from 5.6 to 2.7 (numerical rating scale NRS , 1-10 scale);
  • 89% experienced more than 50% pain relief

Results were similar in the patients who were told by at least one medical doctor that there was no other treatment option (55 patients) or that surgery was the only option (26 patients).6

In the journal Practical Pain Management, research and case histories are presented citing Prolotherapy as a reasonable and conservative approach to musculoskeletal low back pain, disc disease, and sciatica.

Platelet Rich Plasma and Prolotherapy Injections a non-surgical alternative for low back pain and long-term results

Platelet Rich Plasma or PRP involves the application of concentrated platelets, which release growth factors to stimulate recovery in non-healing injuries.

New research from a team of university researchers in India, writing in the journal Pain Practice says that “Despite widespread use of steroids to treat sacroiliac joint pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.”

In this research, Forty patients with chronic low back pain diagnosed as sacroiliac joint pain were divided into 2 groups, steroid group and PRP group.

Intensity of pain was significantly lower in the PRP group 6 weeks after treatment as compared to the steroid group.
The efficacy of steroid injection was reduced to 25% at 3 months while it was 90% in the PRP group.
A strong association was observed in patients receiving PRP and showing a reduction in pain scores. The researchers concluded: The intra-articular PRP injection is an effective treatment modality in low back pain involving sacroiliac joint pain.”7

Doctors at the University of Toronto have published four case studies investigating the long-term benefit of platelet-rich plasma (PRP) injections reducing SI joint pain, improving quality of life, and maintaining a clinical effect.

At follow-up 12-months post-treatment, pooled data from all patients reported a marked improvement in joint stability, a statistically significant reduction in pain, and improvement in quality of life.

The clinical benefits of PRP were still significant at 4-years post-treatment. Platelet-rich plasma therapy exhibits clinical usefulness in both pain reduction and for functional improvement in patients with chronic SI joint pain. The improvement in joint stability and low back pain was maintained at 1- and 4-years post-treatment.8

1 McClelland S, Goldstein JA. Minimally Invasive versus Open Spine Surgery: What Does the Best Evidence Tell Us? Journal of Neurosciences in Rural Practice. 2017;8(2):194-198.[Pubmed]

2 Skovrlj B, Qureshi SA. Minimally invasive cervical spine surgery. J Neurosurg Sci. 2017 Jun;61(3):325-334 [Pubmed]

3 Vazan M, Gempt J, Meyer B, Buchmann N, Ryang YM. Minimally invasive transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion: a technical description and review of the literature. Acta Neurochir (Wien). 2017 Jun;159(6):1137-1146. [Pubmed]

4 Heider FC, Mayer HM. Surgical treatment of lumbar disc herniation. Oper Orthop Traumatol. 2017 Feb;29(1):59-85. doi: 10.1007/s00064-016-0467-3.[Pubmed] [Google Scholar]

5 Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Journal of Pain. 2016 Oct 1. [Pubmed] [Google Scholar]

6.  Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155.

7. Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid versus Platelet-Rich Plasma in Ultrasound-Guided Sacroiliac Joint Injection for Chronic Low Back Pain. Pain Pract. 2016 Sep 27. [Pubmed] [Google Scholar]

8: Ko GD, Mindra S, Lawson GE, Whitmore S, Arseneau L. Case series of ultrasound-guided platelet-rich plasma injections for sacroiliac joint dysfunction. J Back Musculoskelet Rehabil. 2016 Jun 30. NU3617 [Pubmed] [Google Scholar]

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