Minimally Invasive Therapies

Minimally invasive endoscopic procedures

Minimally Invasive Therapy
Many treatments are labeled “minimally invasive”. These are usually less aggressive than traditional procedures, and offer a shorter recovery time, and less side effects. Minimally invasive therapies fall between percutaneous procedures and open surgeries. A percutaneous procedures does not involve cutting the skin. Usually a needle will be inserted under some type of visualization, such as X-ray guidance, and placed at the area to be treated. An open surgical procedures involves some type of lengthy incision, through which the operation occurs. Minimally invasive procedures utilize either a tubular device with or without an endoscope, to perform the treatment with a minimal (usually less than 2.5cm) incision.

Endoscopic Surgery
An endoscope is a device which is a camera attached to a long tube. There is usually a working channel through which various instruments can be inserted. The camera is attached to fiberoptic cable and ultimately a television screen. This enables, under direct visualization, performing the operation via a very small incision. Many different procedures can be performed, and a vast number of conditions treated. These include most cervical and lumbar spine conditions joint conditions, as well as many joint conditions such as carpal tunnel syndrome, shoulder injury, knee ligament tears and cartilaginous injuries.

Open Tubular Discectomy
A discectomy involves removing a portion of a spinal intervertebral disk. There may be pressure on the spinal elements, or nerve impingement “pinched nerves”, or a disk herniation with or without an annular tear (disruption of the structures which contain the disks). Many sophisticated intervertebral procedures can be performed. This can include a foraminotomy (removal of bone impinging upon a nerve), discectomy (removal of disk material), as well as removal of hypertrophic joints (over-growth of spinal joints). This is opposed to a traditional discectomy, during which bone must be removed from the spine to visualize and treat the abnormal disk. A minimally invasive approach avoids a large incision, unnecessary removal of bone, and the potential of scar formation (adhesions etc) which can entrap the nerves and spinal cord and lead to permanent nerve injury.

Open Tubular Rhizotomy
A Rhizotomy is a procedure whereby heat is generated at the tip of an ablation device to treat a pain generating structure. Such structures including ligamentous and other structural tissue, entrapped nerves, and spinal joint conditions may be treated with this device. The joints in the spine are named the facet joints, and these are a common cause of localized neck and back pain. Traditionally, a percutaneous ablation has been utilized to treat these conditions. However, the disadvantages of that are that the needles are guided by an X-ray, and in this “blinded” approach, the actually structures are not visualized. An open tubular rhizotomy however, can be used to permanently treat a cervical or lumbar facet injury by directly visualizing the structure, thus leading to a more successful outcome.


Morbidity
Minimally invasive procedures have a much lower morbidity, or complication rate, versus open procedures. In a discectomy operation, as mentioned above, removal of lamina (bone) is avoided, and the spinal nerves are not manipulated in a way which avoids the potential of epidural adhesions, and scar formation around nerves. Additionally, less disruption of supporting structures (muscles, ligaments and fascia) lead to less post-operative discomfort. Patients can resume their normal activities much quicker, and avoid complications of prolonged bed rest (such as pneumonia and lower extremity blood clots).


Recuperative Time
One of the most important issues is the recovery time for the patient. As opposed to open surgical procedures, from which the patient may take weeks or months to recover, patients undergoing minimally invasive therapies can recovery in a matter of one week. The greatest factor has to do with the amount of dissection of tissue necessary to reach the diseased area. It isn’t the treatment or removal of diseased tissue that is the greatest factor, but the injury to the muscle and fascia (connective tissues) needed to reach the targeted area. During open surgery, muscles and fascia are cut and dissected, leading to injury. During minimally invasive procedures, much less tissue to handled, and it is spread and not cut to allow insertion of a tubular device. The tissue regains its normal position as soon as the surgery is completed. This results in less tissue swelling and edema, less post-operative discomfort, and thereby a much-shortened recuperative time.


Conclusion
More and more procedures are being performed in a minimally invasive approach, versus traditional open operations. Many joint and spine procedures exist which can treat the condition and allow the patient to return to normal activities, much sooner than in the past. I have treated many patients with various cervical and lumbar facet disease and cervical and lumbar disk herniations, which have alleviated their pain, and allowed them to return to normal functioning much sooner than had they undergone more conventional therapy.

Author
Dr. Todd Koppel

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