Minimally invasive technologies were introduced to the spinal surgery sphere later than to the other surgical fields. This was due to the difficulty of forming the full-fledged surgical access and imaging of the spinal cord while working with miniature endoscopic instruments, through small incisions in the surrounding tissues.
Nevertheless, after the beginning of active CT and MRI use, a better understanding of the spine biomechanics has led to a wider introduction of microsurgical procedures into clinical practice. Development of more advanced instruments and surgical techniques has also contributed to this. Today, minimally invasive spinal surgery ranks among the list of first-line procedures in case of conservative treatment ineffectiveness.
What types of diseases can be cured with minimally invasive surgery?
According to the World Health Organization, back pain, or spinal pain, occurs at least once in a lifetime in 80% of the world's population. Moreover, more than 2% of patients require surgical treatment. Minimally invasive surgeries are performed in the case of lack of effect from conservative therapy and physiotherapy in the following conditions:
- Spinal disc herniation
- Congenital malformations of the spine, such as spina bifida
- Degenerative vertebral changes
- Traumatic spinal injuries, including compression fractures
- Persistent vertebral column deformities, such as scoliosis
- Spinal instability, spinal stenosis
- Tumors of the spine and spinal cord
- Infectious vertebral lesions, including infectious spondylodiscitis
While choosing appropriate candidates for microsurgical interventions, such aspects as age, weight and concomitant pathology presence are taken into account. Also, the equipment of the hospital influences significantly choice of the surgical technique. In order to carry out the endoscopic operation, the medical facility must have the appropriate equipment and specialists who are authorized to work with it.
Types of minimally invasive surgical procedures
Microsurgical techniques are most widely used for the following types of interventions:
- Discectomy is a resection or total removal of the herniated spinal disc followed by the replacement surgery. Most often, it is used for the treatment of lumbar spinal disc herniation.
- Spinal cord decompression, or laminectomy, is most often performed in the lumbar spine pathologies. During the operation, part of the arc of the lumbar vertebra is removed. Due to this pressure on the spinal cord and the spinal nerve roots is reduced. In addition, intervertebral joints and pathologically changed spinal ligaments can be removed.
- Transforaminal lumbar interbody fusion is performed in case of degenerative changes in the intervertebral discs, recurrent hernias, displacement (spondylolisthesis) or vertebral instability.
- Treatment of radiculopathies. In persistent spinal pain and irreversible changes in the nerve endings, the affected roots of the spinal nerves are intersected. Another effective therapy method is implantation of an infusion pump for the injection of painkillers directly into the affected nerve region.
Depending on the type of surgery, various endoscopic systems and treatment programs are used, for example:
- TESSYS is the transforaminal access system. The access to spine and spinal cord structures through the enlarged intervertebral foramen is the safest and is used in patients of all ages.
- iLESSYS is the system for intralaminar access. The system is used in interventions on the dorsal part of the spinal canal. The access to the surgical field is created through an opening in the arch of the vertebra, in a place, which was previously determined by means of CT/MRI.
- CESSYS is the system for cervical spinal disc herniation surgery. The system creates anterolateral access through the body of the intervertebral disc. This approach is used in the treatment of cervical spinal disc herniation in Germany.
- MultiZYTE RT is the system for radiofrequency endoscopic rhizotomy. The system is designed specifically for interventions on the intervertebral joints and is used in the treatment of "facet syndrome".
Surgical equipment is constantly being modified according to the new scientific inventions. For example, the software for preliminary computer simulation of the operation course, as well as the intraoperative neuromonitoring and monitored anesthesia care techniques are constantly being updated.
Course of the surgical intervention
Surgical interventions on the spine are performed by operating orthopedists with an additional specialization in neurosurgery. Also, German surgeons receive an additional certification, which allows them to perform endoscopic operations.
Prior to the operation, the antibiotic prophylaxis is carried out using broad-spectrum drugs. This is a preventive measure, which minimizes risk of infectious complications. A patient also receives anesthesia. Depending on the planned surgical technique, the anesthesia can be local (a patient is conscious during the procedure) or general (the patient is in the state of medication sleep).
After the start of anesthesia action, the medical team assesses such vital signs as pulse, blood pressure, oxygen saturation, ECG. Under the accurate monitoring, a surgeon makes a small incision near the affected spinal area. A tubular retractor is introduced through the incision. The device provides access to the surgical field without extensive dissection of tissues and blood vessels.
A specialist introduces miniature surgical instruments, a camera and a light source through the retractor. If necessary, the intervertebral discs or vertebral bodies are replaced in the same way. After that, the surgeon performs necessary actions under the visual guidance or, in some cases, under the CT/MRI control. For additional protection of the spinal cord, an O-shaped arm is used. This is the computer-assisted neuronavigation system.
After the operation completion, the surgical instruments and the retractor are removed from the wound, skin incisions are closed with a single suture or surgical glue. A small dressing is applied to the damaged area. During the postoperative period, the repeated antibiotic prophylaxis is carried out, if necessary, over-the-counter pain medications are prescribed.
Benefits of minimally invasive surgery comparing to the conventional one
In comparison with conventional open surgery, minimally invasive interventions have a number of significant benefits, such as:
- Simple preoperative preparation, which includes quitting smoking, temporarily stopping anticoagulants intake (such as aspirin), and carrying out new MRI or X-ray examination. Also, the patient should not eat or drink after midnight before the operation.
- Preliminary 3D planning of the operation using computer. For example, during the diagnostics of spinal disc herniation, CT, MRI, or MSCT is required. Also, computer-assisted neuronavigation system is used during the operation in order to protect the spinal cord and increase accuracy of manipulations.
- Reduced risk of paravertebral muscles damage. During the operation, the muscles are mainly moved apart in a "blunt" way, without dissection. After the removal of microsurgical instruments, the muscle function is fully restored.
- Reducing the of developing infectious complications due to preliminary antibiotic prophylaxis and maximum preservation of the skin integrity.
- Minor intraoperative blood loss. Magnifying optical instruments, which are used for the surgical field visualization, allow the surgeon to see the blood vessels and not to dissect them during the operation.
- Less pronounced postoperative pain syndrome, the patients do not need to take painkillers for a long time. It also eliminates the risk of developing psychological dependence on analgesics.
- Faster recovery after surgery, a short rehabilitation period. The patient is discharged from the hospital on the second or third day after surgery. Certain microsurgical interventions are even performed on an outpatient basis.
- Good cosmetic result. The skin incisions of 2-3 cm are sufficient for the introduction of endoscopic instruments. Such incisions are closed with single sutures and heal without scarring.
In addition to the obvious benefits, microsurgical interventions are more cost-effective. The cost of the procedure often exceeds the cost of a classic open surgery, however, a short hospitalization period and quick recovery significantly reduce the total treatment cost. Due to this, microsurgical interventions are covered by large insurance companies.
Choosing a hospital for undergoing treatment
The countries of central and western Europe, in particular Germany, are leading in the field of endoscopic and minimally invasive surgery. Paradoxically, the list of indications for spinal surgery is 9 times shorter here compared to the CIS or Arab countries, since doctors use all the possibilities of conservative treatment, and the diagnostics in Germany allows them to detect pathology at the early stages.
Nevertheless, in presence of absolute indications for surgery, treatment in German hospitals is carried out with the minimum complications rate (up to 0,1-1,0%) and the accuracy of 98,9%. For example, according to the summary statistics for 2017, more than 1,658 robotic interventions were successfully carried out in German medical centers. The most reputable German hospitals in this field are:
- University Hospital Würzburg, Department of Adult and Pediatric Orthopedics
- University Hospital Hamburg-Eppendorf, Department of Adult and Pediatric Neurosurgery
- University Hospital Erlangen, Department of Adult and Pediatric Neurosurgery
- University Hospital Carl Gustav Carus Dresden, Department of Adult and Pediatric Orthopedics, Trauma Surgery
- Charite University Hospital Berlin, Department of Adult and Pediatric Neurosurgery
As a rule, in large university hospitals, children and adults undergo treatment in the same department. This additionally confirmes high qualification of operating orthopedists and neurosurgeons, who consider the specificities of operations in patients of different age categories.
How to receive treatment in a foreign hospital?
In most cases, the world's leading university hospitals have quotas for the treatment of international patients. If the documents are prepared correctly, the administrative staff registers the request and puts the patient on a waiting list. As a rule, the waiting period for high-tech medical care exceeds 1-2 months.
If you need to undergo a treatment in a shorter time or have comfortable and safe trip to a foreign hospital, you can contact Booking Health. Booking Health is the only certified medical tourism provider in the world (ISO 9001:2015 certification), which helps patients from 75 countries to undergo the necessary treatment or examination abroad.
Specialists of Booking Health will support you in such important aspects as:
- Selection of the right hospital based on the annual qualification profile
- Establishment of direct communication with your attending physician
- Preparation of a medical program in advance, without repeating previous examinations
- Provision of favorable costs for a treatment in Germany, without overpricing and additional coefficients for foreign patients (saving up to 50%)
- Booking the appointment with a doctor on the necessary date
- Monitoring of the medical program at all its stages
- Assistance in buying and forwarding of medicines
- Communication with the hospital after treatment completion
- Control of invoices and return of unspent funds
- Organization of additional examinations
- Top-class service: booking hotels and plane tickets, transfer organization
Please, leave a request on the official website of the company and wait for a call from medical consultant who will study your situation in detail and give recommendations on the treatment options and preparation for the trip. After that, during a treatment in Germany, you will be accompanied by a qualified interpreter. Also, a personal coordinator will be constantly in touch with you, helping with all medical and non-medical issues.
Choose treatment abroad and you will for sure get the best results!
Author: Dr. Nadezhda Ivanisova