Transcription:
Understanding Minimally Invasive Spine Surgery

Intro: This is Hello Healthy, a Dignity Health podcast..

Scott Webb: Welcome back to Hello Healthy. I'm your host, Scott Webb. And There are many benefits to minimally invasive spine surgery, including faster recovery times and smaller scars. And joining me today to discuss things is Dr. Michael Cluck. He's an orthopedic surgeon with Dignity Health.

Doctor, it's so great to have your time today. And we're talking about spine surgery, specifically minimally invasive spine surgery. But before we get to that, I just wanted to ask you who's a candidate for spine surgery in general?

Dr. Michael Cluck: You know, there's multiple indications for spine surgery. The primary ones in my practice are anytime there's neurological compression, so that means compression of the spinal cord or the nerve roots in the neck or the low back typically, that to me is an indication for surgery. Those patients that have neurologic pain that's typically unrelenting, they don't respond to kind of nonsurgical treatments very well, so that's a candidate.

Anytime you have instability of the spine, and that can be from fracture, trauma, degeneration, you can even be born with it. Scoliosis, for example, is a deformity of the spine that you can develop deformity as you age. And then, trauma, anytime you've been involved in an accident and there's a fracture or dislocation that's unstable. Then of course, with those things come pain. So the main reason someone sees me, obviously, is they're in pain in their neck or their back, and then that leads into, you know, a series of questions, answers, exams, and diagnostic testing, and often reveals one or more of those conditions we talked about.

Scott Webb: Yeah. And those conditions sound like sometimes they're acute, sometimes they're chronic. And I'm sure there is still open spine surgery, but today we're talking about minimally invasive spine surgery. That seems to be the buzz in medicine, is everybody wants it minimally invasive because smaller scars, faster recovery time and so on. So I just want to have you take us through that. What does that mean, minimally invasive spine surgery?

Dr. Michael Cluck: Well, it's two-fold really. Minimally invasive spine surgery is a philosophy and it's a technique. And so philosophically, it's performing the same surgery you need to perform, whether it's nerve root decompression, spinal cord decompression, or some form of stabilization through the least amount of tissue destruction or manipulation as possible, but using and taking advantage of natural anatomic planes. So for example, instead of just cutting through things and moving things over to access the spine, we go through natural occurring planes, that lie between two muscles, so that we just retract the muscle instead of cut through it, that would be kind of one example.

So philosophically, it's accomplishing the goals we need to accomplish, which were usually or in the past performed maximally invasive with large openings, in a minimally invasive way, taking advantage of natural planes that occur in the anatomy, you know, to allow us to access the spine. And that results in of course smaller incisions, you know, faster recovery, less narcotic use for pain and so on. But we still have to accomplish, you know, the primary goal.

And then from a technical perspective, you say, "How do you go from a large opening in the spine to a small minimally invasive opening to do your standard work that you need to accomplish?" And that's based on the type of equipment we have. So now, we have these very sophisticated retractors, microscopes, imaging modalities that allow us to visualize the spine and in fact, sometimes even using artificial intelligence and, you know, nonconventional radiology, for example, to see the spine in ways that we never used to see it before and thereby allowing us to do much smaller incisions and, you know, less tissue destruction compared to what we used to do in the past.

Scott Webb: It sounds pretty amazing. And I know that you've completed over 3000 spine surgeries in your career, so I'm guessing a lot has changed. And I'm wondering if you can take us through that. How has spine surgery changed over the last, let's say 15 years or so?

Dr. Michael Cluck: Yeah. So, I've been in training and practice probably for almost 20 years, 15 to 20 years, depending on when you start the clock. And in that time, you know, things have changed dramatically in terms of diagnosis, how we go about diagnosing pain generators in people, imaging modalities, you know, how do we see what we feel or what we think is causing the pain? And then of course, what we talked about a little earlier, which is how do we approach the spine to fix these things. Every single one of those areas has evolved in the past one to two decades.

And what we're focusing on now more than we maybe did in the past is let's make an accurate diagnosis of why this person hurts. You know, in the past we would say, "Well, the person has pain, we'd get an image." It would show something abnormal. And then we would assume that was the problem. It's different if there's an obvious deformity or a broken bone or something like that.

But when we're dealing with pain that's not obvious and we have imaging studies that show things in the past I don't think we've done a good job figuring out, are those changes on the images really causing this person's pain? So we've been doing work in the past decade or so to develop diagnostic techniques, diagnostic nerve root blocks, various types of functional studies to see are these nerves impaired for some reason? And can we prove that through a diagnostic, say for example, EMG or some sort of functional study?

And then moving on, once we've identified the pain generator, then how do we fix it? You know, what do we do for that? And that's the area we've talked about earlier, which is a minimally invasive approach and ways to see and access to spine, you know, that we are doing now, that we never did in the past, and that's based on technology.

And I think that's driven mostly by surgeons and industry. The industry leaders, thought leaders come to the surgeons and say, "You have this problem. We've thought of it that we could solve it this way. Does that make sense?" And so with industry engineers partnering with surgeons, we've been able to develop these sophisticated ways now to access the spine with very minimal, you know, dissection and exposure. And so that's what's really changed.

I mean, I went into a fellowship that was maximally invasive. I wanted to see the whole spine. I wanted to open the spine up from top to bottom because that's what I thought I needed to learn to really be a good surgeon, to see everything open. And I think that's helped me tremendously. In fact, having that experience now I can visualize things, you know, in my mind, particularly when doing minimally invasive procedures where I don't need to have it open anymore.

And so one of the controversies, and this might be for another discussion is what do we do with the new spine trainee who's coming out of a program today, where all they learned was minimally invasive surgery? How are they ever going to open the spine? Because there are going to be reasons to open a spine. If you have a large tumor that's encroaching on the spine and destroying the vertebra and causing nerve root compression and paralysis or something along those lines, you can't necessarily do that with a minimally invasive approach. So in education, I'm an associate professor at UCSF and, you know, we're trying to figure out the ways in which we can still adequately train people in a world of minimally invasive spine surgery.

Scott Webb: That's really interesting. I was thinking, I don't know if this is an appropriate analogy, but I was sort of thinking about, let's say younger pilots who, you know, don't have the background that Sully Sullenberger had to be able to land in the Hudson and pilots that rely so heavily and understandably on autopilot, you know. So I was just thinking, as you were saying, you talking about these surgeons, these younger, newer surgeons who don't have the experiences that you have, where you came in during the maximally invasive period and transitioned into minimally invasive, as you say, minimally invasive spine surgery isn't always indicated. That's a lot to think about.

Dr. Michael Cluck: Yep. And the other thing that kind of spin off from that is, you know, there's some amazing technology out there. Artificial intelligence, 3D anatomy and, you know, visualization through virtual reality, robotic surgery. We have a very sophisticated way to monitor the nerves during surgery that we didn't have in the past. And we're able to actively stimulate different nerves, individual nerves in the spine while we're working around them to see if they're being irritated by or influenced by the procedure we're doing. So we get real time in-surgery feedback from the nerves that we're working on.

And so in the past, many decades ago or more, we would be doing the spine surgery, we wouldn't have that immediate feedback. You know, we would wake the patient up, we would do our exam and find out, "Okay. Well, the patient lost some sensation in this muscle group or the nerve we're working on isn't functioning as well now because maybe it was stretched during surgery or there's more inflammation." we would find out those things later. Now, we're getting live intraop information back about the function of the nerve as we're working on it. So that's made the safety profile tremendously better for spine surgery.

You can imagine this particularly living in Silicon Valley, that there's just tremendous amount of interest in the technology of surgery but not all that technology really, you know, translates into better patient outcomes or, you know, easier surgery or safer surgery.

And so that's the other challenge that we have as surgeons, is, you know, kind of saying to the engineers and these technology leaders, you know, "This isn't really helping us. So, actually the 'old way' is better than what you're proposing." And so the point is is that, especially for me and I think a lot of surgeons, is we don't just jump into the next best technology because it's cool and exciting. You know, there has to be a real reason to adopt a newer technology or some sort of innovation like minimally invasive surgery, because it's better for patients. We can perform the standard procedure that we did in the open technique, you know, that we did 10 years ago in our fellowship or 20 years ago or whatever it is. And so that's the challenge we have as surgeons, is what technology do we want to incorporate into our practice? What makes sense?

Scott Webb: And as you say, it always comes back to the patients. And it prompted me to think a little bit, you know, listeners listening here who might be a candidate for minimally invasive spine surgery, I'm sure they would want to know what are the risks?

Dr. Michael Cluck: One of the advantages, if you will, of the minimally invasive spine surgery is that it somewhat mitigates the risks of conventional spine surgery. So for example, a risk of traditional open spine surgery is infection. We know that with minimally invasive spine surgery, there's a risk of infection, but that risk has decreased tremendously because of the small incisions we make and the minimal amount of tissue destruction.

You know, there's risks when we operate around your nerves, that that's going to create, you know, additional pain temporarily. It may cause some weakness in the muscle groups. Those things typically resolve over time. And just as any other procedure, there's risks that, you know, it doesn't work as well as you wanted it to work. So patients don't necessarily heal the way we would expect them to heal. And so expectations have to be managed, both on the surgeon side and the patient's side.

But by and large, one of the main advantages of minimally invasive surgery is it's just the safety profile is amazing. I mean, we just don't have the blood loss. We don't have the infection rate. We don't have the tissue destruction, you know, and the chronic pain. That's the other thing. Minimally invasive surgeries allowed us to get away from doing these big surgeries, which lead to or impose on patients kind of chronic pain, you know, because we've destroyed some tissue around the spine getting there. So the risk profile is I believe diminished tremendously in spine surgery because of minimally invasive surgery.

Scott Webb: It certainly sounds like it. And it seems that if someone was a candidate for spine surgery and specifically minimally invasive spine surgery, that this would be the way to go for all the reasons that you've outlined today. You've taken us through the techniques and advantages and changes over the years. Really educational today.

And as we wrap up, you know, I wanted you to talk a little bit about the fellowship you did at Case Western with Dr. Henry Bowman. He's considered to be the father of contemporary spine surgery, which is pretty cool that you worked with him. And I just wanted you to take a few moments to tell us what that was like.

Dr. Michael Cluck: Sure. Thank you for asking about that. It was definitely an honor to train with Henry Bowman. He was a pioneer in spine surgery, both cervical spine surgery or the neck surgery as well as lumbar spine surgery. And, you know, that all started in the '70s when he worked with Dr. Robinson basically doing research, academic research, on managing people with spinal cord injuries and operate on those people, hoping that they would regain function. And in fact they did, and that led to kind of a landmark paper talking about decompressing the spinal cord in injured vets. In other words, people injured in military setting in the past would be written off in terms of, you know, any kind of neurological improvement. In other words, if you were injured and you had a spinal cord injury, there was nothing we could do about it. He went along with his colleagues operated on them, stabilized them and they regained function. And so he made his way, I guess it was in the '70s, publishing these amazing papers. And he was a thought leader at the time.

And as a result of that, gained a following, you know, in the academic world. And so people from all over the world want to train with him, you know, as he went through his training and, you know, went into taking on faculty positions and becoming directors of programs. People wanted to train with him. And so of course, I was one of those and fortunate enough to be selected to train with him.

Many of the things we do now are a direct result of the research he performed, so that research led to, you know, basically the ideas and the research and data behind doing the types of surgeries we do today. For example, decompressing the cervical spine in trauma and stabilizing the neck if someone has a broken neck and neurologic injury, we now know that we should go in and fix those people. If you have instability in the low back and pinched nerves and you have pain radiate into your legs, some of the work he did show that we should decompress those and fuse those patients so that they can walk again and stand straight.

So his pioneering work in the early decades of '70s, '80s and even into the 2000s is what led to our current thinking of how to manage these spinal conditions. And of course, over the years, we've developed these minimally invasive ways of dealing with those conditions, which is what I talked about earlier.

Scott Webb: You have an amazing story. You've done over 3000 spine surgeries. A great way of taking us through all of this today. Some, you know, highly technical things, but putting it in terms that we can all understand. And one of the great advantages of hosting these is that I get to have experts on to explain these things. Most of us don't get 15, 20 minutes with an expert spine surgeon, but I did today and we hope listeners appreciate that. And doctor, thanks so much for your time and you stay well.

Dr. Michael Cluck: Thank you, sir. Have a great day.

Scott Webb: And if you need an orthopedic spine surgeon, visit dignityhealth.org/ourdoctors. And if you've found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Hello Healthy, a Dignity Health podcast. I'm Scott Webb. Stay well.