Maggie McKay (Host): Getting a diagnosis of minimally invasive spine surgery can sound scary, but today Neurosurgeon Dr. Anna Terry will share what you need to know to take the fear factor out of the equation. Welcome to Wellness First, a St. Joseph Hospital podcast, where we hear and learn directly from the experts on all things health and wellness.

I'm your host, Maggie McKay. Thank you so much for being here today, Dr. Terry.

Anna Terry, MD, MPH: You're welcome. Thanks for having me.

Host: So what exactly is minimally invasive spine surgery? Because I'm sure when the patient hears it, even though it's minimally invasive, they probably just hear, they probably just hear the spine surgery part.

Anna Terry, MD, MPH: Yeah. So minimally invasive spine surgery is some of the ideas we're trying to achieve a goal for the patient. Okay. So typically in spine surgery, that's alleviating pain, improving function. Now there's a traditional kind of old school way to get to the spine. You basically make a big incision in the back.

You open up everything so you can see everything and then get the job done. The idea behind minimally invasive surgery is that we want to get the job done for the patient, but we want to do it in a way that disrupts their tissues and the normal anatomy in the least possible, as the least traumatic for the patient.

So if you can think about an analogy, you know, people, um, get their gallbladder or their appendix out laparoscopically, right? So, traditionally you would make a big incision over that area and go right down to the anatomy and remove the organ that you want to remove. But nowadays, we do it with two or three small ports and cameras, and the patient can go home earlier and have a faster recovery.

So, that's what minimally invasive spine surgery is. Since we want to get the job done, we want to accomplish the goal, but we want to do it in a way that's less traumatic.

Host: That's encouraging. What are the common conditions or issues that can be treated with MISS?

Anna Terry, MD, MPH: These conditions fall into the general category of degenerative spine disease. So, we're talking arthritis of the spine, disc degeneration, spinal stenosis um, these are really common conditions, especially as we age and folks with degenerative spinal conditions can have narrowing of the spaces where the nerves go through, right?

So the spinal sac can become narrow, the nerves don't have enough room to work, and that can cause pain, numbness, weakness, back pain, leg pain. So those are the conditions that are amenable to spine surgery in general, and MIS in particular.

Host: How does MIS benefit patients compared to, say, traditional open spine surgery in terms of recovery time, pain, and overall outcomes? I know you mentioned they get to go home earlier, so that's a good one.

Anna Terry, MD, MPH: Right. So, spine surgery is very difficult for patients, really, no matter how you do it. These are incredibly painful conditions, very debilitating. Sometimes people are very deconditioned coming into it because they've been in too much pain to, to move as much as they're used to. And we understand that and so with an MIS approach, the idea is that we want to treat that condition in a way that is less traumatic for the patient.

So you're going to have a shorter incision, typically instead of one big incision, you're going to have two or maybe three small incisions, maybe just one small incision. That leads to less muscle dissection or trauma to the surrounding musculature getting to the spine, on the way to the spine, so that's also less blood loss, lower chance of infection with a smaller incision, typically a shorter hospital stay, reduced use of opioid pain medications which is really nice because those have all kinds of side effects and can become habit forming. And then the quicker discharge home and return to function, return to work, et cetera. So all of those things are really, really advantageous for the patient if they're a candidate for a minimally invasive approach.

I tell them, look, you're going to have a lot of pain up front. This is a painful condition. We have to treat this condition. But your pain's going to get better more quickly, and you're going to be cleared for activity sooner with this type of approach.

Host: That's got to be helpful for somebody in pain. Are there potential risks or complications associated with MIS? And if so, how do they compare with those of traditional surgery?

Anna Terry, MD, MPH: Yeah, so the complications, because the surgeries are very similar, it really is just a matter of the approach and the size of the incision. So, the complications like with any surgery, you have a small risk of excessive bleeding, a small risk of infection, a small risk of healing problems. Those risks all are less in minimally invasive approaches, which is a good thing. The other complications that can occur with spinal surgery, there's something called a spinal fluid leak, which is literally just a hole or a tear in the nerve sac. So that can happen during surgery. With a minimally invasive approach, that's typically less significant for the patient.

So the concern is that if there's a small hole there, somebody could stand up too quickly and get a severe spinal headache. Ultimately that ends up being a huge hassle for the patient. They may need to be on bed rest for a while. They may need something called a blood patch to treat that. It can be really a huge frustrating, frustrating situation for the patient, but when we have a smaller opening, those types of complications, while not super common, even when they do happen, are a lot more manageable and a lot of times we can negotiate that in a way that is not a problem for the patient. So those are all advantages.

So the complication rate is less and the outcomes are, again, we're talking about same long term outcomes, right? We're treating the same conditions and doing the same surgery, but the immediate period of getting someone through that is a little easier.

Host: And you mentioned being a candidate. How do surgeons determine if a patient is a good candidate for MIS?

Anna Terry, MD, MPH: So I would say that, the excellent candidates for an MIS approach are people with a problem that's relatively limited to one or two levels of the spine. So, the spine is kind of a segmented structure in the body, right? We have many levels. And we have multiple vertebra, okay, so each one of these levels is called a motion segment and that would include the disc, the joints the nerves in the middle.

And so a good candidate for a minimally invasive procedure is somebody who has pretty localized problem like to one or two levels. So by the time you start to get into somebody who has three or four or more levels that need to be addressed, or, someone who has a problem called scoliosis, which is an abnormal curvature of the spine; occasionally, those types of problems just need more extensive corrective operations, and there's no real way around that. Plenty of surgeons use minimally invasive spine approaches in conjunction with other approaches to treat these conditions. But for myself, the ideal candidate is somebody who's got a fairly localized problem that needs treatment, but really doesn't need a big incision to get there.

Host: And can all spine surgeries be performed using minimally invasive techniques or are there still certain cases where, say, traditional surgery is still preferred?

Anna Terry, MD, MPH: So that's a great question. Um, so degenerative spinal conditions are amenable to minimally invasive techniques. Most of the time you can at least consider those techniques, except if it's a more extensive problem, as I mentioned. Spinal tumors are typically not amenable because removing a spinal tumor, whether it's in the bone or this, or, internal, or on the nerves, typically does require a bigger opening so that we can actually see and take out the tumor without retracting or pressing on vital structures. So not typically amenable in oncology type situations when we're treating cancer, but for degenerative spine disease, this is where we do most of our minimally invasive approaches.

Host: Let's talk about technology and techniques, Dr. Terry. How do advancements in these areas continue to improve the effectiveness and the safety to MIS?

Anna Terry, MD, MPH: So, I think the biggest advance in neurosurgery in general that has led to these approaches is the invention of the operating microscope, which actually occurred in the 1970s, but the optical technology has just improved by leaps and bounds since then, okay? So, looking through a microscope, we have to be able to look through a very small retractor.

A lot of our retractors that we use for these surgeries and again, a retractor is just something that keeps the other tissues out of the way for you as a surgeon so you can see what you need to see. These are specialized retractors and some of them are only as big around as like a nickel or a quarter and we're using specialized long instruments to reach down in there.

If we have a patient who has a larger body habitus, for instance, we could be looking down perhaps a 7, 8, 9 centimeter tube, which is quite long. We could be looking down that long tube and using specialized instruments to reach a tiny area, just as big as a nickel or quarter. So the microscope is really key in that being able to see the anatomy and see everything. The retractor design, and then, you know, some surgeons, I don't personally perform endoscopic spine surgery, but occasionally some conditions are actually amenable to endoscopic surgery, which is just involves a camera to sort of assist what you're doing down the small tube and look around corners and things like that. And then finally, the spine robot is a device that is used for accurate insertion of spinal hardware when it's needed which helps with our basically just eliminate some of the variability in human error and the process that's in just inherent to any process that human beings perform and just helps us be safe and accurate.

Host: And what type of anesthesia is typically used for MIS? Are there any differences in the anesthesia process compared to traditional spine surgery?

Anna Terry, MD, MPH: No, there are really not any major differences. Typically for most, the vast majority of spinal surgeries are going to require a general anesthetic. By that I mean, you go to sleep, we put you to sleep, we, the anesthesiologist inserts a breathing tube and monitors your airway throughout the surgery.

And the reason being is most of our surgeries are done in the prone position, which means the patient is positioned on their stomach, okay? It's really tough to be awake when you're laying on your stomach in the operating room, right? And it does provoke a lot of anxiety, and it certainly, you know, for someone who's elderly and may not have the lung function that they once did, it can actually be dangerous.

And so typically you're looking at a general anesthetic that allows you to be safe, comfortable. It allows me to essentially complete the procedure as quickly and safely as I can. So typically, you're talking about a general anesthetic. We do not use spinals and epidurals a lot, as perhaps those of, you know, folks watching might have experience with orthopedic surgery joint replacements.

A lot of times the spinal anesthetic is used. The problem with that is that if we put a spinal anesthetic in you, you're not going to be able to move or feel your legs for a few hours. And as a neurosurgeon working on the spine, you know, as soon as that person wakes up, you want to make sure they can move and feel their legs to make sure that there's not something like a bleed pressing on the spine that we need to go back in and address. So, typically you're looking at a general anesthetic and generous local anesthetic so that the incision will be less painful at the end of the day.

Host: And what about cost? How does the cost of minimally invasive spine surgery compare to traditional open surgery, including things like hospital stays, rehabilitation, and follow up care?

Anna Terry, MD, MPH: That's a great question. And so, there's kind of two elements of costs. So one is the upfront costs. So minimally invasive spine surgeries often are more expensive up front because we have specialized equipment that we're using. Okay. So, and some of these equipments, some of this equipment is sort of very necessary, it's useful for kind of one type of procedure. So there's higher upfront costs. The other element of cost is how long much is that episode of care costing the hospital? So with shorter hospital stays, less use of opioid pain medications and quicker return to function, those costs all go down on the back end.

And so typically you know, a day in the hospital is, really, really costly. And so hospitals are very interested in this technology as a way to be able to help patients not only have a better experience, but also be able to be discharged home, and free up space in the hospital and reduce the costs on the back end.

So that's a really important part of the discussion when you're talking with hospitals about the value of this technology.

Host: Absolutely. So what advice would you give to patients who are considering minimally invasive spine surgery as an option for their condition? And how can they best prepare themselves mentally and physically for that procedure?

Anna Terry, MD, MPH: So first of all, I would recommend that patients go and see an experienced operator who does these types of procedures quite frequently, as do I, multiple times a week. You're looking for a neurosurgeon or an orthopedic spine surgeon. There's a little bit of difference in orthopedics and neurosurgery training.

 Orthopedists operate on all the bones in the body and they end up doing a, they do a spine fellowship, which is a special one to two year program after their residency. Neurosurgeons, we have a longer residency, but we have more exposure to the spine. We split our training between spine and brain.

First thing I would say is make sure you're seeing a qualified person, either a neurosurgeon or a spine fellowship trained orthopedic surgeon. Both are wonderful at what they do. So, the mental preparing for spine surgery is, um, you know, I would tell people these are tough surgeries to get through, right?

We're doing these for like this painful, functionally debilitating condition. Your quality of life at that point is not very good, right? You might not be able to walk well. You might have debilitating pain. You have a really tough problem. And these surgeries are tough to get through. There's no sugarcoating it.

But, you know, there's a way. Here's the process. And I'm going to explain exactly what I'm going to do and tell you what to expect at each stage in the process. So there's going to be no surprises. And then you'll have to do the following activity restrictions for a few weeks, and I'll be there for you throughout this process, and at the end of it, you'll feel better, you'll be functioning better, walking better, et cetera.

So I just try to just tell people up front, here's what to expect, these are tough surgeries, but here's a way to do it that will make things easier on you in the long term. And our long term goal is improved function and less pain.

Host: Well we so appreciate you sharing your expertise and telling us all this useful information. It was really informative. Thank you so much.

Anna Terry, MD, MPH: Of course. Thank you so much for having me.

Host: Again, that's Dr. Anna Terry. And if you would like to find out more, please visit stjosephhospital.com/services/neurosurgery. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay.

Thank you for listening to Wellness First, a podcast from St. Joseph Hospital.