Caitlin Whyte (Host): Welcome to the Live Greater podcast series. Information for a healthier you from the University of Maryland Medical System. Do you have back pain? Well, minimally invasive surgery might be your answer. Today we are joined by two experts, Dr. Khalid Kurtom and Nurse Practitioner Wendy Towers. Both from U. M. Shore Medical Group Neurosurgery, a member of the U.M. Spine Network. They will talk all about this procedure, who can benefit from it, some of the cutting edge advances, and much more. Doctor, I'll start with you today. What is minimally invasive surgery and how can it help with back pain?

Khalid Kurtom, MD: So minimally invasive surgery is surgical procedures that are meant to achieve decompression and fusion in the spine without having major disruption in the soft tissue leading to the exposed site. It requires you to work through small openings and get to that area that you need to operate on without having the bleeding and risk of infection and the scar tissue that develops after surgery.

It's used frequently in back operations, including surgeries for back pain. And the advantage of it is that the recovery is significantly better than open operations, and that's been documented. The downside to it is that it's technically much more difficult to do an operation through small openings because your hands are limited and the amount of instruments you can put through it is limited. So it requires a lot of training and a lot of experience over time.

Host: Great. Thank you so much. So, Wendy, I'll go to you now for a question too. How do you determine if a patient is a suitable candidate for minimally invasive back surgery? What kind of factors influence this decision?

Wendy Towers, MSN, AGACNP-BC: Factors that influence our decision for minimally invasive spine surgery really are, in my mind, mostly limitless. There's not many limitations.  With regard to age, we really don't look at age as a factor like we do in   open surgery where the recovery time would be extended, blood loss would be much more than minimally invasive surgery.

So that's kind of taken off the table for the most part.  Other things that we look at are   weight. If you have weight issues, sometimes minimally invasive surgery is actually better for the patient because they have less tissue to go through,   and incisions are much smaller and that really does help with their recovery post op.

So weight doesn't necessarily have to be an issue either. Sometimes it is, but it's on an individual basis. It's not something that we immediately say, no, you're not a candidate for minimally invasive surgery. We also look to see how many levels of procedure do you need? Is that something that would dictate us deciding to do open versus minimally invasive?

And that again is not an issue for the most part, because the recovery time is much quicker, the blood loss is less, the disruption of muscle tissue is less. So there really isn't anything that's, that really in my mind that says, no, you're not a candidate for minimally invasive surgery. And this is also true for patients with spinal tumors,  we've done minimally invasive. It really is something that's individualized, but   having really worked on the technique for many years, Dr. Kurtom's able to really   not limit ourselves to which patients we care for in the minimally invasive realm.

Host: Great to know. Thank you. Now, Doctor, what are the main advantages of minimally invasive approaches for back pain? Are there any potential drawbacks or limitations compared to more traditional surgical methods?

Khalid Kurtom, MD: So I think that the main factors that people talk about and   well known factors that separate minimally invasive spine surgery from open surgeries is intraoperative blood loss. Clearly, if you go through less tissue, you have less bleeding.   Risk of infection drops down to almost zero.   Length of stay in the hospital is significantly better with minimum invasive spine surgery. And a lot of our operations, actually, I would say the majority of our operations are outpatient surgeries.  And again, return to work and return to full activity is significantly different, much improved minimally invasive spine surgeries. The majority of my patients are back to work within two or three weeks.

 So the, when it comes to recovery, when it comes to factors that are associated with the actual operation, complications, et cetera,   minimally invasive spine surgery is clearly more favorable than open surgeries.  And for people that have back pain, and are hesitant because they've been offered significant surgery that involves multiple levels and significant complication  risk factors,  they usually tend to gravitate towards minimally invasive spine surgery because they find that the risks that are associated with it are, are more tolerable in their mind than, than open surgery. So I get a lot of people that have been offered open surgeries and end up electing to come to me for minimally invasive spine surgery because of what we just discussed, the improved   post operative course.

Host: Well, I'd love to turn towards talking about that recovery process now. Wendy, what is the typical recovery process like for patients undergoing minimally invasive back surgery? It sounds like it's much shorter, but what other benefits are there?

Wendy Towers, MSN, AGACNP-BC: There are some benefits that I believe are completely different from open procedures, meaning we really tell the patients that the only limitations that they have in the first two weeks after surgery is not lifting anything heavy for themselves. So we don't really restrict their mobility, such as bending and twisting and being able to, you know, make their bed, do laundry, those kinds of things.

Because they don't have that tissue disruption like they do in open procedures, they really get back to their lives much quicker. We start them on physical therapy a week after surgery. And it gets pretty intense right away. Whereas in open procedures, the patients are sometimes not even out of the hospital the first week.

So then they're beginning their transition process much at a slower pace. So that really helps. Medication wise, we really only give the medication that is for that immediate post operative period, the first week after surgery. So they really don't have   these long term opioid use effects.  We give them nerve pain medication,   some anti inflammatory medications, and really that limits their need for extensive opioid use, which of course, in our nation is an epidemic. So really focusing on that whole patient where we want to get them as active as possible and limit the need for strong pain medications is really a key to their recovery.

Host: Well, from a patient perspective, Dr. Kurtom, what can individuals expect in terms of that pain relief, mobility improvement, and just overall quality of life following a minimally invasive back surgery? And on that question, are there any patients who are not good candidates?

Khalid Kurtom, MD: I think that has a lot to do with how long they've had symptoms, the severity of their condition, and the type of surgery that we're going to do. So, we're grouping a lot of surgeries under the title of minimally invasive spine surgery, but under that title, there is, you can talk about, you know, lower back, thoracic, cervical, which is the neck area, you can have multiple levels, and patients can come in with many years of pain and many levels.

Obviously, those patients are going to be more gradual, you know, improvement in their, in their symptoms than the people that come in with six weeks or less of pain and they have only one level to treat. And the location of the level is also a huge factor. So, you know, it's, it's all variable between patients.

But it also highlights the discussion that you have with the patient and your judgment as a surgeon prior to surgery of who you should operate on and who doesn't. And being clear about what your threshold is of the surgical approach that you have. So, for example, for our practice we are extremely conservative.  The majority of our patients that get offered surgeries elsewhere, we don't offer surgery to.  The people that we do offer surgery to is only because we see a huge potential in their improvement of their symptoms and a huge potential for their recovery. So, I think a lot of that has to also do with judgment in addition to the approach that we use.

Host: Well, Wendy, what can patients who need minimally invasive surgery do both before and after to make sure the procedure is as successful as possible?

Wendy Towers, MSN, AGACNP-BC: One of the things that our spine network has developed is a criteria for preoperative management. And this includes,    treatment to prevent infections, such as  certain antiseptic on the skin prior to surgery, also using things to reduce the risk of MRSA through medications prior to surgery. Having the patients drink   fluid, usually a sugar based, glucose based fluid, two hours ahead of time.  Those are found to be extremely helpful for patients in that. Uh,  

Khalid Kurtom, MD: There's already a protocol that we follow that's actually   has been established as a guideline across the country in the literature of how to enhance patients recovery after surgery, and we follow that protocol as a system.   But I think the other factor that we look at is patients' pre morbidities, meaning what other conditions they have prior to surgery that need to be managed to improve their outcomes. We go through an extensive process here, we don't skip steps. So if a patient has a pulmonary issue that needs to be made ideal before the surgery, cardiac issues have to be managed.

People who are overweight, sometimes we tell them to lose weight prior to doing surgery. People that are deconditioned start physical therapy to, you know, get back in shape   and be in better shape to recover after surgery. So there's a lot you can do as a patient, and we'll direct patients towards that pathway, but bottom line is from a medical standpoint, from a physical standpoint, you need to be optimized in addition to following these protocols to get you ready to have the best possible outcome from your surgery.

Wendy Towers, MSN, AGACNP-BC: Exactly. And we're looking at their blood work, making sure that they have, their A1C is under control and that their blood pressure's managed. There's lots to medically preparing the patient to surgery also.

Host: Absolutely. Well, as we wrap up here, Dr. Kurtom, how has technology played a role in the evolution of these minimally invasive procedures for back pain? And are there any recent advancements that have significantly improved outcomes?

Khalid Kurtom, MD: Yeah, absolutely. I think, obviously, the idea of doing surgery without maximal exposure and limited view of your surgery, lends to the idea of how do we improve what we can't, seeing what we can't see. Putting in hardware and screws and rods and operating in areas that are not fully exposed. So, that's where navigation systems have been developed.

 Different robotic systems that help us put instrumentation in place. I think there's further technology that's coming up here soon that allows for the robotic systems to even do more than just put hardware in. Actually help us do the actual operation of the decompression. That's coming up. Things that we're now exploring within the Spine Network across Maryland is virtual reality and AI systems being utilized in spine surgery. But this is the ideal surgery to have these technologies applied to. The minimally invasive approaches will become a lot more easy to learn and a lot more applicable and user friendly the more that you have these technologies around you.

Host: Thank you, and Wendy, final question for you. What are some key ideas our listeners can take away from this episode?

Wendy Towers, MSN, AGACNP-BC: Last thoughts are, along with what Dr. Kurtom was saying, with the conservative management, always trying that first and really giving it a good solid try when you can. Sometimes patients, and we see this quite frequently, have tried physical therapy and it makes things worse. Their symptoms seem to not get any better, and sometimes it really aggravates what's going on.

So really trying hard to avoid surgery, but when surgery is necessary, we try very hard to listen to what our patients are telling us and making a plan that's very specific and good for them. And I think sometimes that's that trust that we build with the patient is very key to a successful outcome is saying, I hear you.

This is what I see on your examination. This is what we see on the films. And this is how we feel like we can offer you the best chance of feeling better in the future. And to me, that's really key is really listening to our patients and making a good plan for them. Whether it's conservative management or minimally invasive spine surgery, whichever way they need, we're there to hear them and to make a good plan.

Host: Great. And wrap it all up for us, Doctor, as we close out. Are there any key takeaways for listeners?

Khalid Kurtom, MD: Yeah, so, you know, back pain is debilitating. Obviously, it changes people's lives and outlook. This is a chronic illness   to a lot of people. There is a lot of light at the end of the tunnel. Being conservative,   doesn't mean that you don't qualify for surgery. It just means that surgery should be your last resort.

I think going to any of the surgeons across our University of Maryland system and asking them for an opinion or getting an opinion from them, I think you'll be steered in the right direction.  And again, starting with the conservative approach, and if it requires surgery,   and it's, you know, you're deemed a good candidate for minimally invasive spine surgery, obviously we have the resources to accommodate that.

Host: It was so great to have you both join us today. Thank you so much for the conversation. Find more shows just like this one at umms.org/podcast and over on YouTube. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media.