Minimally Invasive Spine Surgery

The Universal Guide to Minimally Invasive Spine Surgery: Everything you ever wanted to know, straight from the experts.

In This Article: What Is MIS?   |    MIS vs Open Surgery   |    Benefits of MIS  |    MIS Candidates   |    Recovery   |    Recent Innovations   |    FAQs   |    Sources

Back problems that lead to chronic pain, sudden spasms, and cancelled plans can seriously interfere with your quality of life. But if you’re a candidate for surgical treatment, there’s good news: Back surgery has come a long way over the last two decades—meaning better outcomes and shorter recover times.

Today, more than one million instrumented spinal procedures are performed every year, many of which are performed using minimally invasive surgical (MIS) techniques.

MIS fusion using computer-aided navigation to minimize muscle damage and increase accuracy of surgical instruments. MIS fusion using computer-aided navigation to minimize muscle damage and increase accuracy of surgical instruments. Reprinted with permission © bjerkespine.com

As 3D imaging technologies have become more sophisticated and accessible, the frequency of minimally invasive spinal surgery has increased. By 2010, approximately one out of six instrumented spine procedures in the United States was considered minimally invasive.

Just six years later, in 2016, that figure approached one in three. Current estimates suggest more than half of all spine surgeries now use minimally invasive techniques.

Not surprisingly, minimally invasive spinal surgery is now available to many for whom it wasn’t previously considered a viable option. For example, obese patients, those with degenerative spinal conditions, and those requiring deformity surgeries are increasingly experiencing good outcomes as the technology continues to develop.

What is Minimally Invasive Surgery (MIS)?

It depends on who you ask. “I think you'll find opinions all over the board,” says Benjamin Bjerke, MD, a spine surgeon with Capital Orthopedics in Clive, Iowa.

Why? Because the very word “minimal” is relative.

In other words, a minimally invasive procedure is one that merely is less invasive than the alternative. While there is no black and white definition of what constitutes MIS, the goals are always the same: to give you the same outcome as an open surgery with less pain, fewer complications, and shorter recovery time.

But generally, says Dr. Bjerke, any surgical procedure in which your surgeon uses special visualization techniques is considered minimally invasive. This means using imaging tools including specialized retractors, computer- and CT-aided navigation, endoscopy, and biplanar fluoroscopy, which is when X-rays taken from two angles simultaneously capture images.

Minimally invasive procedures, therefore, may require you to have special imaging done before your surgery.  Your surgeon will then upload those images for integration with computer software to create three-dimensional representations of your spinal anatomy.

Your surgeon can then use the images ahead of time to map out the exact approach they’ll take in the operating room. This way, they can have the specific surgical tools as well as any plates and screws that are necessary prepped and ready to go.

The visualization technology also enables your surgeon to what they’re doing on a computer screen during the operation. In some cases minimally invasive spinal surgery can be performed via a surgical incision as small as one inch.

How Is Minimally Invasive Spine Surgery Different from Open Surgery?

An open spinal surgery is one in which your surgeon makes an incision, or cut, typically about five to six inches long, and then moves the muscles to one side in order to operate on the bone.

Minimally invasive spine surgery, on the other hand, only requires a cut that’s about an inch long and uses a special tool called a retractor to spread push muscles out of the way. This causes far less trauma to your muscles, which means less post-surgical pain and a speedier recovery. 

During an open surgery, your surgeon wears a pair of surgical eye loupes, small magnifiers attached to a pair of glasses, help them see their work. Without special technology to allow visual access to the surgical site, open surgery generally requires a larger incision. According to Scott Meyer, MD, a neurosurgeon with Altair Health in New Jersey, because that incision cuts off the blood supply to a lot of the muscular tissue, recovery time is much greater.

With the “old process,” or the open surgical approach, says Dr. Meyer, the emphasis was on the bone itself, at the expense of the surrounding tissues. Referring to the traditional approach to spinal fusion, he says the singular focus on muscular and orthopedic stability often ended up compromising function and resulting in higher post-surgical pain levels.

“Now, the idea is, you want that person to have all the benefits from an open surgery, but with a much faster and less painful recovery,” says Dr. Meyer. Previously, surgeons often had their patients wear rigid, cumbersome back braces after a fusion. But now, according to Meyer, surgical techniques have grown more effective, “you probably don’t need them.” Instead, he explains, while you recover, ”the muscles are actually getting recruited. They're not atrophying.”

While your preparation will not vary much, if at all, depending on what type of surgery you’re having, your surgeon’s definitely will. According to Dr. Bjerke, with minimally invasive surgery, “more preparation and more image review are required to get a better understanding of the three-dimensional anatomy,” he says.

The extra time it takes to review the anatomy pre-surgically is well worth it. “Something I hear from patients all the time is, ‘Doc, once you get in there, you do what you got to do. If you change the plan, that’s okay,’” says Dr. Bjerke. “But the imaging is so good nowadays that I have a completely three-dimensional view of the spine before operating. That view gives me more information than directly visualizing the anatomy.” Access to this technology means he rarely encounters surprises in the operating room.

X-rays are used to locate the exact place on the spine for surgery. Metal "dilators" are used to spread and push muscles aside. X-rays are used to locate the exact place on the spine for surgery. Metal "dilators" are used to spread and push muscles aside. Reprinted with permission © bjerkespine.com

An endoscopic tube is attached to a fixed arm and safely positioned for the operation. An endoscopic tube is attached to a fixed arm and safely positioned for the operation. Reprinted with permission © bjerkespine.com

Surgical Tools

In general, the tools required for minimally invasive procedures are longer, thinner, and have curved edges, as your surgeon is working through a much small incision, from a greater distance.

  • Eye loupes: Typically used during open procedures as opposed to minimally invasive procedures, they are a pair of small magnifying glasses that clip directly to the surface of surgical glasses. They help your surgeon see your body and their tools as they work.
  • Retractor: This is a long tool with a curved end that’s designed to hold tissues like muscles, organs, or other body tissues out of the way so your surgeon can access your spine with minimal impact on other tissues. According to Dr. Bjerke, they are a necessary tool for minimally invasive spine surgery, as they allow your surgeon to “best visualize your spine while looking through a specialized retractor.”
  • Endoscope: This tool is specific to endoscopic spine surgery, which is a specific type of minimally invasive spine surgery. It’s a camera mounted on a long, narrow lens with a cable and a light source. The cable connects to a screen where your surgeon can see the area they’re operating on.
  • Tubular retractor: In some cases the retractor your surgeon uses to hold other tissues out of the way is tube shaped; this is a tubular retractor. It also acts as a tunnel through which a microscope and surgical tools are placed. It is passed through a tunnel of back muscles, rather than separating them from the spine, which is what happens during open surgeries. This minimally invasive approach minimizes muscle damage and blood loss during surgery.

Benefits of Minimally Invasive Spine Surgery 

In addition to the shorter recovery times and improved function associated with MIS, other benefits include:

  • Shorter hospital stays, with many procedures being performed on an outpatient basis using local anesthesia instead of general anesthesia.
  • Reduced risk of infection
  • Decreased post-surgical pain and narcotic use
  • Less blood loss during surgery
  • Less damage to soft tissue
  • Reduced scarring
  • Quicker return to activities of daily living (ADL), including work, self-care, and leisure
  • Less post-operative rehabilitation
  • Better postoperative quality of life

Is Endoscopic Spine Surgery Minimally Invasive?

Endoscopic spine surgery (ESS) is a specific type of minimally invasive spine surgery that offers the same benefits noted above. Additionally, small incisions and the ability to target the precise surgical site result in less blood loss and speedier recovery. Also, most ESS’s can be completed in as little as one hour.

During the procedure, your surgeon creates a small, one-inch incision through which they place a tube-shaped instrument known as a tubular trocar into your back. A minuscule camera is then inserted through the trocar to the operative area.

While retractors hold the incision open so your surgeon can access the surgical site, they visualize the camera’s images on a screen while performing your surgery.

While the number of procedures that can be done endoscopically continues to rise, says Dr. Meyer, some still require other approaches. ESS may not be appropriate for conditions such as scoliosis, spinal instability, cancer, or trauma.

Plus, since it’s still considered an innovative procedure, it can be hard to find a surgeon who has enough experience to be considered highly skilled in the technique. That said, with proper diagnosis and adequate surgical training, according to a 2017 study, ESS’s outcomes are comparable to those of open spine surgery.

Am I a Candidate for Minimally Invasive Spine Surgery? 

“Almost all spine surgery involves removing bone or other structures away from pinched nerves or fusing bones to where they should be,” explains Dr. Bjerke. When spinal movement becomes painful, either from wear and tear, trauma, or a decompression procedure, a fusion may be needed to restore spinal stability. This involves using instrumentation to fuse vertebrae.

Decompression, on the other hand, requires removal of bone spurs, damaged discs, or tissues that compress spinal nerves, causing back pain, or radiculopathy (nerve problems that can cause limb pain or weakness).

While your diagnosis alone can’t determine whether you’re a candidate for MIS, procedures that can commonly be performed using minimally invasive techniques include:

The final tube requires an incision that is less than one inch, and minimizes soft tissue damage. The final tube requires an incision that is less than one inch, and minimizes soft tissue damage. Reprinted with permission © bjerkespine.com

It’s your specific situation, including your diagnosis as well as your surgical goals, general health status, prior level of function, and lifestyle, that determine your physician’s surgical approach. According to Dr. Meyer, “It's a patient by patient decision.”

That said, one of the primary considerations is the extent of the disease process. “A minimally invasive procedure is often a one-level, focused problem that can be addressed with a small incision,” Dr. Bjerke explains.

Meanwhile, people experiencing more severe problems, such as certain cases of scoliosis or spine problems affecting more than one vertebrae, may need a traditional open procedure, says Dr. Bjerke. If, for example, you need surgical intervention at ten vertebrae, your surgeon could certainly take a minimally invasive approach, but that doesn’t necessarily mean they should.

Not only does MIS take more prep time, with ten levels of spinal involvement, “you’re not saving any time or morbidity for the patient,” he explains. “The fewer the levels involved, the more local the disease, the more likely it is to be a minimally invasive operation.”

Your diagnosis, however, is not the only factor to take into account. A holistic approach that takes your lifestyle and surgical goals into account is an essential part of surgical decision making. Dr. Meyer describes a hypothetical situation where his patient has ten out of ten nerve pain and would benefit from open surgery. But with their son or daughter’s wedding six weeks away, they might opt for a minimally invasive approach, knowing it will give them enough relief to dance at the wedding, even if it’s not a long-term solution.

Whatever type of spine surgery you end up having, the decision should be made in collaboration with your surgeon. Dr. Bjerke encourages patients to schedule multiple visits with any potential surgeon before scheduling a procedure, so “you can make an informed decision together.” As he explains, “I will tell patients that I'm here to explain the risks, benefits, and alternatives of surgery. You're here to determine whether or not that's the best decision for you.”

What Is Recovery from Minimally Invasive Spine Surgery Like?

MIS has grown more popular in recent years because patients tend to recover much faster and with less pain than with open surgeries.

As Dr. Bjerke explains, while MIS tends to be performed on an outpatient basis, open surgeries are generally done in the hospital, as they come with greater risks, including more blood loss, more pain, and oftentimes, more IV pain medication.

While surgical precautions are typically the same in either scenario—Dr. Bjerke asks his patients to avoid bending, lifting, and twisting for six weeks—with the smaller incisions characteristic of MIS, there is less damage to muscles and soft tissue. That generally means greater ease of movement, substantially less pain, and a quicker and easier return to your prior level of function.

A 2020 study found patients who underwent minimally invasive spinal fusions and decompressions resumed work and driving within three weeks of surgery. Meanwhile, open decompressions and fusions may require months of recovery.

There are also a few possible drawbacks of MIS. While it’s unusual, there’s a chance that a minimally invasive procedure cannot be completed as planned, leading to either a second procedure or full open surgery.

Additionally, some surgeons lack sufficient training or experience to ensure a strong chance of a positive outcome. While secondary visualization technology has been found to be exceedingly accurate, there is still a learning curve associated with the skills required of MIS. 

In any spinal procedure, whether open or minimally invasive, there are some inherent risks. Those include:

  • A potential adverse reaction to the anesthetic
  • Unexpected blood loss during surgery
  • Infection at the surgical site

What’s on the Horizon for Minimally Invasive Spinal Surgery?

Robotics

Robot-assisted surgeries have grown increasingly common, says Dr. Meyer. Currently, the main role of robots in spinal surgery is assistance with pedicle screw implantation. A 2018 meta-study found that using robotic assistance in this way is sufficiently accurate on a very consistent basis.

Minimally invasive spine surgery surgical robotRobotic-assisted surgery is becoming increasingly common, especially for pedicle screw implantation.

That said, one of the downsides of this technology is that the surgeon can’t feel what they’re doing when they’re operating you. During an open surgery, they’d easily feel ’ whether the screw was engaging with a solid piece of bone and creating a strong connection.

When a robot replaces your surgeon’s hands they can run into issues, especially when working on patients with low bone density.   If you have osteoporosis or osteopenia, he suggests finding a surgeon who will work with their hands instead of a robot.

Additionally, it’s still unclear how robot assistance impacts radiation exposure, length of hospital stays, and operative time. And as Dr. Bjerke points out, a surgeon must invest a significant amount of time in training to use robotics effectively; if your surgeon’s skills aren’t at the expert level, you may be better off going the more traditional route.

While Dr. Meyer feels robotics is not yet ready for “mass adoption,” the field is certainly moving in that direction. Research suggests robotics’ role may expand beyond pedicle screw placement to include more complex surgical interventions, such as neural decompression, automated discectomy, and cage placement. It’s also projected that although the future robots won’t replace surgeons, they will help surgeons make minimally invasive spine surgery safer and more efficient.

Machine Learning, Augmented Reality (AR), and Virtual Reality (VR)

While these technologies have the potential to improve minimally invasive spinal surgery outcomes, their widespread use remains on the horizon. A 2019 study found that machine learning can aid in pre-navigating surgical procedures and enhance surgical navigation workflow while ensuring patient safety.

Similarly, a 2019 meta-analysis concluded that AR and VR also have significant potential. Specifically, they’ve been shown to improve surgical accuracy and patient outcomes while limiting radiation exposure.

However, while these technologies are still considered nascent, there is a shortage of high-quality research that explores their efficacy to date.

While minimally invasive spinal surgery technology is always evolving, one thing we can count on is an increasing number of surgeries being performed in an ambulatory setting. Says Dr. Meyer, “As the pandemic has taught us, as hospitals can fill with sick patients, being able to get patients back to their home environments quickly and safely is the future of spine surgery.”

As you may be well aware, back pain can seriously interfere with your quality of life. The limited mobility, discomfort, spasms, and sleepless nights associated with back issues can affect your work, hobbies, and relationships. But this doesn’t have to be the case. Don’t wait to ask your doctor if you’re a candidate for minimally invasive spine surgery. Relief might be a short, safe procedure away.

FAQs

What Are the Benefits of Minimally Invasive Spine Surgery?

For many people minimally invasive spine surgery’s outcomes are on par with those of open surgery. In addition to desirable outcomes, minimally invasive spine surgery generally requires fewer nights in the hospital, if any. Oftentimes, the procedure can be performed in an outpatient clinic. Additionally, minimally invasive surgery presents a decreased risk of infection, less post-surgical pain and narcotic use, less blood loss during surgery, decreased damage to soft tissue, and less scarring around the incision.

Following surgery, the recovery required of minimally invasive spine surgery is generally much quicker and easier as compared with traditional open surgery. After a minimally invasive procedure, you can return to your activities of daily living (ADL), including work, self-care, and hobbies sooner with less post-operative rehabilitation. Overall, your postoperative quality of life will be better.

How long does it take to recover from minimally invasive back surgery?

You will need to consult with your surgeon to find out what you should expect, as recovery time can vary, depending on the type of surgery you’re having, your doctor’s protocols, and how you are progressing. You can usually go back to work with activity restrictions at about six weeks, and without restrictions at about three months.

Is minimally invasive spine surgery effective?

While every case is unique and no medical procedure can be guaranteed, when performed on patients who are good candidates by well-trained surgeons, it is generally as effective as open surgery.

 

Sources

How many instrumented spinal surgeries are performed each year in the United States: iData Research. (May 25, 2018). “How Many Spinal Fusions are Performed Each Year in the United States?” https://idataresearch.com/how-many-instrumented-spinal-fusions-are-performed-each-year-in-the-united-states/

Minimally invasive surgical techniques have advanced significantly over the past two decades: Journal of Spine Surgery. (June 2019) “Current State of Minimally Invasive Spine Surgery” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626758/

Goals of MIS: Journal of Neurosurgery. (February 2019) “The Evolution of Minimally Invasive Spine Surgery” https://thejns.org/spine/view/journals/j-neurosurg-spine/30/2/article-p149.xml

Length of open spinal surgery incision: Orthoinfo (n.d.) “Minimally Invasive Spine Surgery” https://orthoinfo.aaos.org/en/treatment/minimally-invasive-spine-surgery/

What is an endoscope?: SpineUniverse (January 2017) “Basic Introduction to Minimally Invasive Spine Surgery” https://www.spineuniverse.com/treatments/surgery/minimally-invasive/basic-introduction-minimally-invasive-spine-surgery

What is a tubular retractor?: BioMed Research International (2019) “Comparison of Endoscope-Assisted and Microscope-Assisted Tubular Surgery for Lumbar Laminectomies and Discectomies: Minimum 2-Year Follow-Up Results” https://www.hindawi.com/journals/bmri/2019/5321580/

How a tubular retractor works: American Association of Neurological Surgeons (n.d.) “Minimally Invasive Spine Surgery” https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Minimally-Invasive-Spine-Surgery

Less chance of needing postoperative rehabilitation after MIS: American Association of Neurological Surgeons. (n.d.) “Minimally Invasive Spine Surgery” https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Minimally-Invasive-Spine-Surgery

Benefits of endoscopic spine surgery: Journal of Korean Neurosurgical Society. (September 2017) “Endoscopic Spine Surgery” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594628/

Cancer may be a contraindication for MIS: SpineUniverse “Spinal Cancer: What You Should Know”  (September 2019) https://www.spineuniverse.com/resource-center/spinal-cancer/spinal-cancer-what-you-should-know

ESS outcomes are comparable to those of open spine surgery: Journal of Korean Neurosurgery. (September 2017) “Endoscopic Spine Surgery”  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594628/

Earliest forms of minimally invasive spine surgery Journal of Korean Neurosurgery. (September 2017) “Endoscopic Spine Surgery”  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594628/

The first attempt at endoscopic spine surgery was in 1988: Journal of Spine Surgery. (June 2019) “Current State of Minimally Invasive Spine Surgery” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626758/

Surgeons began using image-guided systems to facilitate screw placement: Neurosurgery. (November 2002) “History of Minimally Invasive Spine Surgery” https://pubmed.ncbi.nlm.nih.gov/12234425/

Growth of minimally invasive spine surgery since 2010: Spine. (April 2016). “Breaking Through the ‘Glass Ceiling’ of Minimally Invasive Spine Surgery” https://journals.lww.com/spinejournal/FullText/2016/04158/Breaking_Through_the__Glass_Ceiling__of_Minimally.1.aspx

Minimally invasive fusions and decompressions require shorter recovery times than open procedures: OrthoSpineNews. (June 15, 2020)Study Finds Similar Short-Term Outcomes After Two Common Minimally Invasive Spine Procedures” https://orthospinenews.com/2020/06/15/study-finds-similar-short-term-outcomes-after-two-common-minimally-invasive-spine-procedures/

Minimally invasive spine operations come with a learning curve for surgeons: World Neurosurgery. (November 2018) “Learning Curve and Minimally Invasive Spine Surgery” https://www.sciencedirect.com/science/article/abs/pii/S187887501831310X

Risks of MIS aans.org: American Association of Neurological Surgeons. (n.d.) “Minimally Invasive Spine Surgery” https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Minimally-Invasive-Spine-Surgery

How long endoscopic spine surgery has been an option: Journal of Spine Surgery. (June 2019)  “Current State of Minimally Invasive Spine Surgery” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626758/

Use of robots in spinal surgery: Journal of Spine Surgery (June 2019) “The Use of Robotics in Minimally Invasive Spine Surgery” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626754/

The use of robotics in spinal surgery has benefits and potential risks: Spine. (December 2018) “The Arrival of Robotics in Spine Surgery: A Review of the Literature” https://journals.lww.com/spinejournal/Abstract/2018/12010/The_Arrival_of_Robotics_in_Spine_Surgery__A_Review.15.aspx

The role of robotics in spinal surgery is poised to expand: Journal of Neurosurgery. (February 2019) “The Evolution of Minimally Invasive Spine Surgery” https://thejns.org/spine/view/journals/j-neurosurg-spine/30/2/article-p149.xml

Machine learning contributes to good outcomes in spinal surgery: Journal of Neurosurgery. (March 2019) “Machine Learning for Automated 3-Dimensional Segmentation of the Spine and Suggested Placement if Pedicle Screws Based on Intraoperative Cone-Beam Computer Tomography” https://thejns.org/spine/view/journals/j-neurosurg-spine/31/1/article-p147.xml

Augmented and virtual reality have significant potential for use in spine surgery: Annals of Translational Medicine. (Sept 2019) “The Utility of Virtual Reality and Augmented Reality in Spine Surgery” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778272/

Updated on: 01/04/21
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What Is Minimally Invasive Spine Surgery?

Minimally invasive surgery is an attractive option for patients who want a quicker recovery after surgery, less post-operative pain, and smaller incisions.
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