What Does True Minimally Invasive Spine Surgery Mean? And What Is Full-endoscopic Spine Surgery?



June 20, 2011

“Minimally invasive spine surgery” and “endoscopic spine surgery” have become buzzwords. A recent Google search for “minimally invasive spine surgery” resulted in 226,000 hits, and a search for “endoscopic spine surgery” led to 92,800 links. While the online appearance of these buzzwords continues to increase, other similar words like “true minimally invasive spine surgery” and “full-endoscopic spine surgery” started to emerge.

So what exactly are “minimally invasive spine surgery” and “endoscopic spine surgery”?  Why do some surgeons have to claim they perform “true minimally invasive spine surgery”? Does this mean other surgeons conduct fake or not-so-true minimally invasive spine surgery? If indeed there is “true minimally invasive spine surgery” and there is not-so-true minimally invasive spine surgery, what are the differences? And how could patients know?

And, what exactly is full-endoscopic spine surgery? Are there differences between “endoscopic spine surgery” and “full-endoscopic spine surgery”? If so, what do the differences mean to the patients?

To answer these questions, we need to first look at the history of spine surgery. The history of spine surgery can be traced back to the early 1800s. Back then, there were no visual devices helping the surgeons to look inside the human body. So to perform surgery on the spine, the surgeons had to cut open the skin, dissect muscles, and remove bones so that they could see the spine with their own eyes, and fix the spinal problems directly. Because the patient’s back or neck was cut open during the surgery, the surgery is called open spine surgery.

Obviously, this way of doing surgery could cause drastic pain and trauma, and pose a great deal of operative and post operative risks to the patient. To reduce or minimize the surgical trauma and risks, physicians started to explore different surgical approaches to access the spine (eg, from the back, front, or side of the body), invent new surgical tools (eg, cutting tools with different sizes, shapes, and flexibility), and employ modern fiber optic light sources and visual devices (eg, x-ray based fluoroscopy, microscope, and endoscope).

Equipped with the powerful tools and guided by the advanced visual devices, spine surgery techniques were gradually improved. Less invasive surgical procedures with reduced or minimized surgical trauma and operative and postoperative complications became the trend.

The first recorded minimally invasive spine surgery was performed in the 1980s. And the term “minimally invasive spine surgery” was coined by professor Parviz Kambin, who founded International Society of Minimally Invasive Spine Surgery (ISMISS), and his colleagues in the early 1990s. Because of its many great advantages over open spine surgery, minimally invasive surgery has experienced tremendous growth in recent years.

Today, minimally invasive spine surgery includes endoscopic spine surgery and mini-open surgery with endoscopic or microscopic assistance.

The main differences between open spine surgery and minimally invasive spine surgery are significant, as demonstrated in the table below.

Main differences between open, mini-open, and endoscopic spine surgery

Open Spine SurgeryMinimally Invasive Spine Surgery
Mini-open Spine SurgeryEndoscopic Spine Surgery
Incision1 large incision1 or multiple small incisions1 small incision
Incision size4-6 inches1-3 inches0.2-0.4 inches (5-10 mm)
Muscle removalYesYesNo
Bone removalYesYes in some casesMinimal or no
Visualization Human eyesMicroscopic or endoscopic assistanceDirect vision* under an endoscope
AnesthesiaGeneral anesthesiaGeneral anesthesiaLocal anesthesia in most cases
Hospital stay3-5 daysMany patients don’t needNo
Walking2-4 daysSame daySame say
Recovery time≥ 6 months2-3 months4-6  Weeks

* Direct vision means the surgeon can see the operating area (eg, a herniated disc, a bone spur, and intervertebral foramen) through an endoscope or microscope during the whole surgical procedure.

So, what is true minimally invasive spine surgery, and what is full-endoscopic spine surgery?

Because minimally invasive spine surgery includes endoscopic spine surgery and mini-open spine surgery, true minimally invasive spine surgery is sometimes used to differentiate endoscopic spine surgery from mini-open spine surgery. And because the pathology or pain generator in the spine can be fully visualized and removed under an endoscope, true minimally invasive spine surgery is also called full-endoscopic spine surgery.

Because of its many advantages over traditional open spine surgery, minimally invasive spine surgery has grown very popular these days. But because of the steep learning curve associated with minimally invasive spine surgery, especially minimally invasive endoscopic spine surgery, many spine centers and institutions offer only mini-open surgery. But most of the procedures offered at Atlantic Spinal Care (ASC) are endoscopic spine surgery (full-endoscopic and true minimally invasive spine surgery). To help patients whose spinal condition requires a spinal fusion or fixation, ASC recently has expanded their minimally invasive procedures to include selected mini-open procedures such as XLIF and TLIF.

Frequently Asked Questions About Minimally Invasive Spine Surgery

Are Minimally Invasive Spine Surgery and Endoscopic Spine Surgery the Same?

No.

As we explained earlier, minimally invasive spine surgery includes endoscopic spine surgery and mini-open spine surgery. Mini-open spine surgery is less invasive than traditional open surgery, but is more invasive than endoscopic spine surgery.

To different endoscopic spine surgery from mini-open spine surgery such as XLIF, physicians sometimes refer endoscopic spine surgery as true minimally invasive spine surgery.

Are Endoscopic Spine Surgery and Spine Surgery With Endoscopic Assistance, or Endoscopic-assisted Spine Surgery, the Same?

Not necessarily.

Endoscopes are powerful visualization devices, much better than the human eye. Surgeons therefore often use endoscopes to improve visualization during surgical procedures. And endoscopes can be used in both minimally invasive spine surgery and open spine surgery. So, just because an endoscope is used in a surgical procedure does not mean the surgical procedure is minimally invasive. In other words, endoscopic spine surgery is minimally invasive, but not all spine surgery with endoscopic assistance, or endoscopic-assisted spine surgery, is minimally invasive.

What Does True Minimally Invasive Spine Surgery Mean to the Surgeon?

Minimally invasive spine surgery is associated with a steep learning curve. To master minimally invasive spine surgical techniques, the surgeon needs specialized training in the field of minimally invasive spine surgery and extensive hands-on experience.

What Does True Minimally Invasive Spine Surgery Mean to the Patient?

For patients who need spine surgery to reduce back or neck pain or to fix spine diseases or instability, true minimally invasive spine surgery means that they will benefit from the following advantages:

  • Same day surgery without the need of hospital stay
  • No muscle or bone removal
  • Minimal or no blood loss
  • Preservation of spinal mobility
  • Minimal pain after surgery
  • Mostly local anesthesia
  • Low chance of complications
  • Fast recovery
  • High chance of success

Is the Smaller the Better?

Not necessarily.

In general, the smaller the incision, the lower the chances of tissue damage and complications are. However, the goal of a surgical procedure is to fix a medical problem. In the case of spine surgery for pain treatment, it is to diminish or reduce pain by removing the pain generator. If the pain generator, either a bone spur or disc herniation, can be removed through a minimally invasive procedure, sure, a smaller incision is better. But because the spine is a very delicate and complex structure, not all pain generators in the spine can be easily accessed through a small incision. If this is the case, the surgeon must use a bigger incision, or multiple incisions, to remove the pain generator.

So the size of the incision is largely dependent on the underlying medical problem needed to be fixed, and it shouldn’t be the first thing you consider when choosing a surgical procedure or surgeon. The ultimate goal should be to achieve the surgical goal (eg, reduce back pain, or stabilize the spine) while keeping access-related damage and complications to the minimum.

What Is Mini-open Spine Surgery?

Mini-open spine surgery is one of those medical terms that are commonly used by physicians but not the general public. The term mini-open spine surgery refers to surgical procedures that is less invasive than traditional open spine surgery but is more invasive than endoscopic spine surgery. Mini-open spine surgery involves some muscle and bone removal in some cases. But compared with traditional open spine surgery, it is still considered minimally invasive. Sometimes mini-open surgery is called microsurgery, and mini-open techniques are referred as microsurgical techniques.

What Does Full-endoscopic Spine Surgery Mean?

Clear visualization is critical to the success of spine surgery. After all, if a surgeon couldn’t see the body part he or she is supposed to operate on, how could he or she operate accurately? Endoscopes are modern visualization devices commonly used during surgery.

But because of the complexity of human body and varied surgical approaches used by surgeons, not all body parts to be operated can be seen through an endoscope during any procedure. If the surgeon can see his or her operating area (eg, an intervertebral disc) through an endoscope and the surgical procedure is guided by the endoscope, along with other imaging devices, during the whole surgical procedure, the procedure is considered full-endoscopic. If the surgeon can only use an endoscope to improve visualization at certain point during the surgery, the surgery is considered endoscopic-assisted, but not full-endoscopic.

In other words, full-endoscopic spine surgery and endoscopic spine surgery are supposed to be same. The term “full” is added to differentiate endoscopic spine surgery from endoscopic-assisted spine surgery.

What Does Direct Vision Mean?

Traditionally, direct vision means the surgeon can see the operating area with his or her own eyes. But today, direct vision means the surgeon can see the operating area (eg, a herniated disc, a bone spur, and intervertebral foramen) with his or her own eyes or through an endoscope or microscope during the surgical procedure.