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3 Hot Topics in Minimally Invasive Spine Care at NASS

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This year’s North American Spine Society annual meeting was held in Los Angeles, CA and I was honored to speak in the symposium on minimally invasive spine surgery. The panel members for the symposium included thought leaders in minimally invasive spine surgery from around the world and the lecture hall was jam-packed with spine providers interested in the latest techniques and trends in minimally invasive spine care. I touched on three topics during the symposium that have created a lot of buzz this past year and I believe will continue to do so in 2019 as well.

The first of these topics is the increasing utilization of image guidance in spine surgery. Minimally invasive spine surgery relies on the utilization of image guiding technologies for the accurate placement of hardware. While 2D fluoroscopy is a mainstay of minimally invasive spine surgery, navigation guidance which allows for a 3D picture has been increasingly popular over the last several years. While the primary purpose of navigation in spine surgery has been the placement of pedicle screws, this year we have seen an improved ability to navigate a variety of different instruments including decompression instruments that allow for the use of navigation more broadly. In addition, this year we have seen a significant increase in technologies that marry navigation and robotics in spine surgery. There has been a surge in the use of robots in spine surgery with the main advantage being preoperative planning, reproducibility, and mitigation of surgeon fatigue. As more industry partners offer robotic options to surgeons, I have little doubt that we will continue to see a rise in utilization with a reduction in cost. Ultimately this will benefit patients and providers.

The next area I discussed was the increased consideration of enhanced recovery pathways in spine surgery. This has been a keen interest in general surgery for several years and has resulted in algorithms that provide for an improved patient experience with early postoperative recovery after surgery. Spine surgery is often associated with significant postoperative pain and the potential for medical complications. By using a multi-disciplinary approach that involves the surgeon, anesthesiologist, nursing staff, physical therapy, and medical team, the focus has shifted from open surgery followed by bed rest and narcotic usage to minimally invasive procedures, early mobilization, and multimodal analgesia. At Hospital for Special Surgery, we are leading the way by validating several ERAS (Enhanced Recovery After Surgery) pathways in both open and minimally invasive spine procedures. Specifically, in minimally invasive surgery procedures, we have found shorter time to patient alertness postoperatively which allows for earlier mobilization and discharge. Perhaps most importantly, we have found that we can significantly reduce the use of narcotic medications at all points of the perioperative process.

Lastly, I talked about the trend in doing more spinal surgery procedures on an outpatient basis. This is a particularly controversial topic as different stakeholders have different incentives in performing spine surgeries in ambulatory surgery centers. While several studies have shown that spine surgery done in an ambulatory setting can result in cost savings, as surgeons and spine care providers, we must always consider the quality of care we are providing as well as patient safety.

Ultimately, everything discussed ties together with the changing landscape of spine surgery in the United States and worldwide. As more surgeons perform minimally invasive surgeries, patients will require less postoperative pain medications and be able to return to function more quickly. The ability to have patients be more alert and mobile immediately after surgery will allow ambulatory surgery to be performed safely. I am hopeful that by bringing these topics to the forefront, the spine care providers in the room will think about strategies to implement enhanced recovery pathways in minimally invasive spine surgery to perform ambulatory surgery safely and effectively as will be demanded by all stakeholders.

Dr. Sheeraz Qureshi is an Associate Attending Orthopedic Surgeon at Hospital for Special Surgery and Associate Professor of Orthopedic Surgery at Weill Cornell Medical College. He is a founding member and treasurer of the Minimally Invasive Spine Study Group (MISSG). Conflicts: Stryker Spine- Royalties, Consultant; Zimmer-Biomet- Royalties, Consultant; RTI- Royalties; Globus Medical- Consultant; Avaz Surgical- Equity Interest; Vital 5- Equity Interest.

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