Minimally access approaches to the spine significantly improve the results and outcome of the patients. These approaches result in minimal dissection, reduced morbidity and faster recovery.
Dr Nitin Garg has one of the largest series of treating spinal conditions using minimally invasive methods (MIS). His motto is "Minimally invasive should be maximally effective
He has attended various symposium, conferences and cadaveric workshops both as participants and later as a faculty. He uses tubular ports for accessing the area of interest. In those requiring fixation, percutaneous transpedicular screws are used from D5 below. In some cases where more extensive approaches are required to access the spine such as dorsal spine, "hybrid method" is used wherein the decompression and fusion is done using conventional or mini-open approaches and patient is turned over and posterior percutaneous fixation is done in the same sitting.
The approach is specific to each patient depending upon the general physical condition of the patient and the pathology.
Various spinal disorders that are managed using MIS methods include:
1. Cervical PIVD--
Anterior cervical microforaminotomy (disc sparing surgery) for unilateral disc causing radiculopathy. Also known as "Jho's method", this preserves the major portion of the non-herniated disc and avoids the need for fusion, thereby preserving motion of the segment.
2. Lumbar PIVD --
microscopic discectomy, endoportal microscopic discectomy (see video), percutaneous endoscopic discectomy. The approach depends upon the level, laterality of the disc. These are performed as a day care procedure. Patients are mobilised after few hours and return to their professional activities within 2 weeks.
3. Spondylolisthesis --
Spondylolisthesis is a disabling condition as it causes both low back pain and neurogenic claudication limiting their mobility. Causes include degenerative, isthmic, traumatic. Transforaminal lumbar interbody fusion (TLIF) (see video) is an optimal surgical procedure with good outcomes. MIS TLIF can decompress bilaterally from unilateral approach and upto two levels can be fusion through single 3-3.5cm incision. Multi-level fixation is performed using sextant and longitude systems. Dr Nitin Garg has one of the largest series of MIS TLIF and has presented his work at NSI conference.
4. Tuberculosis --
tuberculosis of spine is a common condition managed by spine surgeons. Surgery for these can also be performed using MIS methods. These patients are already in sub-optimal general condition and MIS is of immense benefit to them. Dorsal, dorsolumbar and lumbar tuberculosis can be managed effectively using MIS methods. Various approaches include transpedicular decompression, mini-open thoracotomy, direct lateral lumbar interbody fusion (DLIF), TLIF, percutanoeus endoscopic lumbar decompression, percutanoeus transpedicular fixation to name a few. He presentd his work on tuberculosis of spine at Society for Minimally Invasive Spine Surgery (SMISS) in USA and was subsequently published as an invited paper in prestigious Clinical Orthopaedics and Related Research (CORR) journal and authored a chapter in "Textbook of Minimally Invasive Spine Surgery". He is one the earliest surgeons to use the DLIF approach in India and first to perform DLIF in tuberculosis (published in Indian Journal of Neurosurgery) (see publications)
5. Trauma --
Spinal trauma can have devastating effect on the quality of life of the patient and on the family. Majority of spinal cord injuries are secondary to road traffic accidents and affect young population from 20-50 years of age. Prompt and timely intervention is the key to good outcomes. Various surgeries performed for this include conventional and minimally invasive surgeries. Surgeries are done for craniovertebral junctions injuries (occipito-C1-C2 fixation, C1-C2 fixation, Hangman's fracture, trans-odontoid screws), cervical corpectomies, discectomy, facet dislocations, lateral mass fixation, for dorsal and lumbar spinal injuries. In those with undisplaced burst fractures with no deficits, minimally invasive method of percutaneous transpedicular screw fixation is performed.
Osteoporosis is a condition affecting the elderly. With advancing age of our population, many patients are now susceptible to spinal fractures due to osteoporosis. MIS surgery offers good options for such patients. Percutaneous transpedicular vertebroplasty is an optimal methods for patients with non-healing fractures. The benefits include minimal access, procedure performed under local anaesthesia, no need for general anaesthesia, and early recovery. Balloon Kyphoplasty is performed in those with significant body height loss and can be performed in these pateints also. In those with complete collapse in whom either of these cannot be performed, corpectomy thorugh mini-open access followed by cement augmented percutaneous transpedicular screw fixation is done.
Intradural tumors and schwanommas and meningiomas are usually confined to one to two levels and can be excised using MIS techniques. The benefits include preserving the bony architecture, minimal muscle loss, less chance of CSF leakage and faster recovery.