By Zachary Tan, BSc., MD, FRCSC
In modern spine surgery, one of the greatest technical considerations is to limit the extent of iatrogenic soft tissue trauma. Thankfully, emerging innovations will allow us to minimize muscle disruption and improve intraoperative visualization without increased radiation exposure, likely lessening early and late complications.
Historically, spine surgery obligates a significant amount of muscle stripping and dissection, in order to reveal pertinent anatomical landmarks in the operating room. While very effective for visualization, such disruption of spinal musculature comes at a high biological cost to patients, putting them at risk for increased pain, postural issues and even late spinal deformity.
In the past decade, the movement to minimally-invasive procedures has reduced muscle injury in many cases. This demonstrably translates into decreased blood loss, improved post-operative pain and shorter hospital stays. However, the endoscopic tube and sequential dilation process is not innocuous to soft tissues. Furthermore, operating with such a limited field of vision can be challenging and time consuming, especially in the case of unexpected complications. This compromises the surgeon’s adaptability and ultimately may affect patient safety. Surgeons also must rely heavily on X-rays and intraoperative CTs due to limited visualization, which increases radiation exposure to patients.
Today, the pendulum seems to be swinging toward a promising middle ground: continuing to work to minimize muscle injury yet improving visualization via innovative technologies and limited-open surgical approaches.
One critical innovation is a novel computer navigation system pioneered at the University of Toronto and just now emerging on the North American market – a technology I’d like to bring to Hampton Roads. In my opinion, Machine-vision Image Guided Surgery (MvIGS) systems is a game-changer because it offers extremely accurate, efficient, real-time navigation with limited open exposure. MvIGS utilizes visible light and intraoperative photography to align with specially protocoled low-dose pre-operative CT scans. This quick, cost-effective technology registers anatomical landmarks and surgical targets and facilitates precise screw sizing and safe placement.
Meanwhile, I employ the Spinous Process Splitting technique to access the posterior spinal elements without needing to injure the adjacent musculature. Visualization is excellent and overall technical utility is much greater compared to standard tubular surgery. My fixation technique of choice includes Cortical Based Trajectory (CBT) pedicle screws and interbody cages, which in combination also significantly decreases the need for unwanted muscle trauma, joint capsule injury and hardware prominence. Overall, these strategies can be very beneficial in the setting of elderly patients with limited spinal muscular reserve to begin with.
Despite all being said, traditional spinal exposures still have a role in the setting of treating severe deformities and spinal trauma. Yet as computer navigation systems continue to improve – and as more surgeons embrace such technology in a tech-savvy world – the future of spine surgery looks much less arduous for many of our patients.
Dr. Tan is a spine surgeon who specializes in the management of trauma, oncology, deformity and degenerative diseases. He will join the staff at Hampton Roads Orthopaedics & Sports Medicine in August after completing a Spine Fellowship at the University of Toronto, where he also did a residency in Orthopaedic Surgery. hrosm.com
