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Archive Orthopedic Surgery 2017

Is It Time to Add Spinal Fusion?

Minimally invasive techniques have transformed a complex open surgery into a viable outpatient option.

Jim Burger

Jim Burger, Senior Editor


Dr. Villavicencio FUSED APPROACH Dr. Villavicencio, shown here performing a minimally invasive transforaminal lumbar interbody fusion, says patient selection is key.

The ability to do minimally invasive spinal fusion comes down to 3 primary considerations: patient preparation, pain control and the ability to minimize collateral damage around the spine. Once you reach the targeted vertebrae, the operation is essentially the same as it would be in an open procedure. What's different with outpatient cases is how you go about getting there.

The spine is deep in the body and surrounded by a lot of muscles. To get to it, you have to expose it, which in itself is no small feat. Then comes the hardware — screws, rods and cages. Until fairly recently, the combination required a large incision, lots of muscle damage, plenty of strong pain meds and a lengthy hospital stay.

So one of the first big challenges is figuring out how to reach the spine without causing too much injury to the surrounding muscles. "We can now do fusion through minimally invasive access and small incisions," says John Liu, MD, co-director of the USC Spine Center in Los Angeles, Calif. "There are several surgical techniques that we incorporate that can lessen the injury to the regular normal soft tissues around the spine.

"The optimal positioning depends on the patient's anatomy and what needs to be done," says Dr. Liu. "There are natural cavities we all have in the belly and those cavities can sometimes be used to get down to the spine without stripping out a bunch of muscle to get there. There are also fewer muscles to go through with lateral or anterior approaches than there are with the posterior route."

Unfortunately, sometimes there are no good minimally invasive options, he says, so an open procedure may be the better choice. The primary mitigating factors are typically the location of the stenosis and the size of the patient.

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