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Minimally Invasive Surgery is a surgical procedure based on the philosophy of performing effective surgical procedures on the patient’s body with the least possible damage to normal tissues, minimal blood loss, almost non-existent postoperative pain, a shorter hospital stay for the patient, and a faster return to normal activities.

Laparoscopic technique and natural-incision surgery are typical examples of the application of this modern philosophy in the field of General Surgery, Gynecology and Gastroenterology.

PERCUTANEOUS TECHNIQUES IN THE SPINE

In recent years, Minimally Invasive Surgery has also found application in Spinal Surgery with the continuous emergence of new techniques such as Percutaneous Microdiscectomy, Percutaneous Lamelectomy, Vertebroplasty and Kyphoplasty, Discoplasty and Percutaneous Spinal Fusion. These techniques are characterized by the aforementioned advantages of Minimally Invasive Surgery, making Spinal Surgery extremely patient-friendly. who no longer hesitate to deal with their spinal problems, as unfortunately was the case a few years ago.

Minimally Invasive Spine Techniques are applied through very small skin incisions (2-3 centimeters long), not only for aesthetic reasons but within the framework of the philosophical principle of minimal damage to healthy body tissues. In this way, the maximum result is achieved with the least cost in blood loss, postoperative pain and recovery time. However, to achieve the purpose of the operation, a way of optimizing vision is required so that any operation becomes possible with a minimum of intraoperative complications.

The surgical microscope and endoscope are used during the performance of percutaneous tubular microdiscectomy and endoscopic microdiscectomy respectively, the C-arm (radioscopy) is used during the performance of discoplasty and the C-arm or O-arm (intraoperative computed tomography) in combination with Neuronavigation for the performance of kyphoplasty and percutaneous spinal fusion.

In contrast to these techniques, the classical (open) techniques require larger skin incisions, detachment of the paraspinal muscles, greater blood loss, more intense postoperative pain and longer recovery time.

Finally, with modern percutaneous techniques, the time required to perform a spinal surgery is significantly reduced compared to classical techniques, since both the time for tissue preparation and the time for tissue fusion are greatly reduced.

STABILIZATION TECHNIQUES OF VERTEBRAL FRACTURES

Regarding the plastic repair techniques of fractured vertebral bodies (Vertebroplasty and Kyphoplasty), these are performed through the wide bore needle (trocar) which is inserted, either unilaterally or bilaterally, through the neck of the vertebra into the interior of the vertebral body, with the aid of either fluoroscopy (C-arm) or intraoperative computed tomography (O-arm) and Neuronavigation (GPS).

Both techniques achieve stabilization and strengthening of the body of a fractured vertebra (of osteoporotic, traumatic or pathological etiology) by injecting acrylic “cement” into its interior.

The difference between the two techniques lies in the fact that during kyphoplasty, the cement injection is preceded by the insertion of a balloon, which is inflated inside the vertebral body, with the aim of restoring its height and improving the spinal deformity.

Both techniques require general anesthesia and are performed in the prone position. The results of both techniques are excellent and the pain relief is immediate and spectacular.

ENDOSCOPIC VERSUS MICROSCOPIC SURGERY IN THE SPINE

The introduction and widespread use of the surgical microscope in Spinal Surgery was made in 1977 by the Turkish Professor of Neurosurgery Mahmut Gazi Yasargil and led to a spectacular reduction in neurological complications of lumbar discectomy. On the contrary, the introduction of the endoscope was made later (in 1983 by Kambin) while the establishment of endoscopic techniques in Spinal Surgery twenty years later (only in 1997 by Yeung).
Microscopic microdiscectomy is performed through a 2-3 cm long skin incision through which dilators (tubes) of successively increasing width are inserted, while endoscopic discectomy is performed through the endoscope which is inserted into the body through an incision of only 5-8 mm.

The first technique is performed with the help of a magnified image which reaches the surgeon’s eyes directly through the eyepieces of the microscope in contrast to the endoscopic technique in which the image reaches a screen through a camera-fiber optic system. That is, to perform endoscopic microdiscectomy, the surgeon must be trained to become familiar with the technique of surgery through a screen.

Furthermore, endoscopic discectomy can be performed both through a posterior intervertebral approach, like microdiscectomy (open or percutaneous), and through a posterolateral interforaminal approach (through an intervertebral foramen). This fact requires additional familiarity of the surgeon with the anatomy of the spine, as seen through the posterolateral approach through the intervertebral foramen.

The endoscopic interforaminal discectomy technique is applied even in patients who cannot undergo general anesthesia since it can be performed only with local anesthesia with or without neuroleptic analgesia (sedation), in contrast to the percutaneous technique which always requires general anesthesia.

ROBOTIC SPINE SURGERY

In recent years, a modern technique has emerged that combines an advanced imaging method and a navigation method. This method is called robotics and is currently being applied in the performance of spinal fusion (open or percutaneous) by increasing both the accuracy of screw placement and the safety of the method.

In this way, spinal fusion is transformed into robotically assisted spinal fusion, since the spine surgeon performs the operation by taking advantage of the stability of the robotic arm to guide the screws on a three-dimensional image, which is identified with the patient’s anatomy through an infrared camera.

However, the capabilities of modern robotic systems are much greater than the aforementioned technique and their future applications seem potentially unlimited in the field of Spinal Surgery. In modern times, however, the role of robotic surgery is far from being anything more than an auxiliary technique, without this excluding its future integration and transformation into a universal and autonomous surgical method that will be able to carry out all the stages of all spinal surgeries.