Minimally Invasive Surgery on the Spine by murplelake76


									                                                                                                              F ro m U s e r s f o r U s e r s

Minimally Invasive Surgery
on the Spine

A step forward or                        pants in the symposium were impres-       Technology of the
backward?                                sed by the new possibilities available,   Finest
                                         some criticism was also voiced: ”We       Robert S. Bray
At the symposium entitled ”Minimally     now have wonderful, new technolo-
Invasive Trends in the Spine Area” or-   gy at our fingertips, but the question    In the operating room of the future,
ganized by Carl Zeiss during the 52nd    remains – who can do what with            parallel, consecutive or alternating
Annual Convention of the German          what?” Some of the participating          use will most certainly be made of
Society of Neurosurgery (DGN) in Bie-    surgeons express their opinions be-       minimally invasive techniques. This is
lefeld, Germany in May 2001, physi-      low.                                      already being practiced at the Cedars
cians and instrument manufacturers                                                 Sinai Hospital. The technical equip-
discussed the question: ”Is endoscopy                                              ment ranges from state-of-the-art
a step forward or backward for neu-                                                microscopes and navigation aids to
                                                                                                                                Robert S. Bray Jr., M.D.,
rosurgery?” Although the partici-                                                  3D endoscopes and voice-controlled           Institute for Spinal
                                                                                   robots. The possibility of transmitting      Disorders at the Cedars-
                                                                                   operations live via the internet al-         Sinai Medical Center in Los
                                                                                                                                Angeles. With more than
                                                                                   ready exists, archival is fully digital,     5500 microsurgical
                                                                                   and the technical equipment in the           operations on the spine, he
                                                                                   OR such as lamps and cameras can             is a recognized specialist in
                                                                                                                                this field.
                                                                                   be voice-controlled. Two experts in
                                                                                   the hospital have specialized in disk
                                                                                   surgery and thoracoscopy. They offer
                                                                                   workshops in which the participants
                                                                                   can learn the techniques step by
                                                                                   step. For example, an anterior lumbar
                                                                                   fusion is possible through four incisions;

                                                                                                                                Prof. Dr. med. Robert
                                                                                                                                Schönmayr, Dr.-Horst-
                                                                                                                                Schmidt-Kliniken GmbH,
                                                                                                                          2a    Hospital of the Provincial
                                                                                                                                Capital Wiesbaden,
                                                     Fig. 1:
                                                     The OPMI® Vario/NC 33
                                                     system was developed
                                                     exclusively for minimally
                                                     invasive surgery in the
                                                     spine area.

                                                                                                                                Figs 2a and 2b:
                                                                                                                                With its higher
                                                                                                                                magnification and more
                                                                                                                                powerful illumination,
                                                                                                                          2b    more anatomical details can
                                                                                                                                be discerned in the surgical
                                                                                                                                microscope (2a) than with
                                                                                                                                loupes (2b).

Innovation 10, Carl Zeiss, 2001                                                                                                                          13
F ro m U s e r s f o r U s e r s

Fig 3:                                                                                                             their space requirements in the OR re-
The ergonomic design of                                                                                            duced.
the surgical microscope
allows the surgeon to work
with the ultimate in
comfort, even over long                                                                                            What does “Minimally
                                                                                                                   Invasive” Mean?
                                                                                                                   Dr. Wolfgang Börm
                                                                                                                   Senior Physician at the
                                                                                                                   Bezirkskrankenhaus Günzburg,
                                                                                                                   Neurosurgery, Germany

                                                                                                                   Minimally invasive – this is a very
                                                                                                                   woolly term. Strictly speaking, only
                                                                                                                   the incision is minimal; a lot of things
                                                                                                                   also happen under it in minimally in-
                                                                                                                   vasive procedures. For the success of
                                                                                                                   the healing process it is not the
                                                                                                                   length of the surface incision that is
                                                                                                                   important, but the traumatization of
                                                                                                                   the tissue under it. On the basis of
                                                                                                                   the experience we have gained to
                                                                                                                   date, we shall not use purely endo-
                                                                                                                   scopic techniques in future either.
                                                                                                                   We prefer to operate with the visual
                                                                                                                   control of the microscope. This is not
                                                                                                                   as good in the two-dimensional en-
                                                                                                                   doscope image, and the aorta is very
                             the patients are hospitalized for only    Quo Vadis?                                  close.
                             two days, even if the stabilization       Prof. Dr. Robert Schönmayr
                             was performed over several verter-
                             brae. Hospital stays for anterior and     It is not a matter of endoscope versus      Preparation Under
                             posterior stabilization total only 11/2   microscope: what we want is a com-          the Microscope
                             days in some individual cases.            bination of the two technologies.           Dr. Hans-J. Meisel
                                 Every spine, with the exception of    However, as I see it, the transition to     Berufsgenossenschaftliche Kliniken,
                             those with severe scoliosis, can be a     the endoscope is a step backward. For       Bergmannstrost, Neurosurgery, Halle,
                             case for endosurgery. Thanks to the       surgeons like us who are accustomed         Germany
                             development of modern technology,         to using a surgical microscope, it is a
                             the physician will also be able to        major drawback that the three-dimen-        ’Biological repair’ must be our top
                             work in areas where there is no room      sionality is missing. The miniaturizati-    priority. What we have to do is pre-
                             for their hands. The major advantage      on of open surgery and the extension        pare osseous components in such a
                             of robots will be that they do not get    of percutaneous techniques have             way that bones can heal again and
                             tired. One example: via an incision       good prospects for the future. For the      no layers of degenerated cartilage
                             measuring only 3 cm, new artificial       patient, it is of great psychological im-   remain in the fusion zone. For this
                             intervertebral disks have already been    portance to have only a small incision;     purpose, a technique must be used
                             successfully implanted in six patients.   the more minimally invasive the proce-      which allows surgery via as small an
                             At the Cedars Sinai Hospital tradi-       dure, the better. In the USA hospital       incision as possible either by open
                             tional surgery is also performed in       stays after surgery are considerably        microsurgery using the microscope or
                             addition to these procedures using        shorter than, for example, in Germany       with the aid of an endoscope in or-
                             sophisticated, high-tech equipment.       due to the greater use of keyhole sur-      der to minimize traumatization and
                                                                       gery. Further improvements should be        muscle destruction. In this way, de-
                                                                       made to navigation aids, robotics, and      compression can be achieved in the
                                                                       miniaturization. The mobility of the in-    area of the spinal canal and the meas-
                                                                       struments must be enhanced and              ures required for stabilization imple-

14                                                                                                                               Innovation 10, Carl Zeiss, 2001
                                                                                              F ro m U s e r s f o r U s e r s

mented. This allows minimization of
what was seen as major surgery in
the past.

Today’s standard
of care

More and more people are now ex-
periencing back problems at an ear-
lier and earlier age. This is attributa-   optics, incredibly simple user guidan-                                Figs 4a and 4b:
ble to the increase in the number of       ce, flexible positioning and the im-                                  Ventral removal of cervical
                                                                                                                 disks (schematic).
sedentary jobs and to the fact that        pressive daylight quality illumination
too much leisure time is spent sitting     are all brought together in a very
in the car or in the armchair. Nowa-       compact, stylish design.
days, most of us have to cope with            Carl Zeiss‘ visualization solutions
increasing stress and less exercise.       have enabled surgeons to develop
Overweight in a rising percentage of       innovative, minimally invasive techni-
people in the Western world and in-        ques that have improved patient
creased life expectancy are further        outcomes and quality of life.
contributory factors. These are all
reasons why the number of spinal
procedures is expected to rise in futu-
re. According to information received
from leading neurosurgeons, these
procedures will jump by as much as
40% in the next 5 to 7 years. From
surgeons, patients are expecting a
higher quality of care with less pain,
and hospital administrators are under
increasing pressure to reduce patient
stays. The medical world is rising to
this challenge by the use of minimally
invasive methods. Surgical microsco-
pes are the ideal visualization tool for
this purpose.

Focus on results

The importance of minimally invasive
surgery on the spine is undisputed: it
reduces patient strain and shortens
recovery times. The use of microsur-
gical techniques reduced hospitaliza-
tion from 4.6 to 1.4 days and costs
by more than 50% (Quality Study of
the Cedars Sinai Medical Center).
   The OPMI® Vario/NC 33 system
was specially developed to meet the
needs of the spine market. The sym-
metrical configuration of the system
and its outstanding ease of use                                                     Fig. 5:
                                                                                    Removal of disk residue on
make it the ideal partner for the spi-                                              the lumbar spine
ne surgeon. Brilliant, apochromatic                                                 (schematic).

Innovation 10, Carl Zeiss, 2001                                                                                                          15

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