Micro-spine-surgery and MISS Who really does this?

[mikaNatalee]

Cassie, I wish you the best of luck in your quest x

 

[xaytmy]

There must be a way, hopefully you will find it

 

[Kool Shelby]

Hi friends.

Here are just a few fact based and researchable points to help with the confusion surounding competing spine surgery procedures. Whilst every one has veiws, a few things are absolutely clear and rooted in the truth.

With regards to the phrase Minimally Invasive Spine Surgery (MISS), it is important to understand the facts of true MISS, and the major problems with the ‘inappropriate way’ that the phrase is being used by Surgeons in the UK and around the world!

Because the phrase MISS has 'not been patented' to describe the most minimally destructive, least damaging, safest approach, leaving the patient with, maximum mobility, the best clinical outcome possible, with next to no collateral damage and using endoscopic visualization and possibly laser bloodless cuts, it has been 'hijacked' by Spine Surgeons around the world, irrespective of the actual techniques that they perform. I even came across a Surgeon advertising ‘minimally invasive intervertibral instrumented fusion’. Outrages!!

I recently had a consultation with 2 Neuro/Spine Surgeons who described ‘NHS open back ‘decompression’ spine surgery’ as MISS, even though their procedure, sometimes also called ‘microdiscectomy’, is actually ‘the same’ as ‘standard NHS open back surgery’ apart from a smaller incision (a min of 2” instead of 4”) and the use of muscle spreading retractors. These retractors stretch and tear muscles, nerves and ligaments, and cause as much damage as open back procedures.

Evidence of its ‘poor reputation’ came when these Surgeons told me that they ‘would not operate’ on me, because as I was relatively young (52) and fit, they believed that the clinical outcome for me ‘would be poor’.
If I were older and less fit, they ‘would’ be prepared to operate!
So ask yourselves, if the young fit person who is capable of tolerating the trauma of the procedure, would 'not' have a good outcome, how the hell would an older, sicker and less fit person benefit from this procedure? The answer of course is,they usually don’t, and re-operations are common place amongst this patient group.

So, why do these 'Surgeons' make these outrages and unfounded claims for their standard procedures? Well, I believe, that they have noticed the 'winds of change' blowing in from the US. The Medical Insurance Companies (like Medicare) have realised (at long last)
that patients who undergo 'standard' decompression, disc surgery and fusions were re-aplying for financial cover time and time again, and often without clear long term benefits. This of course lowers those companies profits. Because of the recent economic conditions they are now having to seriously consider either:
1) increasing the cost of customer subscriptions (unpopular & difficult).
2) find more cost effective treatments which reduce thier long term
exposure to repeated claims.
They have begun to decide to on (2), and as part of this, MISS has become more finacially atractive to insurers and patients alike, as time goes on, as these MISS procedure prove themelves more & more, it is the
insurance comopanies who will slowly, but surely, break down the stiff resistance of the medical establishment.

What the US do now, the UK will follow, and I believe that UK Surgeons are responding to this change, not by 're-training' in MISS, but by 're-branding' existing and standard spinal procedures as MISS instead. They will have to change in the future though, as the number of MISS clinics in the US, have increased 'dramatically' over the last 5 years, and profitable opportunities for American Surgeons to fill MISS gap in the UK, could spell the end of British Spine Units as we know them.

So dear fellow sufferers, before agreeing to Surgery described as MISS, demand that your Surgeon explain (in great detail) how he/she does the procedure, the initial incision size, the amount of muscle stripping/cutting, how do they cut a hole/window in the vertebrae, and do they use endoscope? and so on! If you get this detailed information out of them you, are doing well!!
but you do need this info, only then can you make an informed choice!!

----------------------------
As well as the Surgeons (ABOVE) who perform open back surgery and mis-describe their procedures as MISS, you must also be aware that there are important differences between Surgeons who do ‘genuinely’ offer, what could reasonably be called, MISS.

For example;

Some use a laser & powered reamers for cutting and trimming bones and discs, others might use just reamers.

Some use endoscopes for looking in to the spinal canal, and some use fluoroscopes ‘or’ 3D computer aided visualization.

Some will use a laminectomy technique (cutting a hole in a, possibly healthy, vertebrae) as a way of accessing the spinal canal, whilst others will go through the foraminal opening, a naturally occurring hole in the vertebrae.

Some will utilize only 1 incision/hole to work though. Others use 2 holes, 1 for the endoscope and 1 for the cutting tools. Sometimes these 2 incisions/holes are on opposing sides of the spinal column.

The bottom line is, you have to do your ‘home work’ on the MISS procedures & Surgeons available to you if you want to be sure of receiving the ‘most minimal’ of available procedures. Otherwise, you may just wander ‘blindly’ in to a world of long term pain & suffering, after ineffective and repeated back operations!


See below for links to articles on different types of MISS clinics, locations, Surgeons, videos & procedural information!
(Cut & paste for direct access to MISS info)

www.zerospinepain.com

http://my.clevelandclinic.org/services/minimally_invasive_spine_surgery/sp_overview.aspx

http://www.spineuniverse.com/treatments/surgery/minimally-invasive-spine-surgery-information

http://www.spineuniverse.com/treatments/minimally-invasive-endoscopic-spinal-surgery

http://www.uchospitals.edu/specialties/minisurgery

http://health.ucsd.edu/specialties/miss

http://www.spinal-foundation.org

http://www.doctorbuzz.com/Procedures_java.htm

http://www.bonati.com

http://www.ehow.co.uk/facts_5915333_laser-spine-surgery-effective_.html

--------------------------

I have tried to look for evidence which would support the reason for carrying out ‘open back’ and ‘microdiscectomy’ in the NHS, but this is what NICE say!

“Date notified to NICE:
18 June 2003
Topic area: Microdiscectomy:
Established procedure - Procedures do not fall within the Programme's remit if they are considered standard clinical practice with an efficacy and safety profile that is sufficiently well known.”


However, when I demanded to see these ‘sufficiently well known’ safety and efficacy rates, 4 of the biggest spinal units in the UK said, that they do not make, record or keep any such information on this procedure. So, the question is, where is the evidence that allows these spine units to continue with these ‘most destructive’ of spinal operations????

This link (BELOW), shows how NICE’s special advisors reported on Endoscopic Laser Foraminoplasty (ELF)

http://www.nice.org.uk/nicemedia/live/11028/30622/30622.pdf


This link (below) shows how they reported on Intradiscal Electrothermal therapy (IDET)

http://www.nice.org.uk/nicemedia/live/11055/46396/46396.pdf


Please see the section (2.5 other comments) (IDET) at bottom of this report (below) and read what the specialist advisors say about the effectiveness of this procedure.

http://www.nice.org.uk/guidance/index.jsp?action=article&o=43964


What relevance do these articles have in relation to my point, I hear you ask?

Well, if you read these guidelines and reports, you will see, thatwhilst the introduction of minimally invasive (ELF), as pioneered by Mr. Martin Knight, has been, and still is being ‘actively resisted’ by the medical establishment, (IDET) (a process of ‘cooking’ a patients disc until ‘dry’) has been embraced and carried out by at least 3 of my local Surgeons and many more around the UK!! NICE reports (IDET) as having less efficacy evidence to support its use than (ELF), in spite of having (apparently) more trials done on this procedure. WHY!!

It would seem to me that ‘which’ MISS procedures gets introduced in to every day medical use for the benefit of back pain sufferers, depends on what a Surgeon whim or on his/her ability, NOT on what is ‘thee’ most minimally invasive, safest and effective treatments available for our conditions!!


I hope this helps.



All the very best, my fellow back pain sufferers

SPINELF

 

[The 4th Manimal]

Huh, you said so much in just one post, so where to start...




Yes - there CAN BE minimally-invasive instrumentation and fusion.
Instrumentation and fusion causes a lot of tissue, muscle and disc damage, that is why they invented technology that can achieve all this without additional damage.

Yes - there CAN BE minimally-invasive tubular retractor assisted discectomy, decompression or foraminotomy.

DO NOT compare endoscopic and laser surgery with minimally-invasive surgery. There are many types of minimimally-invasive spinal surgery.

Do not disconcert the patients.



Do not call them surgeons who perform open back surgery. This is not true. As mentioned above, there are few types of minimally-invasive spinal surgery, and few techniques to achieve it.



Fluoroscope is integral part of all MISS and LISS procedures. For laser, endoscopic and micro-endoscopic spine surgery.


In almost all endoscopic cases, this has nothing to do with "some" surgeons. For disc herniation patients, type of surgery (interlaminar or tranforaminal) depend on herniation type and in some cases it depends on diseases level (L5-S1 cannot always be access in transforaminal way).

Please try no to misinform the patients. And let me conclude.

There are several ways of doing minimally-invasive spinal surgery. It would be good to divide MISS into:
-minimally-invasive spinal surgery (laser, endoscopic, percutaneous)
-less-invasive spinal surgery (some advanced surgeries done in minimally-invasive manner - for example stabilization, fixation, fusion, discectomy with tubular retractor, etc.)

Regards

 

[BIEBERLOVER]

I know you are passionate about informing people about MISS Keano, and thats good, but I can't help thinking you have missed the point of another post Keano.

I find some of your arguements confusing and contradictory, and I have to respond to a couple of them, as I am sure you have mis-informed menmbers.

Fusion is not, and never should be considered 'minimally invasive', because it totally restricts the bodies natural movement and usually requires a 2nd, 3rd and even 4th repeat procedures as it fundamentally
destroys the bodies physiology.

The use of any expanding retractors (as opposed to the tubular canulars in MISS) can and often does cause severe ripping, taring and general squashing damage to patients bodies. Not very minimal I say!

A Surgeon is a Surgeon irrespective of his technique or specialty. The point of my post was to warn people about 'assuming' that they all offer MISS, and also to 'empower them' to take the responsibility for research into their own hands, Not to disconcert them Keano.

Endoscopic visualisation of the area being operated on, is a 'feature' of minimally invasive spine surgery, because the images are taken from within the spinal cavity, mm's away from the disc or bone, and in full colour.
Flouroscopic and binocular images are taken from outside the body cavity, an external visualisation that is some times more than 12 inches away from the working area, and in the case of flouroscopes, images are in black and white!

I could go on Keano, but that would just confuse members more.

The reality is clear, the word 'minimal' means:

the least possible:
such as, the least posible damage to tissue, muscle and bone.
the lowest size:
such as, the lowest size of initial incision, MISS, less than half an inch.
the lowest quantity:
such as, the lowest quantity of operating time 'or' lossed blood.
the smallest amount:
such as, the smallest amount of aneasthetic 'or' recovery time.

If a potential patient is not offered 'this' it is not 'minimally invasive'.


All I am trying to say is, because Surgeons around the world are trying to 'appear' to be offering cutting edge, key hole, MINIMALLY INVASIVE spine surgery, are muddying the factual waters regarding procedures, and are mis-representing their procedures to back pain sufferers, we should all be vigillant and demand detailed information from our Surgeons to prove that what they acctually offer is MISS.

I hope this helps people.

SPINELF

 

[Amanda Moore]

Fusion is the last resort for patients with spondylolisthesis, FBSS (failed back surgery syndrome) and last stages of degenerative disc disease, etc. It is "invasive" surgery, and it can be done in completely minimally-invasive manner. Your state that it usually requires few procedures DO NOT STAND. Especially for patients with one-level fusion.


Not sure what are you talking about. I am always talking about MISS and LISS, and that includes ONLY tubular retractors. Never expanding retractors. One example of this retractor is METRx (minimum-exposure tubular retractor). I have attended few surgeries which utilized this technology and I can confirm this is pure state of the art minimally-invasive system. Expanding retractors are used in micro-spine surgery and that is considered as traditional open spine surgery.



This all stand, but why do repeat things that people can find just by writing all this terms in Google?

I am repeating, in your previous post you mentioned this:


Surgeons who use endoscope as working tool, ALWAYS use fluoroscope as navigation tool. You just fail to understand and you fail to listen to someone who know more.



Yes, I am witness of this. However, this is very rare situation. This is why I am working on several educational programs to help spine patients in deciding what is good and what is bad for them (considering their diagnosis).

 

[TomeMoinnet]

I am afraid I have to disagree with many of you points Keano, and I also think you are getting tied up with the technical side of the procedures, rather than the difference it offers patients.

MISS is, as I say, means the least invasive and destructive 'of all possible' spinal surgical procedures, the clue is in the name.
LISS, means simply, that these procedures are less invasive and destructive than the worst possible surgical options.

Theres a big difference!

I am having to repeat myself because you are confusing the issues like the point that of visualisation and navigation, get a grip!

SPINELF

 

[mogar]

Whats the point of writing when you just fail to understand. Message for other members: read my previous posts, you'll find some useful and correct information about minimally-invasive spinal surgery...

 

[Kkeucwrspubyc]

Looks like you'll need to agree to differ folks. Please remember to 'play nice'.

Thanks
Moonfairy
HPmods

 

[GenderS]

Hi guys

So would for instance MK use a flouroscope to see where to place the endoscope in the body, (the angle depth etc) then use the camera inside the endoscope for the actual surgery?
I think the NHS use just a flouroscope if anything then open/stretch the back wide enough to see and still call it MISS!

 

[blackoutparty111]

Yes.

For traditional surgery they don't use fluroscope, in most cases.

 

[peaceandlove<3]

I finally got to see the orthopaedic surgeon my GP referred me to (nearly 3 months ago now) and what a let down it was ! The appointment was 90 minutes late then and all I got was 10 mins of their time . Even worse, it wasn't the surgeon who saw me, but one of his assistants or juniors

Anyway, they've recommended a discectomy and wallis ligament (some kind of synthetic spacer designed to stabilise the spine). The operation is around an hour long they said, but I'd have to stay in hospital for 3-4 days. They also gave me a list of risks and complications. These included among others a 5% chance of dura tear and a 5% chance of a recurring disc herniation. Those look like very big numbers to me, much bigger than those quoted by MISS practitioners. So I wasn't impressed at all by the NHS, not by their surgery, nor their treatment of patients.

 

[Mihara]

{{{{{{{{{{{{{{{Jim}}}}}}}}}}}}} I am so sorry, I know you were hoping for so much more, and you deserve so much more too.

I am sure you will have searched and found this article but it may be intersting to hear other's views on it? http://www.spinalsurgerynews.com/articles.php?key1=4&key2=1

 

[jennababe_68]

Dural tear is usually not dangerous and will not cause permanent damage.

Biggest problem is FBSS (failed back surgery syndrome). With traditional surgery, it occurs in 20-40% of patients (depending on study). FBSS includes post-laminectomy syndrome, reherniation, adhesions, fibrosis, scar tissue, etc.

 

[canaan90]

Thanks Cassie. I had a look at that article and it says the wallis ligament is only used at levels down to L4/L5, but contraindicated for L5/S1 (where my disc compression is). If that's true, then why have the NHS recommended it for me? Actually, it doesn't surprise me. At first they said surgery wouldn't help me, then after disappearing into a different room to look at my MRI on screen, the consultant came back and changed his mind "actually your prolapsed disc is big enough to warrant surgery". That really inspires confidence, huh ?

Anyway, although I'm disappointed with the NHS, I'm not downhearted. It's actually reassured me that MISS is the way to go.

 

[anewskcb]

Will your possible MISS surgery be covered by your insurance company?

 

[Mohammadreza]

Sadly I don't have insurance, Keano. So I'll have to find the money myself. But if I get my life back, it'll be the best 10k I've ever spent.

 

[snipe4lyf]

What Mr. Knight told me was, that he used the flouruoscope to track the insertion of the initial thin wire, that created the route from the initial incision (2 inch right of the mid line) down to the foraminal opening.
Once he had passed the the increasingly larger canulars/tubes to make the 7.5 mm working hole, and had passed the micro endoscope down the hole,he said he no longer needed the flouroscope.

Hope that helps


SPINELF

 

[murry43]

Yes Elfy, that does, now if only we could somehow persuade the nhs to take up MISS preferably with MK.....other methods seem so barbaric!

 

[nhfhdgoj]

Hallaluya sister! Lets man the baracades!!