Achieving MISS on a Global Level

57 Achieving MISS on a Global Level

Roger Härtl, Franziska Anna Schmidt, Taylor Wong, and Sertac Kirnaz

“The future is already here—it’s just not very evenly distributed.”

(William Gibson, 1993)

Summary

This chapter provides a succinct overview of the history, global prevalence, challenges, and economic impacts of MISS. Authors illustrate the concept of “leapfrogging” over the older techniques directly into MISS with the use of 2D and 3D navigation along with robotic surgery. This leads to the main challenges of training and equipment. Centers that received temporary spinal surgery assistance though MISS saw a great benefit to their outcomes, even if the assistance was temporary due to the emergency. A novel MISS curriculum has been developed by the AO Spine as a representation of the framework for providing access to MISS education globally. The global future looks to the organized spine societies to capture the initiative of implementing MISS education.

Keywords: global MISS economic analysis future directions

57.1 Introduction

Minimally invasive spine surgery (MISS) has rapidly evolved over the past decades in Europe, North America, and parts of Asia. Key events in the evolution of MISS included Yasargil’s and Caspar’s introduction of microscopic discectomy in 1977,1^,² Böhler’s odontoid screw in 1981,³^,⁴ Magerl’s C1/2 transarticular screws⁵ and his description of thoracic and lumbar percutaneous skeletal fixation in 1984,⁶ computed tomography (CT)–guided navigation for pedicle screws in the early 2000s,⁷^,⁸ Foley’s minimal invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF),⁹ Pimenta’s transpsoas fusion,¹⁰ and more recently, the introduction of robotic surgery and augmented reality for pedicle screw placement.¹¹^,¹²^,¹³^,¹⁴ An important publication that laid a lot of the groundwork for spinal MISS and microsurgery was Paul Young and John McCulloch’s book Essentials of Spinal Microsurgery published in 1998.¹⁵ Improvements in endoscopic systems and percutaneous implants have increased the range of applications for MIS in spinal surgery.¹⁶ In addition, ongoing technological advancement in the field of MIS has led to improvements in surgical outcomes. The spectrum of MISS now includes the whole spectrum of spine, namely, spinal degenerative diseases, spinal trauma, spinal deformity, and spinal tumors.¹⁷

Promising current developments in MISS include the increased potential in outpatient surgery,¹⁸ “single stage–single position” lateral decompression and fusion surgery,¹⁹ three-dimensional printing technologies,²⁰ and MISS for metastatic and primary spinal tumors.²¹ The frontiers for MISS are multilevel instrumentation of the cervical spine,²² complex cervical and thoracolumbar deformity correction²³ as well as the potential for biological and tissue-engineered disc repair, regeneration, and replacement.²⁴^,²⁵^,²⁶

As outlined in Chapter 1, Fig. 1.2, a large portion—we estimate up to 75%—of spinal procedures could be performed completely or partially using MISS, illustrating the potentially huge impact on spinal surgery worldwide.

Some of the MISS related strengths, weaknesses, opportunities, and threats based on the opinions of MISS leaders from around the globe are summarized in Chapter 2 (Table 2.2). In this final chapter, we address three aspects of MISS that are relevant in order to understand its significance for the global landscape of spinal surgery:

a)MISS can be performed with relatively modest investment in surgical equipment and resources while still having a big impact on patients’ outcomes and overall costs savings.

b)Concept of leapfrogging; MISS accelerates the advancement of spinal surgery by skipping older techniques and “jumping” directly to advanced spinal procedures.

c)Economic impact of MISS on health care in health care systems worldwide.

Although some aspects of MISS require substantial investment by hospitals and/or surgical centers in infrastructure, equipment, and expensive implants, a lot of what MISS is about can be achieved with relatively inexpensive technology and techniques. This pertains especially to what has been covered under “Surgical Techniques” and “Training” in Chapter 1. A good example is the unilateral tubular or endoscopic laminotomy for bilateral decompression (ULBD); compared to open surgery this minimizes instability and avoids fusion surgery in a large proportion of patients²⁷ and therefore, it has a potentially big impact on cost reduction in spinal surgery. In addition, benefits like reduction of infection and blood loss as well as less postoperative pain and earlier return to normal activities with these surgical techniques provide big advantages for communities worldwide, especially in the settings with limited resources.

Good examples from personal experiences are places like Tanzania or Pakistan where surgeons are being trained in tubular surgery and can use this approach to perform lumbar decompression surgery effectively and with all above benefits including relatively low costs when compared to more traditional open surgery. This saves resources because less spinal instrumentation is needed. Although MISS avoids fusion surgery in patients who, if treated with open surgery, may need a stabilization, it allows for an expansion of the benefits of spinal stabilization to patient groups that were previously deemed too old or sick for traditional open fusion surgery. Together this can help retain elective patients who would have otherwise been sent elsewhere for expensive surgery abroad. In addition, this has a hugely positive impact on self-esteem and surgical growth in those countries.

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