2 Global MISS: Perspectives from Asia, Australia, Europe, Middle East, North America, and South America

Summary

Over the past decade, minimally invasive spine surgery (MISS) has gained rapid popularity around the world. With available technologies, MISS can now be performed using advanced surgical tools and background knowledge to treat a myriad of spinal pathologies, including lumbar disc herniation, spinal stenosis, and use in fusion surgery.1^,2,3

Surveying the current state of MISS in the Asian region, we can roughly divide its application into five categories: (1) microendoscopic discectomy (MED); (2) full-endoscopic lumbar discectomy (FELD); (3) percutaneous endoscopic lumbar discectomy (PELD); (4) MISS fusion (transforaminal/lateral/oblique-lumbar interbody fusion [TLIF/LLIF/OLIF]), with or without navigation (i.e., O-arm); and (5) miscellaneous percutaneous procedures such as percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP), etc.

The technique for percutaneous arthroscopic nucleotomy through a posterolateral approach was introduced by Kambin in 1973⁴ and Hijikata et al in 1975.⁵ The first documented microdiscectomy procedures were reported by Yasargil⁶ and Caspar⁷ in 1977. The MED technique was later developed in 1999 by Foley et al.⁸ Since 2002, Foley’s introduction of MISS fusion has shown significant progress and has been widely used for the treatment of lumbar degenerative disease.⁹ The minimally invasive LLIF technique was first described by Ozgur et al in 2006.¹⁰ The minimally invasive retroperitoneal lumbar approach was then introduced by M. Mayer in 1997, but the term OLIF was coined in 2012.¹¹ Image-guidance techniques in spinal surgery procedures have been implemented since 1995.¹² In addition, PVP was performed initially in 1984 by Galibert et al¹³ and PKP was then developed in the mid-1990s by Garfin et al.¹⁴

Several factors that characterize the region-specific strengths, weaknesses, opportunities, and threats can be identified.

2.1.1 Strengths

The development of MISS in Asia is mainly concentrated in East Asia and India. Since 2000, five countries in Asia have published the largest number of articles in the field of MISS each year.¹⁵ Academic activities such as conferences and courses are also the most active in this geographic region. Table 2.1 summarizes the timeline of development of MISS techniques in the top five Asian countries.

Table 2.1 MISS development timeline in the top five Asian countries

The strong support of MISS associations also played an important role in the growth of MISS in Asia. As early as 2002, South Korea established a MISS association, named Korean Minimally Invasive Spine Surgery Society (KOMISS), to promote and develop the MISS field led by C. K. Park. In 2003, the COA-CMISS and CSSA-CMISS were established in China. Subsequently, Japanese Society of Minimally Invasive Spine Surgery (JASMISS), Taiwan Society of Minimally Invasive Spine Surgery (TSMISS), and Minimally Invasive Spine Surgeons of India (MISSICON) also established their respective MISS associations. These societies have made significant contributions to the development of MISS in the Asian countries.

Of the major countries in Asia, the role of South Korea in MISS was most prominent and most of the minimally invasive surgeries were first performed in South Korea (PVP by C. K. Park in 1999, PELD by S. H. Lee in 2002, DLIF/OLIF by J. S. Kim).

The accelerated development of MISS in Asia may be, in part, due to cultural factors and the reluctance of many Asians, especially East Asians, to accept major surgery. Today, endoscopic spinal surgery in Asia has become one of the mainstream approaches to spine surgery unlike in the United States or Europe. This is reflected by the establishment of International Society of Endoscopic Spine Surgery (ISESS) in 2017 for the advancement of endoscopic surgical techniques in spine and the overall development of global MISS. The contributions of ISESS have propelled Asia’s position in the field of endoscopic spinal surgery.

As technology continues to advance and the indications for surgery expand over the years, we have found that endoscopic spinal surgery can not only be used to treat the simple disc herniation but also effectively address lumbar stenosis.2^,16,17 Moreover, there have been a few reports on endoscopy-assisted interbody fusion procedure³ and other applications of endoscopic spine surgery, such as unilateral biportal endoscopic (UBE) technique, which is considered endoscopic-assisted rather than full endoscopic spine surgery.^18,19,20

The improvements in surgical techniques, technologies, and instruments, along with the cultural differences in Asia, have allowed MISS to gain popularity over traditional spinal surgeries in Asia.

2.1.4 Threats

The focus on endoscopic surgery has led to a slower development in other areas of MISS in this region, as seen in Table 2.1. Although percutaneous technologies were described as early as the early 1990s, other very well accepted MISS procedures and technologies such as fusion and navigation were published later, when compared to other regions. This may be a challenge going forward.

References

[1]Ruetten S, Komp M, Merk H, Godolias G, Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine, 2008; 33(9):931–939

[2]Komp M, Hahn P, Oezdemir S, et al. Bilateral spinal decompression of lumbar central stenosis with the full-endoscopic interlaminar versus microsurgical laminotomy technique: a prospective, randomized, controlled study. Pain Physician, 2015; 18(1):61–70

[3]Youn MS, Shin JK, Goh TS, Lee JS, Full endoscopic lumbar interbody fusion (FELIF): technical note. Eur Spine J, 2018; 27(8):1949–1955

[4]Kambin P, ed. Arthroscopic Microdiscectomy: Minimal Intervention Spinal Surgery. Baltimore, MD: Urban & Schwarzenberg; 1990

[5]Hijikata S, Yamagishi M, Nakayama T, Oomori K, Percutaneous discectomy: a new treatment method for lumbar disc herniation. J Toden Hosp, 1975; 5:5–13

[6]Yasargil MG, Microsurgical operations of herniated lumbar disc. Adv Neurosurg, 1977; 4:81–82

[7]Caspar W, A new surgical procedure for lumbar disc herniation causing less tissue damage through a microsurgical approach. Adv Neurosurgs, 1977; 4:74–80

[8]Foley KT, Smith MM, Rampersaud YR, Microendoscopic approach to far-lateral lumbar disc herniation. Neurosurg Focus, 1999; 7(5):e5

[9]Foley KT, Holly LT, Schwender JD, Minimally invasive lumbar fusion. Spine, 2003; 28(15) Suppl:S26–S35

[10]Ozgur BM, Aryan HE, Pimenta L, Taylor WR, Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J, 2006; 6(4):435–443

[11]Silvestre C, Mac-Thiong J-M, Hilmi R, Roussouly P, Complications and morbidities of mini-open anterior retroperitoneal lumbar interbody fusion: oblique lumbar interbody fusion in 179 patients Asian Spine J, 2012; 6(2):89–97

[12]Amiot LP, Labelle H, DeGuise JA, Sati M, Brodeur P, Rivard CH, Computer-assisted pedicle screw fixation. A feasibility study. Spine, 1995; 20(10):1208–1212

[13]Galibert P, Deramond H, Rosat P, Le Gars D, [Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty] Neurochirurgie, 1987; 33(2):166–168

[14]Garfin SR, Yuan HA, Reiley MA, New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine, 2001; 26(14):1511–1515

[15]Fan G, Han R, Zhang H, He S, Chen Z, Worldwide research productivity in the field of minimally invasive spine surgery: a 20-year survey of publication activities. Spine, 2017; 42(22):1717–1722

[16]Ruetten S, Komp M, Merk H, Godolias G, Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique: a prospective, randomized, controlled study. J Neurosurg Spine, 2009; 10(5):476–485

[17]Komp M, Hahn P, Merk H, Godolias G, Ruetten S, Bilateral operation of lumbar degenerative central spinal stenosis in full-endoscopic interlaminar technique with unilateral approach: prospective 2-year results of 74 patients. J Spinal Disord Tech, 2011; 24(5):281–287

[18]He EX, Guo J, Ling QJ, Yin ZX, Wang Y, Li M, Application of a narrow-surface cage in full endoscopic minimally invasive transforaminal lumbar interbody fusion. Int J Surg, 2017; 42:83–89

[19]Hwa Eum J, Hwa Heo D, Son SK, Park CK, Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results. J Neurosurg Spine, 2016; 24(4):602–607

[20]Heo DH, Son SK, Eum JH, Park CK, Fully endoscopic lumbar interbody fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results. Neurosurg Focus, 2017; 43(2):E8

2.2 Australia

Tony Goldschlager

Like most of the world, spine surgery in Australasia is performed by both orthopaedic surgeons and neurosurgeons. The training, however, is managed and regulated by a central body, the Royal Australasian College of Surgeons (RACS). This body is responsible for resident placements, which are rotated among accredited hospitals to provide trainees with a breadth of experience. This means that exposure to MISS during residency is dependent on the supervising surgeons encountered on these rotations, which is generally limited to a duration of no more than 2 years in a given hospital. It is fair to say that in Australasia MISS is generally a skill developed during post-fellowship training; however, this is changing.

The health care system in Australia is divided between the public and the private sector and this provides specific opportunities. Teaching and training typically occur in the public sector, which is generally of high standard but less efficient than the private sector. High-volume, single-surgeon surgery is performed in the private sector, which enables outcome research on specific MISS techniques. This is reflected in the Australasian MISS publications. A search of PubMed on “minimally invasive spine surgery” and “Australia” since 2010 has revealed 62 publications. Many of these publications are single-surgeon consecutive series, while some are descriptions of new techniques.

It is difficult to know the true extent of MISS is Australasia but it certainly appears to be increasing. We recently conducted a survey of Australasian neurosurgeons on their practice of microdiscectomy. This survey sheds some light on current Australasian neurosurgical practice. The majority of responders use microscopic (76.5%) or loupe (20.6%) magnification, but 2.9% use no magnification. The majority of surgeons (77%) perform unilateral muscle dissection; 21% use tubular retractors but almost 3% utilize a bilateral muscle dissection exposure.1 There is a significant number of neurosurgeons who perform “simple spine surgery” only, such as microdiscectomy and laminectomy. These surgeons typically do not perform instrumented operations. For those that do, navigation and robotic technologies are being acquired and utilized by an increasing number of Australasian hospitals. Surgeons are tending to adopt MISS techniques and technologies. However, the challenges are that comparatively, the Australasian market is small and a separate regulatory pathway, through the Therapeutic Goods Administration (TGA), exists. This means that Australasian spine surgeons have lesser and later exposure to new technologies.

In summary, MISS in Australasia is increasing. Many Australasian spine surgeons undertake fellowships overseas where new skills and linkages are developed. The Australasian health landscape provides unique opportunities to develop and study MISS technology and techniques.

2.2.1 Strengths

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