Invited Review

Cost Efficiency of Minimally Invasive Spine Surgery

Isabel Malithuruthel

University of Illinois at Chicago Chicago, IL

Connor Willis-Hong, BS

University of North Carolina School of Medicine Chapel Hill, NC

Vivek Mohan, MD, FAAOS

Orthopedic Spine Institute Hinsdale, IL

Synopsis

Minimally invasive spine surgery (MISS), offers numerous advantages over traditional open procedures. This article provides a brief overview of MISS, focusing on its cost benefits for hospitals, patients, insurance companies, and the health care system overall. This paper also explores the current state of MISS, discussing the devices and techniques used in these procedures, including endoscopic and robotic techniques as well as expandable interbody fusion devices. Additionally, it delves into the new applications of MISS, draws attention to the current limitations, and outlines the foreseeable future of this evolving surgical approach.

Introduction

Over the last decade, there has been a considerable transition in the area of spinal surgery from standard open procedures to MISS. The traditional open technique may be associated with morbidity related to surgical exposure.1,2,3,4,41 The damage to the muscle and adjacent tissues may prolong recovery from the surgery. Surgeons recognized this limitation and began implementing procedures that would result in the least amount of tissue damage while efficiently treating spinal pathology.5,6,41 Attention to soft tissue disruption has resulted in a paradigm shift in the direction of MISS. Surgeons are using minimally invasive procedures for common conditions such as laminectomies for spinal stenosis,5,7,8,9 cervical or lumbar microdiscectomies,5,10,11,12,13,14 and pedicle screw fixation.5,15,16,17,18,19,20,21 MISS was initially limited to a few applications, but subsequent improvements have broadened its scope to include complex spinal diseases such as spinal trauma,6,22,23,24 intradural and extradural cancers,6,22,25,26,27,28 and spinal deformity correction.6,22,29,30,31 MISS has demonstrated advantages over open surgery in many studies. Reduced blood loss, lower infection rates, shorter hospital stays, decreased narcotic use, and reduced physiological stress on patients are just a few of the benefits.32,33,34 Importantly, the results and safety of MISS have been shown to be comparable to typical open surgeries. The purpose of this review is to describe the expanding amount of research supporting the benefits of MISS and how it can change the approach to spinal surgery.

Overview of MISS, Benefits, and Current State

The field of minimally invasive surgery began with the introduction of laparoscopic surgery in the early 1980s, with Karl Semm performing the first laparoscopic appendectomy in 1983.35,36 MISS has since evolved into a subset of surgical methods targeted at treating diverse spinal problems while causing as little disruption to surrounding tissues as possible. This method employs fewer incisions, specialized equipment, and enhanced viewing technologies.22,35 MISS adoption by hospitals can result in a variety of benefits, including increased market share. Patients are drawn to the appeal of minimally invasive procedures due to smaller scars, less blood loss, and faster recovery. The use of smaller incisions results in less scarring, which improves cosmetic outcomes with decreased pain from soft tissue disruption. Shorter hospital stays and less postoperative pain, are other benefits of MISS, as compared to standard open procedures. As a result, MISS centers are profitable for hospitals and health systems.35 MISS may also decrease cost. Minimally invasive procedures may result in lower hospitalization expenses, quicker recovery times, and fewer postoperative problems. Studies have found that for procedures such as lumbar stenosis and transforaminal lumbar interbody fusion (TLIF), hospitalization costs are lower when performed using the minimally invasive method. The median cost for open laminectomy for lumbar stenosis is $7,305 compared to $4,518 for the minimally invasive approach. For TLIF patients, indirect savings from using a tubular approach ranged from $3,569 to $9,295 per patient, while direct benefits ranged from $1,758 to $2,820 per patient.37,38 In a study comparing open vs MIS TLIF, a 3.4% decrease in the rate of postoperative infections was noted in MIS vs open patients.38,39 This decrease in cost and decrease in infection rates directly benefit patients and the system as a whole. Insurance companies, including Medicare, are reluctant to pay for prolonged hospitalizations or complications after elective surgeries. MISS continues to develop. To improve patient outcomes, surgeons are constantly refining and expanding the discipline, adding percutaneous screw placement and enhanced imaging guidance. Furthermore, the incorporation of regenerative medicine approaches and tailored treatment plans hold great potential for additional breakthroughs and better patient care.

Devices and Techniques

MISS employs a variety of instruments and techniques to produce optimal results while creating minimal tissue disruption. Interbody fusion devices, such as uniplanar and biplanar expandable interbody fusion devices, add an important dimension to MISS.40 These modified devices are used in procedures to restore disc height and segmental lordosis while lowering the risk of cage subsidence.42 In comparison of minimally invasive transforaminal lumbar interbody fusion (MITLIF) to open transforaminal lumbar interbody fusion (OTLIF), MITLIF has resulted in lower blood loss. MITLIF’s mean blood loss of 247.83ml versus TLIF’s mean blood loss of 568.18ml.34 Furthermore, anterior lumbar interbody fusion (ALIF), a commonly utilized MISS procedure, consisting of an anterior approach to the lumbar spine, guided by the da Vinci robotic surgical system has been performed, forging a path for novel techniques.35 Endoscopically-assisted spinal surgery is another key technique in MISS. Endoscopy is a minimally invasive procedure that enables for visualization and access using small specialized instruments. Many discectomies are being performed endoscopically now with significant benefits and earlier discharge as well as technical and medical benefits specifically in treatment of obese patients. This approach is routinely used to treat a variety of spinal diseases, allowing surgeons to execute procedures with smaller incisions and less tissue damage.22 Another crucial treatment in MISS is pedicle screw placement. Accurate placement of pedicle screws is critical for success, and guided procedures improve both safety and precision.21,44,45 To increase precision and lower the risk of neurovascular injury, navigated screw placement employs modern imaging technology and real-time guidance. MISS has trended away from standard fluoroscopy and toward the use of CT registration for navigation. CT registration improves imaging model accuracy, allowing surgeons to rely less on fluoroscopy during surgeries.6 This technology improves visualization and precision, while lowering radiation exposure by over 90% for both surgeons and patients.6 Devices and techniques such as interbody fusion devices, MITLIF, the da Vinci for ALIF, endoscopic spinal surgery, and CT navigation may have a higher upfront cost, but it benefits the system by lowering costs in the long run. Not only do they potentially reduce costs for the patient, but they have been shown to improve patient outcomes by lowering blood loss and decreasing the risk of post-operative complications. Overall, MISS technologies and approaches are evolving to achieve better patient outcomes while reducing tissue damage and promoting quicker healing. MISS's future is being shaped by the integration of advanced devices and procedures, as well as navigation and endoscopic support, paving the path for more accurate and effective spinal interventions.

Figure 1. Incision lengths for a one-level minimally invasive TLIF, about 3-4 cm.

Figure 2. Intra-operative X-ray with C-arm, showing tubal retractor. Sizes of retractors vary from 12mm through 22mm in diameter.

Figure 3. Preoperative Lumbar X-rays showing an L5-S1 spondylolysis and spondylolisthesis. Minimal lordosis noted at the L5 S1 disc level.

Figure 4. Three month postoperative Lumbar X-rays showing a minimally invasive lumbar interbody fusion with bilateral facetectomies and TLIF cages performed outpatient. L5-S1 lordosis is improved with restoration of sagittal alignment and reduction of anterolisthesis.

New Applications, Current Limitations, and Future Direction

MISS has expanded beyond its initial applications and is now utilized for tumor resection and spine reconstruction, spinal deformity correction, and spinal fusions.5 The ability to perform these minimally invasively procedures provides significant benefits to patients, but come with limitations in regards to its adoption. The adoption of MISS is influenced by risk-based pressures, cost of new equipment and training, as well as the emphasis on patient outcomes. Hospitals are increasingly evaluating the cost-effectiveness of new technologies and their impact on patient recovery. In the dynamic health care landscape, where cost containment initiatives are prioritized, hospitals are scrutinizing new technologies like MISS more critically.35,47 This scrutiny may lead to evolving competency standards and training requirements for surgeons performing minimally invasive and robotic surgeries. To ensure patient safety and achieve optimal outcomes, training and certification programs have been established for laparoscopic and robotic surgeons. The Foundation for Laparoscopic Skills (FLS) certification exemplifies the current training standards.35 It is foreseeable that future certification may be required for physicians seeking to perform robotic or endoscopic spine surgery, reflecting the ongoing advancements in MISS and the need to maintain high standards of competence and safety. Integration of MISS training mechanisms into standard neurosurgical and orthopedic training programs can facilitate wider adoption. Advances in navigation systems, intraoperative imaging, robotics, and artificial intelligence will continue to shape the future of MISS.

Conclusion

In conclusion, minimally invasive spine surgery has prompted a fundamental change in the field of spine surgery, providing numerous advantages over traditional open procedures. MISS now comprises a wide range of approaches, tools, and procedures, and its future looks promising with the incorporation of new equipment and technologies. However, in order to reach widespread adoption, financial considerations and high standards of competence must be addressed. As research and technology advance, MISS will play an increasingly important role in improving the quality of life for individuals suffering from spinal problems, altering the approach to spine surgery.

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Author Disclosures

I Malithuruthel: Nothing to disclose

C Willis-Hong: Nothing to disclose

V Mohan: Consulting: Carelon (B), Innosys (Future Compensation Expected), Sanara Medical Technologies (B); Royalties: SeaSpine (B); Speaking and/or Teaching Arrangements: Baxter (B).

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