199- All About Minimally Invasive Surgery

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are talking about minimally invasive spine surgery. Hopefully something everybody listening to this never has to go through. But there is unquestionably patients that will walk into your practice having previous work done to their spine. So we're gonna talk a little bit about minimally invasive, counterbalance it against traditional surgery. What are the differences? What does the research say? And we'll mix in a little bit of the surgical techniques as well to make sure that you feel comfortable and confident. And as you have those conversations with your patients, before we get started, I will say a few words about Rock Tape. Roc Tape has revolutionized the soft tissue world again with Rock Blade's Mohawk. It's my favorite tool. I was dming with the lifting doc. It's his favorite tool. If you're doing soft tissue work and you have not checked out Mohawk, be sure to do so. It's 175 bucks. It comes with all the attachments and the case. You can check it out@rocktape.com Mohawk and additionally at that web address, you'll be able to find all of the educational courses which are happening all over the place to show you how to use Mohawk to its maximum benefit. But as we said at the top, today we are talking all about minimally invasive spine surgery and the differences between traditional and minimally invasive, which gets very blurred, by the way, as well as some techniques and some research as well. So super important for you to be aware of minimally invasive techniques. Ten years ago, it was considered by and large experimental. Nobody was doing it. Now you probably can't drive down the highway or drive anywhere on your way to practice without seeing a billboard with some spine surgeon touting minimally invasive spine surgery. So that's where we start with things. It is a catchphrase. I used to work in a outpatient surgery group that specialized in minimally invasive surgery. And we'd have patients call in, let's say that lives far away. They'd say, why should I come to see you? My local surgeon does minimally invasive. We wouldn't say this to the patient, but internally it would be, well, they used to do a 12 inch incision, your surgeon. Now they're doing a 10 inch incision and they're considering that minimally invasive, which is obviously laughable. But a lot of docs out there and a lot of practices be warned, a lot of practices are using this as a marketing term. True, minimally invasive surgery is not necessarily about the size of the incision, but I can tell you that by and large, that should be two inches or less. Again, it depends on the procedure. It depends on if it's outpatient or inpatient. But minimally invasive surgery, as we'll talk about, the hallmarks of it are our maximum preservation of the structure and function of the spine. You want to maintain the musculature, you don't want to have to rip and tear through the erectors, rip and tear through multifidus to get down there. And if you have a 10 inch incision, well, you're using calipers to get in, and you're definitely doing that right. So a 2 inch, 3 inch or less incision is usually a hallmark of minimally invasive. But by and large, it is that maximum preservation of the structure and function of the spine that is so, so important and why it matters to us as chiropractors. Minimal disruption to the musculature, those deep stabilizing muscles, I mean, even the best person who sutures on their way out, so to speak, all of those muscles still heal with scar tissue. When you're taking stuff out of the body, right? Disc material, when you're taking out ligament, when you're taking out bone, ultimately something's gotta fill that space. It's either scar tissue or it is fluid collection, which is very, very common. Minimally invasive surgery. Another advantage is it can be done outpatient. So minimally invasive surgery, outpatient, it depends on the state. But outpatient's a little gray too. But outpatient usually means less than 24 hours in a facility. So day surgery, in other words, you're not staying overnight. And because you're not staying overnight in the hospital, because the incision size is less, because the procedure time is less, this equates to less complications, a quicker recovery, and less scar tissue formation, which is pretty obvious, right? You make a huge incision, you use calipers to pull everything to the side so the doctor can directly visualize what's going on. Well, of course, of course that increases the damage to the surrounding tissues. And anytime that you increase the damage to the musculature, the fascia, the skin, et cetera, this is where recovery time starts to become a challenge. Post operative pain becomes a real challenge in these cases. Whereas if you have A one inch incision, a one and a half inch incision. With minimally invasive surgery, and you use an endoscopic tube no larger than the size of your thumb, well, you can clearly understand that that causes so much less damage to the surrounding tissue. There's huge advantages from a recovery perspective. Now, how does that translate? Well, let's talk about traditional open surgery versus minimally invasive. Again, hospital stay in traditional, usually two to five days. Hospital stay in minimally invasive, usually zero. It's outpatient and done same day. The infection rate also drops dramatically. So we've seen up to 4.5% of traditional open back surgeries. The infection rate is about 4.5% in a minimally invasive procedure, that can drop well below 1% or even below half of 1%. So pretty stark dynamic difference there. And it's pretty obvious, right, when you don't have that big of an incision, when you're not opened up 8, 10, 6, 12 inches. The wider that incision, the longer that incision, hey, there's a lot of opportunity for stuff to happen where if you're working again through an endoscopic tube about the size of your thumb, it's the portal of entry becomes much, much smaller, let's put it that way. Complication rate also drops substantially. Complication rate of most spine surgery is about 25%. Now, thankfully, a majority of those complications are minor, but 25% complication rate is pretty outrageous when you think about it. That's a lot of people. One in four people are going to have some form of a complication. Minimally invasive kind of pulls that down. It's been estimated to be between 5 to 10% instead of 25%. And again, minimally invasive surgery tends to be muscle sparing instead of tearing through and cutting through those muscles. So what are some procedures that are commonly equated with these techniques, so to speak? Well, the interesting thing, or kind of the confusing thing is at this point, even fusions, single level fusions, can be performed minimally invasive and outpatient. And I've seen it done time and time again. I've actually been in a practice that performed hundreds of them where there were ACDFs, right? Anterior cervical disectomy infusions, those are through the front. The anterior. Of course, it's the cervical spine, right? We see those a lot. You know, you see an X ray of a cervical spine, you can't miss an acdf, that's for sure. Those can be done minimally invasive and outpatient. Those can be done in less than an hour's worth of time, which is pretty crazy. Then we look at our LIF procedures. Our LIF procedures, our lumbar inner body fusions, those can also still be done minimally invasive and outpatient. Now, anytime you see a lif, I want you to keep in mind there's always a letter before it. So you might hear the nomenclature. A lif, tlif, P LIF or xlif, for example, the first letter simply tells you the direction the surgeon's taking. Tlif, Transforaminal lumbar inner body fusion. Alif, Anterior lumbar inner body fusion. Xlif, extreme lateral interbody fusion. P lif, posterior lumbar inner body fusion. So just keep in mind, anytime you see an lif, it simply means that there has been hardware placed in and that it's a lumbar procedure. And the first letter simply tells you the direction those can be done. Outpatient, minimally invasive disc replacements. Right? Our disc replacements, cervical spine, we've seen a bunch of them. Lumbar spine, they weren't able to do them in the United States for X number of years. Now they are FDA approved and cleared in the United States. So for lumbar disc replacements, you can see those being performed minimally invasive and outpatient. And then of course, all of the non stabilizing procedures, your laminate, your laminectomies, your foraminotomies and your microdiscectomies, all can be performed minimally invasive and outpatient. Well, if this sounds so great, what are some of the restrictions? Well, some of the restrictions on minimally invasive surgery is because you're only working through that tube about the size of your thumb, let's say endoscopic tube, about 10 millimeters, 12 millimeters in diameter. You cannot basically do multilevels. So if somebody has multi level pathology, there are exceptions to this rule, but by and large it's not a great case for minimally invasive outpatient surgery. If it's multi level pathology, sometimes you can get away with two levels. Outpatient, minimally invasive, but beyond that is beyond the scope of minimally invasive. So keep in mind the amount of levels is important. Also, are there compression on both sides? Is there bilateral challenge? Right. Is the disc in the foraminal canal? Is there nerve root compression on both sides? Because again, I want you to think about the spin is if you're approaching the spine posteriorly, right? Somebody's laying down on a table, you have the spinous process in the middle. You have to choose which laminar you're going to put that tube on right, the left or the right hand side. And if you choose one, once you get in there, the spinal cord's in the way to get to the contralateral side. So it's great for single or unilateral cases. You can get to that ipsilateral side of your approach very, very easily and decompress the disc, decompress the spinal cord and or the foraminal canal. But it's very challenging, AKA pretty much impossible to get to the contralateral side. So that's another thing to keep in mind. So let's take a look at some of this research regarding surgery. I think it's important always to frame that risk of complications in spine surgery. The Open orthopedics journal in 2015, complications occurred in 23% of cases with infections. Oh, wonderful. Infections being the most common. Almost 10% of individuals in this study underwent revision surgery, fixing what they were supposed to have fixed the first time again. And just over a quarter of patients in the sample developed complications. Most of these were specific and minor, but 11% of patients experienced major complications and a sample wide risk of death was 3%. So spine surgery, while it is much, much safer than it was maybe 20 years ago and completely different than it was 50 years ago, people need to understand their risks. There's no panacea. Spine surgery is no exception. Having something quote, unquote fixed with surgery, yes, when it's a red flag case, you absolutely have to do what you have to do. But in terms of elective surgeries, people need to better understand the risks that they're going through because they are still substantial. Now, incidentally, from a chiropractic perspective, Manipulation or microdiscectomy for sciatica, a prospective randomized clinical study. This was put out in 2010. Listen to this. Most of the patient, quote, most of the patients who were considered surgical candidates for the treatment of radiculopathy from lumbar disc herniation improved with standardized spinal manipulative care to the same degree as those who had undergone surgery. Of those who failed spinal manipulation, subsequent surgical intervention provided excellent outcome. So if you heard me on the Smart Chiropractor, our weekly show that we do every Tuesday at the Smart Chiropractor on Facebook, you heard me ranting and raving about this. The bottom line is this. There is not a single person without red flags doing elective spine surgery that should not experience chiropractic care before. Why do I say that? We have research showcasing surgical microdiscectomy or chiropractic care. Over 60% of individuals, most people have the same result or better with chiropractic care than if they had the surgery. And if you are one of those people who quote unquote, fails chiropractic care, that means you're probably a great case, right? Limitation of matter, right? That disc is just sitting in that canal too much. So you are probably a great candidate to have something surgically done. There is not a single person without red flags. I'll say it again, that should not be visiting a chiropractor before they have spinal surgery. The research proves it out. We have none of those risks, none of the complications associated with surgery. Think about 25% risk of a complication. Imagine if it was a 25% risk of a complication when somebody came into your practice. It would be front page news. But that is part and parcel to what goes on in the surgical realm. And now we have studies showcasing that we can perform just as well as surgical intervention in a lot of people. And by the way, I'll bring out one more study. This was from 2011, Chiropractic Management of post surgical lumbar spinal pain. So let's say these people go through with surgery and they still have pain, which we know is a lot of people. It could be up to 40% of individuals. Well, what they found was a change was observed in the mean pretreatment and post treatment pain scores of 6.4 to 2.3, a reduction of 4.1 of 10. So people in this group still had 6 out of 10 pain. And once these are post surgical patients, 6 out of 10 pain, they're supposed to be down below that. And chiropractic care was able to get them to a 2.3. That's a reduction of 40% on somebody who's had. These are the hardest patients. Their anatomy's been changed, we're permanently. They have scar tissue, they are compromised and we're still able to reduce their pain by 40%. I say all this, you can tell I'm getting fired up. But I wanna wrap it up for this week. Important to understand what's going on in the spine surgery realm. Really important to be able to communicate this to the other healthcare providers in your community and to be able to build these relationships. I'll also wrap up with this. I had an awesome email from a friend and member of the evidence based chiropractor. He wrote to me just yester saying, quote, we just hit 18 referrals last month from medical doctors. A new high since implementing your program, what would 18 referrals do to your practice from medical doctors? These are patients that you would have never seen getting directly referred in from the other healthcare providers in your community. If that sounds like something of interest to you, then check out the evidencebasedchiropractor.com, become a member. I'd love to work with you. This is about bridging the gap. It's about being part of a healthcare team. It's not about acquiescing what we do as chiropractic chiropractors. It's about showcasing it in the best way possible to all of the other individuals in our community. So I hope you have a fantastic week in practice and I will talk to you soon.

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Sam.