Minimally invasive Surgery (MIS) and spinal fusion (mending the spine bones together)

Using innovative technology, a minimally invasive surgery (MIS) spinal fusion (mending the

spine bones together) can now be accomplished using two small poke-hole incisions with

minimal tissue dissection resulting in a faster recovery. Using the MIS procedure, Posterior

lumbar fusions (PLF) and transforaminal lumbar interbody fusions (TLIF) can both be

performed in less time, with less tissue damage, and less pain than traditional open spinal

fusion surgery.

Posterior Lumbar Fusion (PLF) is the general term used to describe the technique of

surgically mending two (or more) lumbar spine bones together along the sides of the bone.

Bone graft is placed along side the spine bones (not in between the disc spaces, which is

called an interbody fusion), and ultimately fuses together. Minimally invasive PLF is

generally always performed in conjunction with instrumentation (use of metal screws/rods)

so as to impart immediate stability while the bone mends and to increase the fusion rate

(percentage of patients where the bone successfully mends together). MIS TLIF includes the

PLF described above, as well as performing an interbody fusion, which means the

intervertebral disc is removed and replaced with a bone spacer (metal or plastic may also be

used). A MIS TLIF involves placing only one bone graft spacer in the middle of the interbody

space, without retraction of the spinal nerves.

The MIS PLF technique is often favored as the 2nd staged procedure when a multiple level

ALIF is performed, and a laminectomy is not necessary. A MIS TLIF is commonly performed

when one or two spinal levels are being fused in conjunction with a partial posterior

decompression (facetectomy and laminectomy), and interbody fusion is indicated.

MIS PLF and MIS TLIF are commonly performed for a variety of spinal conditions, such as

spondylolisthesis and degenerative disc disease, among others.

Surgical Technique

The surgery is performed utilizing general anesthesia. A breathing tube (endotracheal tube)

is placed and the patient breathes using a ventilator during the surgery. Preoperative

intravenous antibiotics are given. Patients are positioned in the prone (lying on the

stomach) position, generally using a special operating table/bed with special padding and

supports. The surgical region (low back area) is cleansed with a special cleaning solution.

Sterile drapes are placed, and the surgical team wears sterile surgical attire such as gowns

and gloves to maintain a bacteria-free environment.

A 1 inch (depending on the number of levels) poke-hole incision is made on each side of the

low back, directly over the involved spinal levels. The fascia and muscle is gently divided

using special cannulated retractors and sleeves. The pedicle screws and rods are implanted

and the facet joints are fused through the two tiny incisions under x-ray guidance. If a TLIF

is to be performed, a partial laminectomy (removal of lamina portion of bone) and complete

facetectomy is performed to allow visualization and removal of the intervertebral disc. The

intervertebral disc is then removed using special biting and grasping instruments (such as a

pituitary rongeur, kerrison rongeur, and curettes), an operating microscope, and x-ray

guidance. Special distractor instruments are used to restore the normal height of the disc, as

well as to determine the appropriate size spacer to be placed. A bone spacer (metal or plastic

spacers may also be used) is then carefully placed in the disc space.

The wound areas are usually washed out with sterile water containing antibiotics. The deep

fascial layer and subcutaneous layers are closed with one or two sutures. The skin can

usually be closed using special surgical glue, leaving a minimal scar and requiring no

bandage.The total surgery time is approximately 2 to 3 hours, depending on the number of

spinal levels involved.

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