Minimal Invasive Cervical and Lumbar Surgery Future

Daniel Gastambide, M.D., Orth. Surg., Paris (France)

Minimal invasive spine surgery is becoming more important for multiple causes:

- progress in diagnosis with MRI and TDM

- progress with surgical tools: laser, video

- progress with anaesthesiology pain prevention, patient comfort and security

- general ageing of the population, with more degenerative osteoarthritis

- more people requirement against pain

Lumbar minimal invasive surgery future will evolve in 3 axes:

- Better endoscopic tools with minimal fibre optics diameter,

- Laser Optimization

- Better knowledge of inflammatory process

Better endoscopic tools have been made by several authors, such as T. Hoogland (Germany), M. Knight (Great Britain), A.T. Yeung (USA), using a specially designed multichannel endoscope with:

- a large working channel

- a consistent quality imaging

- a flow integrated system keeping the surgical field clear even when the endoscope is targeted to bleeding areas

Laser optimization is now obtained with Ho-YAG laser with continuous saline irrigation with 0.3-0.5 mm cutting depth, and possibility of making a large foraminoplasty by destruction of facets anterior wall, giving the possibility of taking off under visual control all excluded hernias

A better knowledge of inflammatory process will allow to inhibit enzymes in situ with new chemical substances.

In the cervical miniinvasive surgery, progress will be made with the tightness of instruments, allowing the use of trephine, forceps, laser and irrigation at the same time.

In both cervical and lumbar minimal invasive surgery, two trends are emerging:

- by surgical means:

percutaneous posterior osteosynthesis with pedicular screws and plates

graft and spacers: after my personal experiences of 5 cases of percutaneous lumbar iliac cortico-cancellous grafts, with variable success, Gepstein R. (Israel) and Lee S.H. made a percutaneous spacer expandable like a "stent" (Expandable Spinal Fusion System -ESFS), Husson J.L. (France) presents a nucleoplasty: spiral prosthesis put in place by the same posterolateral approach as usual, made in polycarbonate urethane, presenting a memory of form; S.H. Lee describes a cervical percutaneous spacer.

mobile prosthesis: the minimal invasive endoscopic retroperitoneal approach allows disk replacement by mobile prosthesis like Thierry Marnay with "Prodisc"

- by biological means:

culture of patient chondrocytes reinjected in the disk

culture of patient iliac medullary cell stems transformed in chondrocytes (Lab. Hatzfeld, Paris)

In conclusion, the indications of percutaneous minimal invasive spine surgery will grow exponentially for a larger efficiency.