Surgery is a discipline that relies primarily on surgery to treat disease. Spine surgery is a subspecialty of surgery. Spine surgery is generally highly traumatic in terms of tissue trauma and high operational risk. Protecting healthy tissues and restoring body function are the treatment objectives of spinal surgery and the basic principles that must be followed. Minimally invasive spine surgery can be understood as a way to achieve the best results with the least trauma.
The development of minimally invasive spine surgery has been integrated into telemedicine in developed countries in Europe and the United States remote consultation of difficult cases of minimally invasive surgery, the development of surgical protocols and the implementation of remote remote control surgery by robots have entered into real life. A few pioneers in China have also made promising progress in the field of computer simulation research, but more spine surgeons are still exploring minimally invasive spine surgery in their clinical work from traditional surgery.
The main reasons for the gap between minimally invasive spine surgery technology in China and developed countries are: lack of clear minimally invasive awareness, lack of a firm minimally invasive concept and solid minimally invasive techniques.
1. Minimally invasive consciousness
As early as the 4th century B.C., the ancient Greek physician Hippocrates warned doctors “not to do too much”, and in ancient China there has long been a gold needle bone extraction method to rectify fracture displacement, which has bred the germ of minimally invasive awareness. Many theories in modern orthopedics are permeated with minimally invasive consciousness. The “Ao” theory
In the 1930s, the “Ao” principle developed into the “Bo” principle of fracture treatment, from emphasizing the direct anatomic reduction of fractures to the indirect functional reduction of fractures. The emphasis on inter-block compression fixation to elastic fixation, mechanical stabilization to stable biological fixation, and minimally invasive and non-invasive techniques were emphasized. Early active and painless functional exercises, etc. It shows even more the sublimation of minimally invasive awareness and the highest level reached.
Several problems in the treatment of spine surgery are invariably related to the negative effects of surgery. The process of minimally invasive awareness permeates the requirements and ideas of spine surgeons seeking to reduce or eliminate these deficiencies, leading to improved and enhanced treatments. Minimally invasive consciousness in spine surgery treatment is reflected in the unassisted traction rehabilitation, prone functional training, bone pin traction repositioning, plaster helmets, plaster undershirts, orthopedic braces, and craniopelvic traction fixation in spine surgery.
More significantly, spinal fracture treatment has moved from multi-segmental fixation to single motion segmental fixation . Disc removal from early total laminectomy to current open-heart surgery and endoscopic surgery are all examples of minimally invasive awareness in spine surgery. It should be said that minimally invasive awareness is one of the basic qualities of a doctor. A doctor without minimally invasive consciousness cannot be called a qualified doctor.
Whenever we treat a disease, we should think of how to be minimally invasive, minimize trauma, shorten the course of treatment, restore function as soon as possible, and save money as much as possible. Only with minimally invasive consciousness can we establish a clear concept of minimally invasive and create more minimally invasive techniques. It should be said that minimally invasive consciousness is the basis of minimally invasive theory.
2.Minimally invasive concept
Minimally invasive concept is the sublimation of minimally invasive consciousness, and minimally invasive concept is not created out of thin air. Rather, it arises from a large amount of information of minimally invasive consciousness. As far as spinal surgery is concerned, the minimally invasive concept includes the following aspects.
(1) The concept of “minimally invasive access”. Traditional spine surgery requires adequate exposure in order to ensure precision and detail. Does adequate exposure necessarily mean a wide incision? With the development of modern medicine, can we achieve “full exposure” without incision or with minimal incision? The use of lumpectomy can achieve direct “full exposure”, and the use of modern imaging technology can achieve indirect “full exposure”, and the combination of the two effectively reduces the trauma of the access.
(2) The concept of “minimally invasive repositioning”. Traditional surgery hopes to fully expose the tissues and avoid important nerves and blood vessels for repositioning, while the concept of minimally invasive repositioning means that the operator should perform postural repositioning, freehand repositioning and pry repositioning with minimal trauma and imaging technology to achieve the minimum normal tissue damage.
(3) The concept of “minimally invasive resection”. Minimally invasive decompression also aims to be complete and thorough, but its main purpose is to remove the diseased tissues thoroughly while involving as few surrounding normal tissues as possible and reducing the damage to normal tissues. For example, lesion removal is accomplished with the help of microscope, thoracic laparoscope, arthroscope and endoscopic light source, higher precision and high resolution camera system.
(4) The concept of “minimally invasive fixation”. Fixation is a common method of spinal surgery. The author of the concept of minimally invasive fixation is to use the least amount of fixation possible and the simplest operation to obtain maximum stability. Traditional spine surgery has moved from posterior long segment fixation to single motion unit fixation, and from open internal fixation techniques to percutaneous internal fixation techniques and endoscopic internal fixation techniques, all as a result of the concept of minimally invasive fixation.
(5) The concept of “minimally invasive fusion”. Minimally invasive fusion is based on strong fusion to reduce the scope of fusion as much as possible. As much as possible to preserve the motion of the segment to ensure the normal physiological range of motion. Multi-segment posterior fusion of the lamina and transverse process is replaced by single-segment or few-segment intervertebral fusion. From minimally invasive awareness to minimally invasive concept is a qualitative change. With minimally invasive concept, we can challenge minimally invasive techniques, think about new surgical methods, design new surgical instruments, and create new surgical methods.
With minimally invasive concept, we can demand more accurate and higher resolution images in diagnosis, more accurate anatomical structures, safer operation methods and better treatment results in treatment. Therefore, the embodiment of minimally invasive concept should focus on the selection of indications. Only by establishing the concept of minimally invasive can we achieve quick diagnosis, scientific and rational treatment design. Smaller and shorter surgical access. The surgical operation should be standardized and precise. If minimally invasive consciousness is the foundation, minimally invasive technology is the result, then minimally invasive concept is the bridge between the two.
3. Minimally invasive techniques
Minimally invasive technology is intended to achieve the best treatment effect with minimal damage, and is the inevitable result of the development of minimally invasive consciousness and minimally invasive concept. Minimally invasive spine surgery techniques are derived from traditional spine surgery, but are not a complete replacement for traditional spine surgery techniques. The general principles and techniques of traditional spine surgery are still applied to the practice of minimally invasive spine surgery techniques. To carry out minimally invasive techniques, it is important to first correctly understand the intent of minimally invasive techniques.
①Small incision operations are not the same as minimally invasive techniques. Simply reducing the incision, inadequate exposure, and increasing the strength of the pulling hook make the operation difficult to be done properly, making it difficult to perfect hemostasis and increasing tissue damage.
②The blind pursuit of tiny incisions is not minimally invasive technology. Although with the configuration of highly sophisticated instruments, the smallest incision can achieve the least damage, but the blind pursuit of tiny makes the anatomy unclear, the operation is too rough, the steps are not in place, and it is easy to accidentally injure important organs. The blind pursuit of micro makes the operation too difficult, prolongs the operation time, and even turns into traditional surgery in the middle of the operation, which instead becomes invasive or mega-invasive surgery and fails to achieve the purpose of minimally invasive.
③ Destabilizing the internal environment is not a minimally invasive technique. Trauma is a kind of malignant stimulation to human body, trauma can cause systemic reaction, and strong trauma reaction can lead to serious complications and even endanger life. In order to achieve the purpose of minimally invasive, too much damage to normal tissues, prolong the operation time, disturb the stability of the internal environment of the body, cause other serious complications, and fail to achieve effective treatment, this kind of surgical operation is never minimally invasive technology.
④Detachment from the monitoring of imaging instruments. This is not a minimally invasive technique. Not a minimally invasive technique. Due to the lack of equipment or fear of x-ray radiation damage, the surgeon only relies on his “rich” clinical experience and intuition. Although the operation is completed blindly and randomly, the tissue damage is minimal, but the accuracy of the operation is not objectively tested. The meaning of minimally invasive techniques is lost.
Minimally invasive spine surgery technology must break the shackles of traditional concepts, be familiar with local and overall anatomy, master the performance and use of modern high-precision instruments, inherit the experience of traditional surgery, establish a highly responsible professional ethics, implement a rigorous, scientific and meticulous research style, and possess a hard-working and self-dedicated work ethic.
Minimally invasive spine surgery techniques currently carried out in China are rich in content and broadly include.
① Microsurgical techniques of the spine. Such as transoral access microscopic dentatectomy; anterior cervical microsurgery; posterior cervical microsurgery; small incision transthoracic microsurgery; thoracolumbar junction microsurgery; lumbar intervertebral disc microsurgery removal technology; anterior lumbar microsurgery questionable interbody fusion technology.
② percutaneous spinal internal fixation techniques. Such as percutaneous posterior cervical lateral block internal fixation technology; percutaneous anterior cervical lateral block internal fixation technology; percutaneous dentate screw internal fixation technology; percutaneous thoracolumbar fracture internal fixation technology; percutaneous pelvic ring injury internal fixation technology.
③Endoscopic surgical techniques. Such as thoracic laparoscopic discectomy technique; thoracolumbar fracture decompression and internal fixation technique; tumor excision and reconstruction technique; vertebral tuberculosis lesion removal and decompression and reconstruction technique; scoliosis orthopedic fixation technique; anterior cervical endoscopic discectomy and bone grafting internal fixation technique; lumbosacral endoscopic decompression and internal fixation technique, etc.
④Mediated minimally invasive techniques. Percutaneous puncture disc excision and suction technology; percutaneous puncture disc laser vaporization radiofrequency ablation technology; percutaneous puncture vertebroplasty technology: percutaneous puncture vertebroplasty technology, etc.
It is very difficult to fully grasp such a large number of techniques. However, the future of minimally invasive spine surgery in the 21st century is very exciting. Minimally invasive surgery is an emerging technology. To achieve the same, similar or better results than traditional spine surgery, surgeons need to strengthen their awareness of minimally invasive techniques, to firmly grasp the concept of minimally invasive techniques, not to exaggerate the advantages of minimally invasive techniques, not to devalue traditional surgical techniques, not to violate medical ethics, but to be aggressive, constantly explore and seek new ideas.
The innovation of minimally invasive techniques requires not only strict theoretical basis and rigorous experimental methods. It also requires adequate clinical validation, objective evaluation and analysis, and testing by evidence-based medicine and ethics. Only repeated practice, prospective research and long-term follow-up can lead to final results and conclusions.
With the in-depth development of modern biological science, network information science, nanomaterial science, and computer intelligence science, the ideal of minimally invasive and noninvasive spinal surgery operations can certainly be realized.