Minimally invasive spine surgeries (MISS) aim to minimize soft tissue damage during spinal procedures. MISS techniques using tubular retractors or endoscopes have been applied to procedures like discectomy, decompression, and fusion. MISS may provide benefits over open techniques like less blood loss, shorter hospital stays, and faster recovery. However, MISS also has disadvantages like a steep learning curve, dependence on technology, and higher initial costs. The applications of MISS continue to expand but further research is still needed to fully understand its advantages and disadvantages.
Minimally invasive spine surgeries (MISS) since its inception around 15 years ago has undergone rigorous changes with ever evolving technologies. Minimally invasive spine surgeries with “percutaneous” and “tubular” approaches is based on novel concept of minimizing collateral soft tissue damage, while achieving surgical goal in various spinal pathologies. MISS has been applied to simple spinal procedures of discectomy, decompression and fusion to even complex surgeries like deformity correction. MISS vis a vis “conventional open techniques” has benefits in terms of postoperative pain, concurrent tissue damage, disruption of spinal stabilizing structures, estimated blood loss, need of blood transfusion, length of hospital stay, surgical site infections, time to ambulation and functional recovery.
http://www.drsandeepagrawal.com/spine.php
There are many different types of conditions that cause back pain. Like most medical conditions, back pain is treatable through several methodologies. Determining what condition you have is the key to determining the right treatment option for you. Back pain comes in many forms, lower back pain, middle back pain, and upper back pain are just a few of the symptoms associated with spinalconditions. You may also have pain or tingling in your extremities that may be indications of spinal conditions. Feel free to browse through our articles about conditions. Contact your doctor to set up an appointment to start your road to recovery.
Every person is different, so symptoms of conditions may present
differently for different people. Symptoms also vary depending on the
condition, its severity, location, and other factors.
Local Konnect Presents a new technique on Endoscopic Spinal Surgery - Destandu Technique with small incision, minimal post-operative pain and reduced rate of infection.
Full-endoscopic lumbar discectomy is an innovative, minimally invasive alternative to microdiscectomy for patients with symptomatic lumbar disc herniations. IELD and TELD offer two complementary surgical corridors to spinal pathology and allow for treatment of the vast majority of lumbar disc herniations. There is level one evidence suggesting that full-endoscopic spine surgery results in similar functional outcomes compared with microsurgical technique, and has a favorable rate of perioperative complications.
Minimally invasive spine surgeries (MISS) since its inception around 15 years ago has undergone rigorous changes with ever evolving technologies. Minimally invasive spine surgeries with “percutaneous” and “tubular” approaches is based on novel concept of minimizing collateral soft tissue damage, while achieving surgical goal in various spinal pathologies. MISS has been applied to simple spinal procedures of discectomy, decompression and fusion to even complex surgeries like deformity correction. MISS vis a vis “conventional open techniques” has benefits in terms of postoperative pain, concurrent tissue damage, disruption of spinal stabilizing structures, estimated blood loss, need of blood transfusion, length of hospital stay, surgical site infections, time to ambulation and functional recovery.
http://www.drsandeepagrawal.com/spine.php
There are many different types of conditions that cause back pain. Like most medical conditions, back pain is treatable through several methodologies. Determining what condition you have is the key to determining the right treatment option for you. Back pain comes in many forms, lower back pain, middle back pain, and upper back pain are just a few of the symptoms associated with spinalconditions. You may also have pain or tingling in your extremities that may be indications of spinal conditions. Feel free to browse through our articles about conditions. Contact your doctor to set up an appointment to start your road to recovery.
Every person is different, so symptoms of conditions may present
differently for different people. Symptoms also vary depending on the
condition, its severity, location, and other factors.
Local Konnect Presents a new technique on Endoscopic Spinal Surgery - Destandu Technique with small incision, minimal post-operative pain and reduced rate of infection.
Full-endoscopic lumbar discectomy is an innovative, minimally invasive alternative to microdiscectomy for patients with symptomatic lumbar disc herniations. IELD and TELD offer two complementary surgical corridors to spinal pathology and allow for treatment of the vast majority of lumbar disc herniations. There is level one evidence suggesting that full-endoscopic spine surgery results in similar functional outcomes compared with microsurgical technique, and has a favorable rate of perioperative complications.
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
Nuclear medicine in orthopaedic conditionsGokul Kafle
This presentation helps to develop a basic concept in Nuclear Medicine, It also helps to outline the use of Nuclear Medicine in Orthopaedic diagnostics and Orthopaedic therapeutics.
Colorado spine surgeon, Donald Corenman, MD provides a training on the benefits, use and technique of the O Arm surgical procedure. O Arm surgical technique benefits the surgeon and his team, along with the patient. Through reduced surgical time, increased accuracy of screw placement and reduction of incision size, O Arm is an effective surgical technique.
This video explains Lumbar Disc Replacement in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
Nuclear medicine in orthopaedic conditionsGokul Kafle
This presentation helps to develop a basic concept in Nuclear Medicine, It also helps to outline the use of Nuclear Medicine in Orthopaedic diagnostics and Orthopaedic therapeutics.
Colorado spine surgeon, Donald Corenman, MD provides a training on the benefits, use and technique of the O Arm surgical procedure. O Arm surgical technique benefits the surgeon and his team, along with the patient. Through reduced surgical time, increased accuracy of screw placement and reduction of incision size, O Arm is an effective surgical technique.
This video explains Lumbar Disc Replacement in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
The basic term for Microscopic surgery is operating microscope.The most development procedures which allows anastomosis of successively smaller blood vessels and nerves(diameter of 1 mm).This kind of super facility operations can be occurred in the multi specialty hospitals in the major metro cities.
Surgery is the best method for treatment of cancer. Dr. Martin Malawer uses the finest surgical methods to treat the sarcoma cancer in patients. He had got specialization in the field of limb sparing surgery.
Subchondroplasty® (sub-con-drō-plas-tee, and also referred to as SCP), is a minimally invasive surgery that allows orthopedic surgeons to access and treat bone defects associated with chronic bone marrow lesions (BMLs).
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Arthroscopic Management of Anterior, Posterior, and Multidirectional Shoulder...Peter Millett MD
Arthroscopic treatment of the unstable shoulder has evolved rapidly and significantly in recent years. Better understanding of the pathoanatomy, advancements in technology, and improved surgical techniques have led to dramatic improvements in outcome. An arthroscopic approach includes significant advantages. Arthroscopy provides better identification of concomitant pathology, lower morbidity, less soft tissue dissection, maximal preservation of motion, shorter surgical time, and improved cosmesis. There is less pain, and many patients have an easier functional recovery, with greater returns in motion compared with traditional open techniques. Finally, some of the inherent risks of open procedures, such as postoperative subscapularis rupture, are virtually eliminated. Surgeons can now routinely expect results that are at least comparable, if not better than, those achieved with open techniques. For more shoulder surgery and instability studies, visit Dr. Millett, Orthopedic Surgeon, Vail Colorado http://drmillett.com/shoulder-studies
Malignant Mixed Mullerian Tumor – Case Reports and Review ArticleApollo Hospitals
Malignant mixed mullerian tumors are very rare genital tumors. They are biphasic neoplasms composed of an admixture of malignant epithelial and mesenchymal elements. In descending order of frequency they originate in the uterus, ovaries, fallopian tubes, cervix and vagina. Also they arise denovo from peritoneum. They are highly aggressive and tend to occur in postmenopausal low parity women. Because of rarity, there is as such no treatment guidelines available. Multimodality treatment in the form of radical surgery followed by adjuvant chemotherapy or radiotherapy or combined chemoradiation gives a better prognosis & outcome. Two case reports of such tumors, one from ovary and other from penitoneum are presented along with the review of literature.
Intra-Fetal Laser Ablation of Umbilical Vessels in Acardiac Twin with Success...Apollo Hospitals
To interrupt blood supply to the acardiac twin in a case of TRAP sequence of monochorionic diamniotic multiple pregnancy to allow for continuation of the normal twin.
Breast Cancer in Young Women and its Impact on Reproductive FunctionApollo Hospitals
Breast cancer is the most common cancer in women in developed countries. Chemotherapy for breast cancer is likely to negatively impact on reproductive function. We review current treatment; effects on reproductive function; breastfeeding and management of menopausal symptoms following breast cancer.
Turner syndrome (gonadal dysgenesis) is one of the most common chromosomal abnormalities occuring 1 in 2500 to 1 in 3000 live-born girls. It is an important cause of short stature in girls and primary amenorrhea in young women that is usually caused by loss of part or all of an X chromosome. This review briefly summarises the current knowledge about the syndrome and the management strategies.
Due to pregnancy thyroid economy is affected with changes in iodine metabolism, TBG and development of maternal goiter. The incidence of hypothyroidism in pregnancy is quite common with autoimmune hypothyroidism being the most important cause. Overt as well as subclinical hypothyroidism has a varied impact on maternal and neonatal outcome. After multiple studies also, routine screening in pregnancy for hypothyroidism can still not be recommended. Management mainly comprises of dosage adjustments as soon as pregnancy is diagnosed based on results of thyroid function tests. The aim should be to keep FT4 at the upper end of normal range.
Growth Hormone Deficiency (GHD) can persist from childhood or be newly acquired. Confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. Growth harmone (GH) therapy offers benefits in body composition, exercise capacity, skeletal integrity, and quality of life measures and is most likely to benefit those patients who have more severe GHD. The risks of GH treatment are low. GH dosing regimens should be individualized. The final decision to treat adults with GHD requires thoughtful clinical judgment with a careful evaluation of the benefits and risks specific to the individual.
Advances in the management of thalassemia have led to marked improvements in the life span and quality of life of children and young adults. This poses new challenges for the treating physicians. There is now increasing recognition that thalassemics have impaired bone health which is multifactorial in etiology. This paper aims to highlight the factors that predispose these patients to osteoporosis and suggests measures to minimise the impact on bone health.
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
Occupational Blood Borne Infections: Prevention is Better than CureApollo Hospitals
Viral infections like HIV, hepatitis Band C virus pose a big risk to the contacts of individuals with high risk behaviour as well as to the attending health care workers. Blood, semen, vaginal and other potentially infectious materials can transmit the infection to the susceptible contacts. Universal precautions should be strictly implemented during clinical examination, laboratory work and surgical procedures to prevent transmission to the health care providers. Health care workers should receive vaccination for hepatitis B infection. An inadvertent exposure should be managed with proper first aid and infectivity of the source and severity of exposure should be assessed. Severity of exposure is based on the nature and area of exposed surface, mode of injury and volume of infective material. Post-exposure prophylaxis (PEP) should be started as soon as possible after a proper counseling about the effectiveness of post-exposure prophylaxis, side effects and risk of carrying the infection to his familial contacts and its prevention.
Evaluation of Red Cell Hemolysis in Packed Red Cells During Processing and St...Apollo Hospitals
Storage of red cells causes a progressive increase in hemolysis. Inspite of the use of additive solutions for storage and filters for leucoreduction some amount of hemolysis is still inevitable. The extent of hemolysis however should not exceed the permissible threshold for hemolysis even on the 42nd day of storage.
Efficacy and safety of dexamethasone cyclophosphamide pulse therapy in the tr...Apollo Hospitals
Various drugs used to treat pemphigus can cause remission, but none can provide permanent remission as relapses are common. With the introduction of DCP in pemphigus in 1984, patients started being in prolonged/permanent remission. This study was done to compare the efficacy of DCP to oral corticosteroids and cyclophosphamide in combination.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)Apollo Hospitals
Severe skin adverse drug reactions can result in death. Toxic epidermal necrolysis (TEN) has the highest mortality (30–35%); Stevens-Johnson syndrome and transitional forms correspond to the same syndrome, but with less extensive skin detachment and a lower mortality (5–15%). Hypersensitivity syndrome, sometimes called Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), has a mortality rate evaluated at about 10%. It is characterised by fever, rash and internal organ involvement. Prompt diagnosis is vital, along with identification and early withdrawal of suspect medicines and avoidance of re-exposure to the responsible agent is essential. Cross-reactivity to structurally-related syndrome caused by Carbamazepine medicines is common, thus first-degree relatives may be predisposed to developing this syndrome. We report a case of DRESS secondary to use of Carbamazepine.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Deep vein thrombosis prophylaxis in a tertiary care center: An observational ...Apollo Hospitals
Deep vein thrombosis (DVT) is a major health problem with substantial mortality and morbidity in medically ill patients. Prevention of DVT by risk factor stratification and subsequent antithrombotic prophylaxis in moderate- to severe-risk category patients is the most rational means of reducing morbidity and mortality.
The spread of dengue and dengue haemorrhagic fever is increasing, atypical manifestations are also on the rise, although they may be under reported because of lack of awareness. We report two such cases of dengue hemorrhagic fever with hepatitis, intraocular hemorrhage, ARDS and myocarditis.
A 71-year-old male presented in ENT department with dysphagia for last three weeks, more to solids than liquids. He had a hard bony bulge in the posterior pharyngeal wall on palpation and hence was referred for an Orthopaedic opinion. Lateral radiograph of the cervical spine revealed diffuse ossification of the anterior longitudinal ligament. This ossification was extending almost half the width of the cervical body from its anterior body at C1 and C2 vertebra level.
Pediatric Liver Transplant (LT) is now an established procedure for End Stage Liver Disease (ESLD) with biliary atresia being the commonest indication. Intensive pre-transplant evaluation, nutritional buildup and immunization are the fundamental pre-requisites of a successful LT. With improvement in surgical micro-anastomotic techniques and superior immunosuppressive regimens the success rate of pediatric LT is in excess of 90%. Most of the transplants in our country however are Living related, due to which a fairly large number of children expire awaiting a donor liver. There should be a concerted effort to evolve the cadaveric donation program, so that majority of the children are benefitted.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. 308 Apollo Medicine 2012 December; Vol. 9, No. 4 Jaiswal
Disruption of the midline supraspinous and interspinous discectomy has an advantage in morbidly obese patients
ligament complex in conventional open approaches can where surgical exposure through tubular retractor is better
lead to loss of tension band and thus can result in late post- attained than with conventional retractors used in micro
operative instability. MISS avoids the loss of integrity of discectomy.6
this midline supraspinous/interspinous complex which in Percutaneous transforaminal endoscopic discectomy
addition to providing structural stability to spine, also acts under local anesthesia is another way of doing MISS for
as a tie beam for effective functioning of paraspinal discectomy. Yeung and Hoogland are credited for the
muscles.2 Moreover, less muscle disruption in MISS also development of the Yeung Endoscopic Spine System
leads to decreased blood loss and lesser surgical stress (YESS) in 199711 and the Thomas Hoogland Endoscopic
response. Spine System (THESSYS) in 1994, respectively.12 The
purported advantages are avoidance of general anesthesia,
smaller skin incision, conduction as a day care surgery
MINIMALLY INVASIVE LUMBAR and intraoperative active feedback of patient about allevia-
DISCECTOMIES tion of radicular symptoms. However, it is not without limi-
tations, being applicable for specific types of disc
Lumbar discectomy has undergone a radical change in herniations and necessitates even steeper learning curves.
approach since its first description by Mixter and Barr using Superiority of percutaneous techniques over conventional
laminectomy in 1934. Progressively, it was noted that the microdiscectomy still remains unclear as similar outcomes
goal of discectomy and decompression is achievable with has been demonstrated with both methods.
lesser invasive approaches. Introduction of use of microscope
for discectomy by Yasargil and Caspar revolutionized this
procedure and still microdiscectomy is considered as MINIMALLY INVASIVE TRANSFORAMINAL
a “gold standard”. MISS was described by Foley and Smith LUMBAR INTERBODY FUSION
in 1997 for discectomy using tubular retractors. This relies
on dilating the way through muscle fibers rather than stripping Lumbar fusion is commonly done for spinal instability or
it from lamina and spinous process. Endoscope or microscope deformity resulting from spondylolisthesis or scoliosis as
can be used as an adjunct for visualization. Many spine well as low back pain from degenerative disc disease refrac-
surgeons prefer using microscope owing to 3-Dimensional tory to conservative treatment. Interbody fusion is the most
visualization and also, as most of them are already acquainted preferred approach for lumbar fusion as it facilitates larger
with use of microscope, while with endoscope, it has limita- surface of fusion bed, opening up of neural foramen through
tion of 2-Dimensional vision and one needs an additional skill “jack up effect” and additional anterior stability when a cage
to master due to unfamiliarity. However superiority of MISS is placed. Currently, transforaminal lumbar interbody fusion
over microdiscectomy is debated by some as, in microdiscec- (TLIF) is most commonly performed for lumbar arthrodesis,
tomy, already there is a minimal surgical exposure and long as TLIF provides exposure of the disc space while requiring
term results of both the approaches have been found to be less dural and nerve root retraction. However in traditional
similar.6 Adequate decompression, regardless of the operative open approach TLIF requires extensive surgical exposure.
approach used, may be the primary determinant of radicular The iatrogenic injury of muscle and soft tissue is an impor-
pain relief. Adversely, it has been noted that there is a higher tant cause of postoperative low back pain which might even
of incidental durotomy in minimally invasive discectomy8 counteract the effects of surgery and sometimes labeled as
with possible explanation being limited visualization, poor “fusion disease.” MISS transforaminal lumbar interbody
depth perception and steep learning curve. Some argue that fusion using nonexpendable or expandable tubular retractor
microdiscectomy can itself be considered as a minimally inva- and bilateral percutaneous screw placement reduces such
sive procedure for discectomy and controversy persists collateral soft tissue damage and has shown to produce
whether to stick to age old microdiscectomy or to adopt favorable outcomes in respect to postoperative back pain,
tubular discectomy where again, even an experienced spine total blood loss, need for transfusion, length of hospital
surgeon needs to tide over a steep learning curve. However, stay, time to ambulation and functional recovery.4,5 Iliac
MISS seems to be more beneficial for spinal procedures crest autograft remains the gold standard, with the osteo-
with extensive surgical exposure and soft tissue disruption genic, osteoinductive, and osteoconductive components
like spinal instrumentation and fusion.4,5,9,10 It can be argued required to achieve fusion, but it comes with associated
that discectomy is the most common surgery in spine, hence donor site morbidity. Majority of spine surgeons use locally
one should master MISS for discectomy before graduating harvested bone from bony decompression as a graft to avoid
to more extensive procedures with MISS. Minimally invasive donor site morbidity. However in MISS transforaminal
3. Minimally invasive spine surgeries (MISS) Theme Symposium 309
interbody fusion when the amount of local graft is inade- MISS has a potential to reduce the approach-related
quate or even otherwise allograft or bioactive agent like morbidity associated with conventional techniques which
recombinant human bone morphogenetic protein (rhBMP- is even more crucial in setting of pre-existing injury.
2) can be added to facilitate fusion. However MISS has limited indications in thoracolumbar
injuries. Pure osseous injuries like bony chance fractures
are ideally suited for MISS fixations where one can do
MINIMALLY INVASIVE DECOMPRESSIONS IN away without bone grafting and decompression.9 Fixation
LUMBAR CANAL STENOSIS in such a pure osseous injury has further advantage of
possibility of implant removal with restoration of spinal
Lumbar canal stenosis (LCS) is a common degenerative mobility.9 Spinal fractures needing decompression may be
process among the elderly leads to progressive neurogenic fixed with percutaneous instrumentation and decompression
claudication and often needs surgical decompression to can be achieved with expandable tubular retractors or ante-
alleviate the associated symptoms and disability. Indeed, rior laproscope/thoracoscopic decompressions.10 However
LCS is the most common indication for surgery of the spine one has to conversant with all the procedures and carefully
in patients over the age of 65 years. Conventionally lumbar select fractures types amenable for such MISS interven-
laminectomy was indicated surgical procedure for LCS. tions. Specific clinical indications for MISS interventions
However with advances in noninvasive imaging especially in spinal fractures are still evolving.
MRI, it was noted that most of these pathologic compres- Percutaneous vertebroplasty and kyphoplasty are mini-
sive changes typically occur at the level of the interlaminar mally invasive procedures when performed in symptomatic
window, hence it seems more prudent to do focal decom- osteoporotic vertebral fractures provides dramatic pain
pression at level of compression rather than wide laminec- relief to patients who are not responding to conservative
tomy. The ultimate goal, regardless of the technique used, is care.13 Vertebroplasty entails the percutaneous injection
to perform an effective decompression of the affected thecal of bone cement into the fractured vertebra, while kypho-
sac and nerve root. Current MISS techniques for decom- plasty addresses pain and kyphotic deformity by the percu-
pression avoids collateral damage and have successfully taneous expansion of an inflatable bone tamp to effect
shown to shorten hospital recovery times, reduce intraoper- fracture reduction before cement deposition in a fractured
ative complications, and minimize soft tissue trauma with vertebra.
resultant decrease in surgical stress response which is
a crucial factor in consideration in elderly patients.1e3
There has been constant endeavor to adopt a minimally SUMMARY
destructive method to attain aimed surgical neural decom-
pression in lumbar canal stenosis. Various methods of Although the authoritative definition of minimally invasive
less invasive approaches namely spinous process splitting spine surgery remains elusive, the one proposed in
approach, bilateral laminotomies, bilateral decompression summary statement published by McAfee et al14 looks
via unilateral laminotomy etc has been described. MISS most apt. “An MISS is one that by virtue of the extent
for lumbar canal stenosis using tubular retractors aided by and means of surgical technique results in less collateral
endoscope or microscope has been employed successfully tissue damage, resulting in measurable decrease in
to treat LCS.1e3 However, limitation of MISS in LCS morbidity and more rapid functional recovery than tradi-
decompression is that it may fail to provide an adequate tional exposures, without differentiation in the intended
decompression in patients with bony foraminal stenosis. surgical goal.” Growing experience with MISS techniques
In patients with lumbar stenosis in the setting of spondylo- by operating surgeons and development of newer instru-
listhesis, scoliosis, or severe degenerative disc disease, the mentation by manufactures are now enabling an increas-
inherent destabilizing nature of posterior decompression, ingly large portion of spine surgical procedures to be
even using MISS, may warrant a fusion operation in addi- performed via minimally invasive techniques.
tion to decompression.3 Extensive tissue trauma in traditional surgical exposures
cause exaggerated surgical stress response and leads to
variety of complications like deep venous thrombosis,
MINIMALLY INVASIVE FIXATIONS IN THOR- pulmonary embolism, pulmonary atelectasis, pneumonia,
ACOLUMBAR TRAUMA urinary tract infections, ileus, narcotic dependency etc.
Indeed, the greater the trauma, the greater the response.
Conventional spine exposures add to pre-existing paraspi- MISS plays an important role in reduction of this surgical
nal soft tissue injury secondary to trauma in spinal injuries. stress response and associated complications.7
4. 310 Apollo Medicine 2012 December; Vol. 9, No. 4 Jaiswal
Short term benefit like lower intraoperative blood loss, MISS is an exciting development in field of spine surgery
fewer infections, less intensive care utilization, less postoper- and to some extent has stood its promise and scientifically
ative analgesia, and shorter hospitalization with MISS vis ratified. However there is a need of high quality multicentre
a vis traditional open surgeries are more as compared to long randomized control studies with large study population to
term benefits. MISS techniques may reduce postoperative clearly elucidate the advantages and disadvantages of
wound infections as much as 10-fold compared with other MISS before it is accepted as a “Gold standard” in spinal
large series of open spinal surgery published in the literature.15 surgeries. Moreover clinicians and researchers need to
The steep learning curve of MISS has been one of the constantly endeavor to find out ways to simplify the proce-
greatest barriers to the widespread adoption of minimally dure, reduce the financial implications, reduce the steep
invasive spine surgery. The surgeon practicing this needs learning curve, improve clinical accuracy, reduce peropera-
a specialized training and experience. He should be expert tive radiation and broaden the clinical applications of MISS.
in doing open surgeries too, as at times he may need to
convert to open procedure, if it is not feasible to carry on CONFLICTS OF INTEREST
with MISS. MISS has a disadvantage of being an instru-
mentation dependent procedure. MISS techniques require The author has none to declare.
an extensive knowledge of the focal structural/radiological
anatomy and safe surgical corridors of spinal region of
interest.16 Additionally, one should be aware of possible REFERENCES
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