John Liu, MD, a neurological surgeon and co-director of the USC Spine Center at Keck Medicine of USC, discusses the latest developments in spine surgery, including advances in laser, robotics, stem cell and minimally invasive procedures.
Yeah. Hello. My name is John Liu. I am a neurological surgeon at University of Southern California. I have been in practice for about 20 years, especially is in neurosurgery, spine surgery. And today, what we're gonna talk about is contemporary topics in spine surgery. Um, including minimum invasive spine, a minimum base of spine operations, laser operations, robotic stem cells. There's just a lot of different topics, and that's it. That involves spine surgery. So hopefully we can try to review and talk about what works. What doesn't work? I don't have any. Any disclosures that for this lecture now, something to keep in mind? I always tell my patients whenever I see patients is that that the body has a natural tendency to heal. Um, S O as a. As a surgeon, we very rarely will go in and try to operate very quickly. There are certain times what we do when there's some muscle weakness, but by and large, we really try to give the body a chance to to heal itself. Now, um, again, we're gonna talk about in terms of what are the kind of the hot topics today in spine surgery? Uh, meant we talk a lot about stem cells. Um, the big feel in in spine surgery and the big advancement very popular will be minimum invasive approaches. Um, including endoscopic approaches. Then we'll talk a little about intra operative navigation as well. Some robotics with these are some of the newer technologies that we have in spine surgery. So stem cells you can think of. What we have today in spine is I think we all want to be able to have a stem cell injection on then have all our, uh, this spaces that go back to being being like 20 years younger. Um, unfortunately, that's not what we have today, and there are a lot of work being done, and hopefully, years from now, we will have that. What we do have today for stem cells is, um, Thio assistant infusion so that we can use stem cell products that can actually help us heal if we're in the process of doing a some type of spine fusion operation, Um, now the minimum invasive approach. A lot of times, patients will ask, what exactly is the minimum invasive? What does that mean? So you can think of the spine is surrounded by a lot of muscle. So the the approach to the spine when we have to expose the spine sometimes can cause a lot of pain and can cause a long term recovery. So the idea is to try to minimize that that approach related, um, injury to to the muscles. And so in the United States, what we've been primarily been doing is using these tubular access, and so what we call it to biology. What we actually can use a tubular access to sequentially dilate through the muscles. So as opposed to stripping the muscles off the spine, we're gonna actually work through the muscle fibers, so we don't damage those muscle fibers, and we minimize amount of injury that occurs with the muscles. So that creates a very small quarter. Or that we and then we work through this this small two tubular approach. And that's essentially how we've been in the United States been looking at minimum invasive spine that's been going on for about 20 years now. Now, minimum invasive is not new to just spine. There's been a lot of other spines. Ah, lot of other surgery specialties. It really started off with cardiothoracic. And Dr Witman, uh, I think really kind of have the best quote when he said Minimal damage. Thio biological tissue at the point of entrance of surgical instruments. I think that's probably the best definition I've heard for for minimum invasive spine. And again, a lot of cardiac operations today are done through these minimum invasive access. Uh, gall bladder surgeries, Um, can be done as well, as well as O, b, g, y n and, um, urology. So there's a lot of other surgical specialties also in using minimum invasive approaches. Uh, in spine surgery. Again, the problem with spine is that really surrounded by a lot of muscles? So here's a good example in this picture where you have incision in the back and you're stripping down these muscles with these big retractors and thes Cobb elevators. And these are just instruments that we work, and you can see potential what that can cause in terms of damage to the surrounding muscles. So for us to do our work in the spine way have to do this exposure that can cause a lot of problems for the patients. So the idea is to try to minimize um that that approach, uh, injury. When I started my practice in 1919, 98. This is how we did it. It's called basically India scope of endoscopic approach. What we actually uses minimum invasive mussels splitting. And then we put this small in the scope and the technology. At that point, the endoscope just wasn't that good. The visualization was poor, and we just couldn't see things that well, so but we kept the minimum invasive mussel dilation part. But instead of using endoscope, we actually used microscope, especially the United States. That's what the majority of the surgeons do today. Um, there are different types of tubes, so we can you can think of it as fixed diameter tubes and modular tubes where some of these tubes you can actually change the diameter. And depending on what operation you're gonna dio, we will use a different type of tube. But the whole idea is to try to keep these incision as small as possible. Now, outside the United States, a lot of the minimum invasive development have been primarily through these endoscopic approach, and these are very popular, and outside the U. S. And in Europe and Asia in the US for some reason that we were not really quite sure it never really caught on. But I think there are surgeons now that's rediscovering the endoscopic approach and actually becoming very interested in terms of learning these newer techniques. Um uh, that that we can use the Indus go for and again the U. S. The majority of what we do today is actually through a microscope as opposed to endoscope. And there's a lot of advantages working through microscopes. You actually get a three dimensional view as opposed to a 22 dimension view. There's great lighting, so it is great for teaching. If you're teaching residents and fellows, you can actually both look through the microscope and see exactly what's what's going on. Um, even though it minimum invasive spine that we talk a lot about it and very popular. A lot of surgeons want wanna learn. It is really less than 20% of all surgeries done, and that's pretty much across the board board. And you can think if you look at different countries and that's really the pretty good number in that low 20 to 30% range. So the majority of patients that have spine surgery are done through a traditional open operation. Uh, in the scope is even less probably less than 11%. So the minimum invasive approaches have have led us to kind of rediscover some older operations, and one operation that was that's been around for a long, long time. UH, is what's called frame anatomy, and we're basically what that is is when you when you have a pinched nerve in your neck and you have a lot of pain going down the arms and there's at your disk or some type of bone spur hitting that nerve, one good operation to do is actually go from the back of your neck, and you can actually make a little tunnel in the back of the neck, Um, and what? That was actually a very popular operation for a long time. The downside with that operation is that traditionally is done through open operation, and there's a lot of muscle splitting, and so it's actually very painful operation. But with women invasive, were actually be able to read, were actually able to rediscover and change that operation. So instead of doing the open operation with a lot of retractors. We just use a very small incision to allow patients to go home the same day and with great outcome s Oh, that's where I think this is a good, good example. I'll kind of show you how we dot dilate through the muscles with these sequential tubes and you look through the tube and you can actually see the same in the enemy that we will see. If we were doing the open operation and we can actually put drills in there, we can actually use special instruments to take away those bone spurs that's pushing on the nerve. And in this image, you could well actually show you the nerve. This little, uh, what's called a nerve book is actually right underneath the nerve itself so you can actually see that we could do a very good decompression off the other nerve itself. And you can actually even pull out a small discrimination and decompress and nerve even mawr. And as you take that, too bad you can not just see that muscle coming back together, E. I think that's the beauty of this approach is that we really haven't done any damage to the muscle and the muscle comes together, it goes back to his natural, uh, position. Now, I'm gonna talk a little about how we use minimum invasive approaches for some of the lumbar operations to. And these are very popular, very common things that we see. Um, in terms of patients coming in to see us, that could include a disc herniation, lumbar stenosis, a swell so even tumor resection. So what kind of touched a little bit? Kind of just show you some examples in terms of what we can use them invasive techniques. For here is an example of somebody very common 34 year old with leg pain from a herniated disc in This lends itself very nicely to a minimum invasive approach there. The open operation is also a very good operation. Um, so sometimes with very small operations like this, I mean, honestly, make a big difference. But as you give some of some of these bigger operation that I'm gonna show you, I think minimum invasive. Really, um, kind of shows. Uh, it is advantage in terms of when we perform some of these bigger operations. Here's a here's example of what we call over the top bilateral decompression, where in the most common used for this is actually in folks with long bar stenosis where they have a lot of lake pains. When they walked and they basically can't walk, they sit and they lean forward. Um, this is where a single incision, one side approach we get both sides decompressed, uh, through a very small incision. This is again the outpatient procedure, so patient go home the same day. Here's an example. If you look at the C T scan, there's a osteo fight with a bone spur that's in the frame. In the frame is where the nerve kind of comes out of the spine, and the pink arrow you can see is actually pointing at the bone spur. So if we want to do a traditional way to decompress that you actually have to take that joint off, there's actually was called off a set joint. You have to remove that joint to actually take that bone spur off. So if we take that joint off, then we probably have to fuse it at the same time because you're going to destabilize the spine. Now we can we can in Instead of doing that, we can actually come from the other side through a minimum invasive approach and go basically sneak underneath the bone on the other side to reach that bone spur the reason we come from the other side, you get a better angle. And through that angle you can actually get that bone spur. And here you can see the post op. We actually this you can see the black, Uh, that's the air that the track that we took that that allow us to take that bone spur off without touching that for side joint. And this becomes really an outpatient procedure, as opposed to a fusion operation with a patient. Needs to stay in the hospital for for a few days. How about a tumor like this? And I actually just took care of, uh, lady with Avery. Similar tumor, the thoracic spine, where it was pushing a lot of putting a lot of pressure on respond accord. Saying fashion. We use the same approach minimum invasive. Uh, unilateral approach. Lemon on amis is kind of over. The top decompression allows us to open up the dura, which is the covering of the spine at the the spinal cord. Find there's nerve. Get it away from the nerve. The find this tumor. Get away from the nerves and then take that tumor out again through a very small incision. Um, and we can actually close that, covering the dura through the tubes with some special instrumentation. So all that can be done and even fusions some. You know, somebody who needs a fusion somebody is a little bit bigger operation. We can actually use minimum invasive approach. And this is you can actually see. We actually use this navigation device. Uh, in U S. C. We actually, I have three of these. What's called? Oh, arm units. Um, that allows us to get some inter operative CT scan, and so that allows us to tackle some of these more complicated operations and spinal deformities minimum invasive approaches so we can actually see the the enemy in in real time. Um, this is us kind of putting in a spacer where cage as part of the fusion operation. And you can actually put those screws in in the same through the same tubular approach. Or sometimes we can use this what's called screwed extenders or per cutaneous placement of of the pentacle screws. And this is the incision that you typically get with the fusion. Like this. Uh, it's a very nice way to have a fusion operation if you ever need a fusion operation versus so you can actually have your choice. But if you need a fusion, would you rather have the incision on the left, which is about the size of a quarter? Would you rather have incision on the right? I think most of us will pick the minimum invasive incision. Now, there are a lot of data to show that minimum invasive compared to open fusion is just is just as effective. Um, very similar, but less blood loss and shorter hospital stays. Uh, complication and fusion rates are very similar to open operation. So we compare vory well to open operations. But we save the patient a lot of pain, less pain medication. And I think one of the more important components is that we also lower the risk of infection. This is the paper that that I I was one of the authors on when I was at Northwestern when we actually had looked at 505 113 patients over 10 year period, and the infection rates for minimum invasive fusion was 0.2% 0.2% whereas an open fusion same operation open done openly. Eyes 4 to 10%. So you can see the dramatic change in terms of an infection. And you can almost whenever if you ever have an infection from a fusion operation, could be quite complicated, because sometimes you may have to go back in and take the hardware. I'll take the screws out. So I think this is a really a true advantage of a minimum invasive approach. We just hardly ever see deep infections anymore. How about these complicated operations, like adults, spinal deformity, tumors and these are more complex? But it can also, uh, we can also use minimum invasive techniques, uh, to help us tackle some of these more complicated operations, uh, using all variety of different techniques in the minimum invasive. We have, ah, really a kind of ah, a five or six different techniques that we can use to help tackle these complicated operations. Here's a good example off a lady with a scoliosis, which is a abnormal curvature, uh, that she was causing her a lot of problems. And this is one where we actually was able to correct her scoliosis all through a perky Titanius in a minimum invasive approach. Certainly cosmetically is much better. Recovery is much better. Lower infection risk, and you get the same result compared to open operation. How about eso? We mentioned a little bit about navigation. Navigation, I think, is very important. Women invasive spine because because we're not exposing the entire spine, you have to know where things are. So when we use intra navigation, it really allows us to be very accurate, very precise reduces to use of fluoroscope e. And I think it just makes things safer. Um, the times that we actually have to take patients back Thio readjusted hardware or screw uh is very, very low compared to when we used to do these operations with the fluoroscope with with, uh, what's called freehand techniques. So I think navigation is certainly is a is a true advantage that we have in spine surgery today. It really kinda has changed how often we tackle these some of these very, um, complicated operations and tumors that destroys the normal anatomy and to have navigation. That really makes the operation much, much safer. Uh, robotics is kind of next generation of navigation where you can actually have a robot where they're moving arm. Uh, not on Lee to precisely tell you where to go, but also, it lines everything up. So you so you know exactly where you where you need to go to play some of these hardware. So you can almost think of it as a more of an advanced navigation. We can. We've actually have used robots, uh, for some tumor resection, and this is actually done quite often with in urology. Uh, right now, where they use a lot of robotics. And I think spine is starting to use the robots. Aziz. Well on. And I think with that, we can continue to push the envelope in terms of tackling some of these world complicated operations. So you can think of the interrupted A fluoroscope e. The always of putting in screws is kind of like reading a map. Right? So I so I'm old enough to remember. Well, we used to have a collection of maps in our glove compartment. So whenever we gotta go somewhere, you kind of pull out the map, And you kind of you have to find out what street you have to turn on. Um, a navigation. It's almost like a, um like if you turn on the GPS. Right. So, uh, it tells you, turn right here. Turn left here where? As a robotics is almost like the self driving car, right, So s so you can think of it as is each each level of complexity. Get UME or, um, in terms of, uh, potential, um, assistance and tackling some of these more complicated spine operation. But we're also aware that you can't just rely on technology for everything. So we're always you have to be careful. Even self driving cars can have problems. So you you can't rely on just on robotics, and so you still have to double check and make sure that the the robot is actually doing what it's supposed to dio Um, so with that, I do think minimum base. It is definitely here to stay. It's been around for about in my career, has been on for at least 20 years. I started my my practice in 1999 when we actually started doing minimum invasive at that point. So it really has come a long way. I think we still have a lot that we can get better at. And I think as new technology comes out like different robots and and other technologies, I think we're just gonna get better and better, uh, with the minimum invasive techniques. And with that, I think, I think with the improving minute invasive, I think it just helps patient care overall in spine in, uh, spine surgery. So with that, thank you so much for your attention. Ah, and I hope to see you soon.
