Newer surgical methods mean small incisions, quicker recovery

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Neurosurgeons can do safer, more effective surgeries on the spine using a minimally invasive technique, which means faster recovery times for patients.

Today I am talking about endoscopic spine surgery with Dr. Ali Hazama. He's an assistant professor of neurosurgery at Upstate and the director of neurosurgery at Upstate Community Hospital, and he specializes in minimally invasive surgery and the spine.

Welcome to "The Informed Patient," Dr. Hazama.

Ali Hazama, MD: Thank you for having me.

Host Amber Smith: I'd like to start by having you explain the differences between an open surgery of the spine, compared with endoscopic spine surgery.

Ali Hazama, MD: Well, that's a great way to start this conversation. Historically and traditionally, spine surgery has been performed using large incisions and exposures through normal tissue of the body in order to get access to diseased body parts, pathology or problems that have to be fixed. There was really no way of getting to those problems without opening a large skin incision going through muscle in order to fix an issue.

And so, with the advent of this technology and a lot of other technologies that have been assistive in this realm, we are able to do these same procedures, achieve the same results, but using much smaller incisions and causing much less damage or trauma to adjacent tissue that is otherwise normal.

Host Amber Smith: Can you describe for me what the endoscope is and what it looks like?

Ali Hazama, MD: The endoscope is something that has been utilized for many years in different aspects of surgery. It hasn't become as popular because of the technology that really wasn't there yet, in terms of, for example, the picture quality or the display quality. And so once we have gotten there with our camera technology, with the 3D monitors that we're able to use, the technology has been more widely adopted. And so the endoscope is basically comprised of a long tube that's the size of a pencil diameter with a camera right at the tip of it.

And this is our eyes, basically, inside of the body. Inside of this tube is an open channel in which we insert those instruments that we use in surgery in order to perform the various procedures that we normally do with the endoscope.

Host Amber Smith: Is it made of metal or plastic?

Ali Hazama, MD: It is a metal tube, and the diameter of it, again, is the size of a pencil. So you can imagine the size of the incision that's needed to be able to get that inside of the body.

Host Amber Smith: So how hard is it to get through the muscle or go past organs or whatever else is in the way there? Does this just slide through easily?

Ali Hazama, MD: Before the endoscope is introduced into the body, to the pathology, there's usually a guiding wire that goes initially, and this wire is beveled so that it really just travels in between the tissue planes, preserving the tissues. And so the endoscope is able to then slide over that and get access to the target area.

Host Amber Smith: Would you say that it requires more surgical skill to do the endoscopic version? Is it more challenging?

Ali Hazama, MD: Absolutely. So again, traditionally, surgeons are trained using the open techniques. So this is, in the beginning, an unfamiliar approach to the spine. And so these procedures tend to be very technically demanding, and so that's why, even though it's a field that is growing, it's a field that is very promising with excellent results, the adoption of it has been slow because of this required training, this extra technical skills that are needed.

And if you take a second to think about it, we are doing the same surgery using much smaller area to operate, a much smaller corridor. And so that technical skill is much more demanding than what you would need for an open technique.

Host Amber Smith: Does it make a difference that you're not able to put your fingers on something because you're using these tools instead?

Ali Hazama, MD: Even with open surgery, we typically don't use our hands. Sometimes you're able to palpate things, but the actual procedures are done using tools in either approach.

Now, the tools that we do use in the endoscopic world are much more refined. They're much smaller, and they're just much more targeted to pathology that we're treating.

Host Amber Smith: What about the length of the procedure? How do they compare timewise?

Ali Hazama, MD: The length of the procedure really depends on the pathology being addressed. In general, it takes less time to do these procedures than it takes us to do a traditional surgery, and for that, there are quite a few reasons, the main one being the time it takes to really dissect and open up the body in order to access a pathology, which is then addressed.

That alone, the exposure portion of a procedure, takes quite a long time. There's a lot of bleeding that sometimes is encountered that has to be controlled. There's a lot of retraction that needs to be done.

With the endoscopic procedures, we are able to gain access to the pathology within minutes because what we're doing is, we're traversing the tissue, the normal tissue, without really introducing any damage to speak of, directly and arriving at the pathology immediately, as soon as we start, concentrating on and treating the pathology rather than gaining access to these areas.

Host Amber Smith: Does it require the same type of anesthesia?

Ali Hazama, MD: In a lot of cases, yes, but there are a certain number of cases where we're able to perform some of these surgeries with local anesthesia or sedation, without the need for a breathing tube or the general anesthesia that's traditionally used.

Now, one of the things that allows for this is not just the shorter length of the procedure, but also the lesser pain that is associated with this procedure. Again, making an incision that's 10 inches long, it can be very painful for a patient if they're awake, and I hope nobody would ever have to be awake through something like that.

But when you are going in through an incision that's the size of a quarter of an inch or so, that pain associated is easily controlled. We can give local numbing medication. And these things really allow for an awake procedure in a certain subset of cases.

Host Amber Smith: Are there risks of complications with the endoscopic procedures? Are they similar to the risks of open surgery?

Ali Hazama, MD: Very excellent question. One of the main risks that is associated with any surgical intervention is the risk of infection. And we know that the larger the operation, it's traditionally associated with an increased risk of infection. And so with using smaller incisions, with using less tissue dissection and tissue trauma, we have seen that that risk, for example, is much smaller in patients that undergo endoscopic surgery compared to open surgery.

Other risks in the spine tend to be similar. A lot of them happen on a much, much lower rate in the endoscopic procedures than they do in the open procedures.

And when we talk about risks, one of the things that I'd like to bring to your attention is there is a risk associated with a surgery, a procedure, but then there's always a risk of anesthesia. Going under anesthesia comes with its own risk. And so, spending less time under anesthesia, avoiding anesthesia, is definitely something that makes endoscopic spine surgery that much more of a consideration.

Host Amber Smith: Are there ever circumstances where a patient would require an open procedure instead of endoscopic?

Ali Hazama, MD: Yes, absolutely. So endoscopic spine surgery is an excellent option for, again, a subset of patients, a subset of procedures. There are surgeries that sometimes are not amenable to endoscopic surgery. Some of these are traumas. Here at Upstate, we are a Level 1 trauma (center), so, as you can imagine, we receive traumas that are really complicated, very severe.

So these cases are automatically not candidates for endoscopic surgery. Sometimes, spinal tumors, we're able to sometimes perform a biopsy on some of these to get an identification of a disease process, whether it's an infection or a tumor. But larger tumors sometimes do require an open procedure.

So there are cases where traditional surgery is still the standard of care. And so being trained in endoscopic spine surgery, I think, gives an edge to deciding that certain cases are to be done in a certain manner, versus just doing everything in the same old way that traditionally has been done for years.

Host Amber Smith: So even though things seem to be moving toward endoscopic, the new doctors coming up through medical school, they're learning the open procedure, right? Because that's always going to possibly be needed.

Ali Hazama, MD: Yes, absolutely. And again, there was really no way around learning the traditional anatomy, the traditional ways of performing surgeries. Technology like the endoscope is really something that is best used by somebody who's very well trained in the open (surgery) world, in the open realm, and then really concentrates or spends the extra time and effort into perfecting and adding onto that knowledge and that training the usage of the endoscope in spine surgery.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Ali Hazama. He's a neurosurgeon at Upstate who specializes in minimally invasive surgery and the spine.

Now, What is robotic endoscopic spine surgery?

Ali Hazama, MD: More recently, technology has been coming to medicine from multiple different fronts. So the endoscope is only one area in which technology has been adopted, in spine robotics. There is really two components to it.

One is neuro-navigation. So just as you would use, on your phone or in a car, a navigation system to take you from one place to the next, we have neuro-navigation that we use as an added measure of safety in order to guide everything that we do. And so the patient's body and anatomy is displayed on a screen, and all of the tools and the instruments that we are either implanting or using to perform surgery are visible on a screen.

Again, you need the basic knowledge of the anatomy, you need the training into doing these. But this is an added measure of safety. Now, once you have adopted the navigation portion, there is a robot that can be coupled with the navigation and would guide certain implants into position by itself.

Obviously, it needs a lot of surgeon planning and surgeon confirmation that this is where it needs to go, and this is how it should be done, but the robot takes away some of the manual work and really ends up placing implants, especially in the spine, in an ideal position, again, taking away the very little human error that can happen in placement of instrumentation in the spine.

Host Amber Smith: Well, let's talk about some of the types of spinal problems that can be addressed endoscopically. What can you tell us about lumbar fusion?

Ali Hazama, MD: So lumbar fusion is only one of the areas that is being addressed with endoscopic spine surgery. The majority of work that is being done with the endoscope actually does not involve spinal fusion.

So when you hear about disk herniations that cause sciatica, the pain that shoots down to the legs, or spinal stenosis, which is the severe narrowing around the nerves and nerve roots in the lumbar spine or the lower aspect of the human spine, the endoscope can be utilized. Again, gaining access through very small corridors in order to remove a disk, free the nerves of compression, treat sciatica, do more general decompressions of the spinal canal that cause the stenosis around these nerves.

So that's really a lot of what the endoscope is being used for. And so since we have gained so much experience with the endoscope in those areas, most recently, over the last couple of years, I have introduced the endoscope because obviously we have it here, available, at Upstate, at both the Community and the downtown campus.

We have introduced it to perform spinal fusions. And again, those, historically, tend to be the most invasive of the spine surgeries. And so, implementing the endoscope in this area has really impacted the way patient care with regards to the spine has been done, with our patient outcomes and, really, multiple metrics in terms of how patients do during the surgery, how patients do immediately after the surgery.

And it also affects patient performance and well-being years down the road from surgery. I'd like to really elaborate on this point: When it comes to using the endoscope, again, it's a great tool. I am more excited about it than anything else that we use here, but it's only a part of this philosophy of introducing less tissue damage to the spine.

So it's not just a cool gadget that we're playing with and using because the pictures are crisp and everything looks cool, which may be true, but it is really a part of a larger philosophy of patient care, of surgical care, where less tissue trauma, less violation of normal human tissue, is really the essence of this line of service.

And so, we spoke briefly about shorter surgical time, less blood loss. So the time of surgery is decreased, patients tend to wake up from surgery faster, tend to recover faster. The pain after the surgery is much better controlled and is generally less than an open procedure.

And then finally, in that same area, the discharge to home from the hospital is much shorter. So the patient is spending in the hospital one or two days instead of spending five days or a week after one of these procedures. So that's on the time during the surgery. When we looked at, and when other institutions, through research and review of these cases, looked at long-term effects of introducing less trauma to the spine, we found that spinal fusions tend to hold up better, tend to be more successful, and tend to cause less issues to adjacent levels, so nearby segments that did not need surgery, that in the future may develop a problem.

Host Amber Smith: So what are the long-term benefits?

Ali Hazama, MD: We spoke about the short-term benefits around the time of surgery when performing endoscopic and minimally invasive spine surgery. Now, on the other hand, there are long-term benefits to performing these procedures.

When we looked at how people did after an endoscopic spine surgery versus a traditional surgery, because of less trauma introduced to the normal tissue and the normal spine around the area of the surgery that was performed in the long term, people that underwent minimally invasive and endoscopic spine surgery tended to fare much better with how their overall long-term performance and recovery was.

And one of the specific areas that I want to mention is a problem known as adjacent segment disease. So around the area of a fusion, there is always a chance that a level above or below, a level adjacent to, the original surgery, may start to wear down and become problematic, just as the initial level was.

And so in these procedures, in the endoscopic procedures, we found that in the long term, this is less of a likelihood to happen compared to an open procedure, which I think is a win-win. If you can avoid additional surgery in the future, that is something that I think I personally would like if I was to ever have spine surgery.

Host Amber Smith: Do you hear from patients who have been told they need spine surgery, and they've avoided it over the years, but now that this is available, they're willing to go through with it?

Ali Hazama, MD: Yes, absolutely. Again, just to add to your question, the best surgery that we do is no surgery, and that's why I am very proud to report, in any venue that I'm invited to speak at, that upwards of 80% of the patients that we see, we're able to manage with conservative treatments, save them from surgery, because historically and from what we know, back pain is one of the most common complaints in health care.

In addition to that, we know that most back pain is a temporary problem that can be managed with conservative means, whether it's physical therapy, pain management, injections, only the subset of cases where the pain lingers, where it causes neurologic issues, where it interferes with life and activities that people like to do, only at that point does it become a surgical problem.

And so, back to your question, there have been instances where patients have been turned down from spine surgery due to the invasiveness of the procedure and really the risk that it imposes on a patient's overall health. And so with these procedures, we're able to do things that we are not able to perform in the traditional sense, just because of the overall impact of such larger operations on the overall health of the patient.

Host Amber Smith: Can endoscopic procedures be done anywhere along the spine, including the neck?

Ali Hazama, MD: Yes. And actually it's one of my favorite procedures to do. Instead of a spinal fusion in certain pathologies, again, we're able to do a very small incision in the back of the neck to do what's called a diskectomy, or a resection of a disk that is herniated, that impinges on a nerve that comes to the arm that would cause arm pain, for example.

And it's a very gratifying procedure because usually the pain is so severe and the patients come out of surgery with much improved pain and really satisfied with the results of their surgery.

And in addition, if you look at the alternative, the alternative to doing that would be doing spinal fusion, which sometimes, again, is a little bit more invasive, comes with some restriction of movement, compared to, obviously, a non-fusion surgery.

Host Amber Smith: Well, let me ask you if you would, please, tell us how you tell patients to prepare for an endoscopic procedure.

Is there anything special they need to do the day before or the morning of?

Ali Hazama, MD: There's really no additional preparation or anything other than undergoing any other surgery.

One of the positives for after the procedure, for people that want to go back to work and resume doing the activities that they like to do, is those restrictions, a lot of times, are much less than those that come with open surgery. So we've had patients that have had spinal surgery using the endoscope on a Friday and went back to work on the next Monday.

Again, it takes the personality and the want to do that, but also, experiencing that amount of relief in the pain helps with being able to do that.

Host Amber Smith: Well, I'm sure it's kind of individualized to whatever the issue was that the person had the surgery for, but initially, is recovery like the open surgery, are they groggy and in pain?

Ali Hazama, MD: The pain is usually much less than open surgery. Patients are able to begin moving much faster. And again, because the pain tends to be a limiting factor for movement, if you move and you get pain, you're really not going to try and move as much. It's, I guess, a protective mechanism against pain.

When you don't have as much pain, I think your ability to move and ambulate and get on the way to recovery is much quicker.

The second point I'd like to make here is the usage of pain medications after surgery. In a lot of these cases, we're able to avoid using medications like narcotics, and it's an epidemic, or an endemic, that the country has been really ravaged by, and so the less opioids that we have to use is always the better. And this is an area where we're able to do that.

Host Amber Smith: Well, this is really encouraging and exciting, and I'm really appreciative that you took the time to explain it to us, Dr. Hazama.

Ali Hazama, MD: Thank you so much for having me. This is a pleasure, and I'd love to come back here for another update, hopefully in the future.

Host Amber Smith: My guest has been Dr. Ali Hazama. He's an assistant professor of neurosurgery at Upstate and director of neurosurgery at Upstate Community Hospital.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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