Clinical Advances in Minimally Invasive Spinal Neurosurgery

Neurosurgeons at Massachusetts General Hospital's Minimally Invasive Spinal Neurosurgery (MISN) Program are advancing MISN for intervention in a wide range of challenging diagnoses, including spinal deformities and tumor-related diseases.

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"We're uniquely situated in the sense that we see extremely complex patients, but we also have techniques and technical advantages that let us be creative about how we can find solutions for them to maintain their function," Theresa Williamson, MD, MPH, director of MISN, which is within the Neurosurgical Spine Service at Mass General.

Applying MISN to Complex Spinal Conditions

MISN includes any type of spinal neurosurgery that uses a small incision and spares dissection of muscle. Unlike large incisions used with open surgeries, MISN uses a tube to dilate soft tissue between muscle fibers. "When we look at MRI studies, we find that when you cut the muscle from its attachment to the bone, you often kill that muscle. One of the nice things about the tube is that it just dilates," observes Dr. Williamson.

A 2023 study published in Neurosurgical Focus compared fusions that used MISN instrumentation with conventional open procedures for lumbar degenerative disease. The study cited lower complication rates of blood loss and a similar rate of neurologic improvement to open procedures.

Mass General's spinal neurosurgeons also use MISN for rare procedures such as hematoma resection, removing the mass through a tube. Dr. Williamson recently used MISN to correct a large scoliotic curve caused by disc degeneration.

"We used anterior and lateral approaches to put in the cages and screws," she explains. "Instead of making a large incision and exposing all the anatomy, we were able to do it through smaller incisions with image navigation guidance and avoided huge muscle dissections."

According to Dr. Williamson, some conditions are still better suited for open surgeries—such as acute spinal cord compression, osteotomy, or a large burden of metastatic disease. However, advanced techniques and technologies enable Mass General's surgeons to apply creative microsurgical solutions to complex disorders that help patients maintain better function.

Using MISN for Motion-sparing Procedures and Spinal Cord Stimulation

Mass General uses MISN for two kinds of procedures that fall into a different category of spinal surgeries: motion-sparing procedures and spinal cord stimulator implantation.

Unlike spinal fusions, which restrict motion, motion-sparing procedures relieve pressure on the spinal cord and preserve a range of motion. As an alternative to cervical fusions, Mass General's neurosurgeons use MISN to perform discectomy and cervical arthroplasty with an artificial disc.

Dr. Williamson notes that motion-sparing procedures are particularly advantageous for younger patients, given the reduced mobility that fusions create. These procedures also reduce the risk of bone and disc degeneration at other levels of the spine.

Mass General neurosurgeons consider surgically implanted spinal cord stimulators for patients who suffer from chronic pain. "This can be done as an outpatient procedure in conjunction with our Neurosurgical Spine Service pain management team," says Dr. Williamson. A 2023 systematic review and meta-analysis published in the European Spine Journal concluded that spinal cord stimulation is an effective treatment for chronic pain relief.

David Hao, MD, an anesthesiologist and chronic pain specialist at the Mass General Pain Management Center, collaborates with Dr. Williamson using spinal cord stimulation or neuromodulation. This technology sends electrical impulses to the spinal cord, adjusting pain signals traveling to the brain.

"Spinal cord neuromodulation is a minimally invasive technology that is an option for treating multiple chronic pain conditions, particularly those that might not respond to other treatments, including surgery," explains Dr. Hao. "Our coordinated approach to spinal cord neuromodulation means our patients can access the most advanced and effective therapies to treat their conditions."

Leveraging Advanced Technologies: Virtual Augmented Reality, Spinal Endoscopy and Robotic-assisted Systems

Today the Neurosurgical Spine Service uses leading-edge virtual augmented reality technology to allow surgeons to better visualize patients' anatomy and enhance surgical precision.

Mass General is in the process of adding two technical advances to further enhance its MISN capabilities: spinal endoscopy and robotic-assisted systems. They are:

• Virtual Augmented Reality: Employing cutting-edge virtual augmented reality technology, neurosurgeons at Mass General wear glasses equipped with augmented lenses. This innovative technology was introduced to MGH by Dr. John Shin, the Director of the Neurosurgical Spine Service, who emphasized the benefits of using virtual reality in Minimally Invasive Spinal Neurosurgery (MISN). "The glasses project an image of the spine, allowing surgeons to view the patient's anatomy while they work, eliminating the need to refer to a remote screen. This enables precise navigation of screws or cages through the augmented lens," explains Dr. Shin
• Spinal endoscopy: Dr. Williamson explains that she anticipates surgical teams will be able to perform decompression surgeries via an endoscope while simultaneously performing lateral approach fusions
• Robotic-assisted systems: Studies have shown the advantages of robotic-assisted systems to aid surgeons with precise instrument placement. Today Mass General's neurosurgeons use X-ray navigation guidance to enhance visualization during MISN. Robotic-assisted systems will help surgeons find trajectories more easily and minimize radiation exposure for both physicians and patients. "You can actually plan your whole surgery beforehand and set out all the coordinates," says Dr. Williamson. "Then the robot will show you exactly where you're going"

Dr. Williamson is excited in her role as director of MISN and the potential of the treatments to help maintain patients' motion and mobility. And she sees a wider benefit.

"I think we should all be thinking about the breadth of disease processes that can be taken care of by MISN. I think it's something that should be accessible to patients from all backgrounds and I believe in talking a little more broadly about who could potentially benefit from this type of surgery."

Refer a patient to the Neurosurgical Spine Service

Refer a patient to the Minimally Invasive Spinal Neurosurgery Program