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cal techniques that we incorporate that can lessen the injury to the regular nor-
mal soft tissues around the spine.
"The optimal positioning depends on the patient's anatomy and what needs to
be done," says Dr. Liu. "There are natural cavities we all have in the belly and
those cavities can sometimes be used to get down to the spine without stripping
out a bunch of muscle to get there. There are also fewer muscles to go through
with lateral or anterior approaches than there are with the posterior route."
Unfortunately, sometimes there are no good minimally invasive options, he
says, so an open procedure may be the better choice. The primary mitigating
factors are typically the location of the stenosis and the size of the patient.
"Obesity is probably the biggest limiting factor," says neurosurgeon Alan
Villavicencio, MD, of Boulder (Colo.) Neurosurgical and Spine Associates. He
routinely performs outpatient minimally invasive transforaminal lumbar inter-
body fusions, which he calls a kind of "mini-open" approach.
Older patients may not be good candidates, either. "But usually if you're
young enough and thin enough, we can do it," says Dr. Villavicencio.
With less muscle damage, patients can recover much more quickly, but con-
trolling pain without massive doses of opioids is a primary consideration.
root, the superior border of the caudal vertebra and the superior articular
process). Using bilateral imaging, the surgeon places a dilator and access portal,
creating a sealed connection from the skin to the disc. The discectomy is then
performed entirely through the portal, and the disc space is packed with tricalci-
um phosphate soaked in autologous bone marrow aspirate. After the portal is
removed, a specially designed cage is inserted through the muscle fibers into the
intervertebral space, and the interbody fusion is accompanied by percutaneous
posterior fixation.
Though it can provide substantial correction of deformities, the primary aim,
says Dr. Abbasi, is to improve symptoms by providing decompression and
increasing structural support to the anterior and posterior column.
— Jim Burger
