A Minimally Invasive Disc Replacement? Should We Police the Use of the Term?
POSTED ON 6/24/2018 IN Regenerative Medicine Education BY Chris Centeno
This week I noticed a surgical sales rep on LinkedIn use the term "minimally invasive" when describing a disc replacement. I was dumbfounded as there is nothing minimally invasive about inserting a metal hockey puck in the front of a patient's spine. This bizarre marketing ploy fits with what I have seen elsewhere: the abuse of the term minimally invasive to push a product. Why should we care? Because companies use the term minimally invasive because it convinces patients that a procedure has drastically fewer side effects. Let me explain.
The Origin of the Term Minimally Invasive
Way back when, in the '80s and '90s, the average fiftysomething-year-old male being admitted into the hospital had a zipper-type scar on his sternum from an open heart surgery. Hence, when the ability to use balloon angioplasty came around, the term "minimally invasive" began to be thrown around. After all, these procedures involved placing a catheter into the groin as compared to cracking a chest open for open heart surgery.
Minimally Invasive in Orthopedics
When arthroscopy came around in the 1970s, it was minimally invasive compared to open joint surgery. Meaning the smaller portal incisions used to place the arthroscope were much smaller than the open incisions needed to visualize the whole joint. However, while that distinction is clear, the use of the term in orthopedic care has, regrettably, been about as transparent as the Mississippi River.
A Minimally Invasive Disc Replacement?
The biggest safety issue I see is that this moniker has been added to countless device products to sell products, and this confuses patients. For example, we now have "minimally invasive" knee replacements and hip replacements. However, there is nothing about replacing a knee or a hip that's minimally invasive. In fact, you're amputating a joint and then shoving a prosthesis into the incision. Hence, all you get is a smaller incision through which you're performing maximally invasive surgery. The same holds true with a disc replacement. You're removing the patient's existing disc and then shoving a small hockey puck-sized piece of metal through an incision. If you make the incision smaller, does it really matter? As an example, if I downsize a nuclear bomb so it fits into a briefcase, is the collateral damage any less when it explodes? Meaning, performing a maximally invasive procedure through a minimally invasive hole seems more like a marketing stunt than a serious reduction in patient risk.
The "Minimally Invasive" Birmingham Hip
Around 2010 or so, I began to get bombarded by patients with severe hip arthritis who weren't stem cell candidates but who were enamored with the new "minimally invasive" hip replacement called a "Birmingham hip," or "hip resurfacing." As I looked this up, as a physician, it was clear to me that the use of the term here was more a marketing gimmick than an actual huge reduction in the risk of the procedure. Why? While the procedure cut away less bone and used a smaller anterior incision, it was still the amputation of a joint and the insertion of a prosthesis. Meaning, in principle, there was prima facie evidence that it was still a hip replacement. It wasn't long before research papers began to be published on the Birmingham, or minimally invasive, hip. Turns out its metal-on-metal design produced copious wear particles that looked like black soot on reoperation. I talked with quite a few surgeons who were blown away by the mess these devices could create. Then the research began to show such goodies as pseudotumors and severe tissue reactions. Finally, a startling 40% five-year failure rate was reported. In the end, the "minimally invasive" Birmingham hip ended up having more complications than a maximally invasive hip replacement.
Interventional Orthopedics Changes Everything
In orthopedics, the only true "minimally invasive" procedure has traditionally been arthroscopic surgery. However, now there's a new kid on the block—interventional orthopedics. Meaning procedures that can heal damaged orthopedic tissue and that are performed percutaneously (through an injection) rather than through an incision. This steep reduction in tissue trauma is highly likely to be associated with far fewer complications. In fact, our recent safety paper demonstrated sharp reductions in side effects for patients who opted for interventional orthopedics (IO) versus the published rates for traditional surgery. So what is interventional orthopedics? First, we can start with what's it's not:
- A nurse or PA performing a simple joint injection in a chiropractor's office is not IO.
- An orthopedic surgeon blindly injecting a knee is not IO.
To learn more about this new and truly minimally invasive technology, see my video below: [dk-video id="e6fMXKsELT8" autoplay="false" button="white" title="" show-title="false" width="70%" align="aligncenter"] The upshot? So inserting a hockey puck disc into the spine or a hip prosthesis through a smaller incision is NOT minimally invasive. Why? These procedures would have similar side effect profiles to their counterparts that use bigger incisions. However, getting rid of the need for more invasive surgery by performing procedures through a needle with advanced imaging guidance is truly minimally invasive. So the next time you see the moniker "minimally invasive" on a big surgical procedure, it's more likely to be a marketing gimmick than something that will truly make you safer. Buyer beware!
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- hip osteoarthritis
- lower back surgery
- surgical risk