Vice Chairman & Head - Ortho Spine, MIS & Robotic Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi
Part 7 of 8 in Advances in Spinal Surgery Technology
Bringing Minimally Invasive Spine Surgery to Resource-Limited Settings
May 26, 2024
For doctors in resource-limited settings, the biggest barrier to offering minimally invasive spine surgery locally may not be technical at all.
The obstacle is in the mind
Minimally invasive spine surgery is achievable in tropical, resource-limited areas once local doctors take the initiative, supported by partnerships that bring in training and expertise. In a recent example, three minimally invasive spinal surgeries, two of them revisions of prior laminectomies, were performed in Abuja, Nigeria, over two months; all three patients were walking the next day, and this led to inquiries from ten different hospitals wanting to start similar programmes.
Training local doctors
Building sustainable local capability means training local doctors directly, including bringing fellows to India for hands-on training, so minimally invasive spine surgery becomes something local teams can perform themselves rather than depending on visiting surgeons indefinitely.
This article is based on a Jivo Masterclass session conducted by Dr. Puneet Girdhar, Principal Director & Head, Ortho Spine, MIS & Robotic Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Puneet Girdhar taught doctors across Africa on May 26, 2024.
FROM THE LIVE Q&A
Moderator
At what point can we say scoliosis bracing has failed and surgery is indicated? Also, for the interbody cage, can long plates not be used instead?
Dr. Puneet Girdhar
For idiopathic scoliosis, once the curve goes beyond 40 to 45 degrees, bracing has failed and surgery is indicated. On plates: long plates such as Steffee plating are no longer used - for the last 15 to 20 years, the standard has been transpedicular screws with a titanium or PEEK cage instead.
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Frequently Asked Questions
What are the possible obstacles to performing minimally invasive spine surgery in tropical, resource-limited areas?▼
There is no real obstacle - the obstacle is in the mind. As an example, three minimally invasive spine surgeries (two of them revisions of prior laminectomies) were performed in Abuja, Nigeria over the last two months, and all three patients were walking the next day; this has already led to inquiries from ten different hospitals wanting to start similar programmes. It is a matter of local doctors taking the initiative, supported by training and partnership.
What would be the medical method for the management and support of individuals with discopathy (disc disease)?▼
The first line is medicine and physiotherapy. If that doesn't help, a nerve block injection is the next step. If that also fails, endoscopic surgery is used.
How long will it take with rehabilitation for a patient to regain full mobility after spinal arthrodesis (fusion)?▼
With minimal invasive and robotic techniques, the patient walks the same day, is discharged in one to two days, can return to work within a week, and can return to active sports within three weeks.
Why is spinal arthrodesis still the technique of choice when a majority of patients who benefit from it develop vertebral listhesis (adjacent-level problems) after years?▼
It is by far the best solution science has invented so far. Vertebral listhesis develops in some patients, not the majority - of around a thousand operations a year, only a small subset develop problems at another level. Just because a surgery might cause a problem many years down the line doesn't mean a patient in pain and unable to walk today should be denied its benefit now - the same reasoning applies to a liver transplant, which is offered even knowing it may extend life by only five to ten years.
Given that a normal disc diameter is around 14-20mm, what is the limit at which surgery is needed - for example, for someone with only 7mm who is still working?▼
Don't measure the millimetres, measure the patient's symptoms. Surgery depends on the patient's symptoms and what treatment has already been tried, not on the measurement alone. If medicine and physiotherapy haven't relieved symptoms, surgery to extend the fusion may be needed regardless of the exact disc height.
Can minimally invasive spine surgery be done in resource-limited settings?▼
Yes - the main obstacle is not technical but a matter of local doctor initiative and partnership support, as demonstrated by successful MIS surgeries performed in Abuja, Nigeria.
How is local capability for MIS spine surgery built sustainably?▼
By training local doctors directly, including bringing fellows to India for hands-on training, so local teams can eventually perform these procedures themselves.
In This Series: Advances in Spinal Surgery Technology
- 1.Advances in Spinal Surgery Technology
- 2.The Technology Behind Modern Spine Surgery
- 3.Robotic Spine Surgery: Accuracy and Outcomes
- 4.Minimally Invasive Surgery for Disc Herniation and Spinal Stenosis
- 5.Scoliosis: Warning Signs and When to Brace or Operate
- 6.Complex Spine Reconstruction: TB Spine, Revisions and Delayed Referral
- 7.Bringing Minimally Invasive Spine Surgery to Resource-Limited Settings
- 8.Spinal Fusion, Symptom-Based Surgery Decisions, and Spine Nutrition