In October 2018, Britain’s Princess Eugenie made news the world over for her choice of wedding gown. Not because the dress was haute couture, but because it showcased a long scar running down her back, the result of a spinal surgery she had as a child. Interestingly, she chose to wear her scar with pride so as to honour the medical professionals who had helped her, and to inspire other patients with scoliosis (curvature of the spine).
Unlike Princess Eugenie, however, not everyone wants to have their scars on show. In fact, many patients prefer not to be left with any obvious scars after their surgery.
Thanks to technological advances these days, patients who require certain spinal surgeries can either go for traditional open surgery or opt for MIS, a newer approach that leaves less noticeable scars and offers a shorter recovery time.
Open surgery vs minimally invasive surgery (MIS): what’s the difference?
Traditionally, spine surgery is performed as ‘open surgery’, meaning that the surgeon makes a long incision along the patient’s back, and cuts and retracts any surrounding muscles to access the spine. Then, depending on the type of procedure, the surgeon proceeds to remove any damaged bone or intervertebral discs, or place screws, cages and bone graft materials necessary to stabilise the spine. Once the surgery is complete, the long incision is sutured up and left to heal, which could take up to several months.
Conversely, MIS is a more localised procedure. With MIS, the surgeon relies extensively on image guidance technology such as pre- and intraoperative 3D imaging, fluoroscopy, CAT scans and intraoperative navigation to plan the surgical approach. The surgeon begins by making small incision(s) directly over the pathological area(s). Then, special retractors are used to help dilate soft tissues and move muscles out of the way, instead of dissecting them like in open surgery. At the end of surgery, sutures are placed to repair the small incision(s).
MIS allows the surgeon to use techniques to limit the size of the incisions that need to be made. Done by an experienced surgeon, it could mean a safer surgery with less blood loss and lower chance of contracting a wound infection. You will usually heal more quickly, spend less time in the hospital, and feel more comfortable while recovering.
Is MIS better than open surgery for the spine?
Based on tracking studies, MIS has been shown to produce similar long-term results as open spine surgery. However, from a cosmetic point-of-view, MIS is a superior approach as it leaves behind much smaller scars. MIS scars are usually only 2 inches or less, whereas open surgery scars are typically 5 – 6 inches long.
However, it is not only about the size of the incisions or scars. It is about minimising unnecessary collateral damage to surrounding tissues, without compromising the tried-and-tested aims and outcomes of open surgery. Because MIS does not involve a long incision or muscle dissection, the risk of tissue damage and post-operative complications is greatly reduced. Many patients report a smoother recovery process and can return to normal activity faster.
In fact, a study published by Dr Yue in 2013 found that for patients who had undergone transforaminal lumbar interbody fusion (TLIF), a surgery that stabilises the spine by creating a solid bridge of bone between spinal bones, those who opted for MIS:
- Experienced about 3 times less blood loss during the operation
- Required close to 4 times less painkillers on average after the operation
- Were confined to bed for only half the usual time needed
- Were hospitalised for around half the duration compared to open surgery patients
- Shared similar longer-term results as open surgery patients when observed over a 5-year period
Furthermore, a separate study also showed that MIS spinal surgery patients were more than 5 times less likely to develop infection at the surgical site compared to patients who had undergone open surgery.
Are there any downsides to MIS surgery?
While MIS offers many advantages, a surgeon’s familiarity with the procedure can greatly impact its success.
Based on a study conducted by Dr Yue between 2005 and 2009, proficiency in MIS TILF procedures can only be achieved for most surgeons after 44 operations. For their patients, this translates to shorter operation times, less pain and improved relief for their condition.
Also, as MIS is a newer approach, there is still a relative lack of research regarding more rare and complex spinal conditions.
If you’re considering spinal surgery, do consult your surgeon to discuss the treatment options available and how you can benefit from the procedure.
Article reviewed by Dr Yue Wai Mun, orthopaedic surgeon at Gleneagles Hospital
Five-year outcomes of minimally invasive versus open transforaminal lumbar interbody fusion: a matched-pair comparison study. Retrieved on 16 November 2018, from https://www.ncbi.nlm.nih.gov/pubmed/23963015
Does minimally invasive surgery have a lower risk of surgical site infections compared with open spinal surgery? Retrieved on 16 November 2018, from https://www.ncbi.nlm.nih.gov/pubmed/23846605
Learning curve of a complex surgical technique: minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Retrieved on 16 November 2018, from
Minimally-Invasive vs. Traditional Open Spine Surgery: Explained. Retrieved on 16 November 2018, from https://spinecenterbr.com/minimally-invasive-vs-traditional-open-spine-surgery-explained/
Surgery vs Traditional Surgery: Pros and Cons. Retrieved on 16 November 2018, from https://www.neurosurgeonsofnewjersey.com/minimally-invasive-spine-surgery-vs-traditional-surgery/
Minimally Invasive Spine Surgery vs. Open Spine Surgery. Retrieved on 16 November 2018, from