Minimally Invasive Spine Surgery: One Innovator's Journey

Bret S. Stetka, MD

Disclosures

January 17, 2019

Editorial Collaboration

Medscape &

Sheeraz Qureshi, MD, MBA

Minimally invasive techniques are reshaping the field of spine surgery. With innovative technology and better tracking of patient outcomes, these surgeries are reducing the functional and recovery burdens previously associated with traditional spine surgery.

One of the key innovators in this field is Sheeraz Qureshi, MD, MBA, associate attending orthopedic surgeon at Hospital for Special Surgery (HSS) and associate professor of orthopedic surgery at Weill Cornell Medical College in New York City. Medscape spoke with Dr Qureshi about how he first came to orthopedic surgery, the techniques and technologies that have given rise to minimally invasive spine surgery, and the ongoing research he's involved with that aims to give patients a clearer picture of their postprocedure recovery.

A Passion for Sports Leads to a Career in Orthopedics

Medscape: What originally led you to your interest in orthopedic surgery?

Qureshi: I went to medical school specifically with an interest in doing orthopedic surgery. My initial passion was really based around growing up playing sports, and orthopedics was the field of medicine that is most connected to sports. But when you actually learn about it, you realize that's just a small piece and the field contains so much more.

I really love the combining of clinical decision-making with the ability to use your hands in an operating room, and there being sort of an art form to it. There is this very nice breadth and variety in doing big things, such as hip replacements and scoliosis correction, and then really fine things, such as microsurgery when you're removing a little herniated disk or fixing an artery in the hand. That was an immediate attraction to me.

Then, of course, the thing that we all love with orthopedic surgery is that there is a bit of immediate gratification, because patients do tend to get better relatively quickly and a lot of those improvements are pretty permanent.

Medscape: Where did you go for your residency?

Qureshi: Mount Sinai in New York City in orthopedic surgery, and then I did a fellowship specifically in spine surgery at Case Western Reserve in Cleveland with Henry Bohlman, who is considered one of the fathers of modern spine surgery.

Then I returned to Mount Sinai for almost a decade as a practicing spine surgeon and director of the spine surgery fellowship. I was also the chief of minimally invasive spine surgery there. Then about 2 years ago, I was recruited to come to HSS to develop a minimally invasive spine program here.

Medscape: In that role, you're dedicated to the spine, right? You don't do other procedures anymore?

Qureshi: That's correct. I have the luxury of being in an environment where I can be hyperfocused specifically on minimally invasive spine surgery.

Medscape: What sort of conditions are you most commonly treating?

Qureshi: I primarily do adult spine surgery, which includes problems of the cervical, thoracic, and lumbar spine. Generally speaking, it deals with such things as herniated discs; spinal stenosis; spondylolisthesis; and, occasionally, degenerative spinal deformities.

On average, I'm operating about 3 days a week and probably perform a little over 300 surgeries a year.

Moving to Minimally Invasive

Medscape: The minimally invasive approach to spine surgery has sort of become your calling card. How did you first get involved in that?

Qureshi: That's my passion and my niche. One of my attractions to going to Cleveland to train with Bohlman was that not only was he known for being an incredible teacher and a mentor, but also for allowing his fellows to be free thinkers. A lot of his fellows before me were leaders in their various fields. Although my fellowship was considered a very open traditional one, while I was there I really got to think about, develop, and gain some experience in certain minimally invasive techniques.

My interest developed from my orthopedic training, during which everything was being done less and less invasively. Of course, one of the initial things we learn in medicine is "First, do no harm." For me, minimally invasive surgery really meant getting to that point. How do we solve the same problem, but create less collateral damage?

Having the ability to translate some of that orthopedic experience, whether it came through something such as arthroscopy or limited trauma surgery, I started to think about how to do limited-access spine surgery. It was at a time where other early adopters like me were also thinking about these things. I could see that they were on to something, and I wanted to make this my passion as well.

Medscape: What does "minimally invasive surgery" mean, exactly? What sort of approaches do you use?

Qureshi: It's a tough question to answer, because "minimally invasive" doesn't have a true definition. It simply means that we are treating the same spinal conditions as traditional open surgery, but accessing the spine in a way that tries to maximize the protection of the stabilizing soft-tissue structures. That's probably the best definition. For me, that means trying to avoid cutting any muscles or removing any bone structures not involved in the specific pathology of the patient.

A good example is performing a spinal fusion surgery, which is something that people immediately picture as a big surgery with lots of downtime. I perform that surgery through three or four 16-mm skin openings, preserving all of the paraspinal muscles and completing it in about 1-1.5 hours. The patient can go home the same day or the next day, because there isn't a lot of pain or instability created by the surgery itself, given that we're protecting those soft-tissue structures by accessing the spine in a very different way. But if you looked at the patient x-ray, you would still see screws, rods, cages, and all of the things that we have to use in traditional spine surgery. They just got there in a very different way.

Operating in Three Dimensions

Medscape: How is that accomplished? Are you using a series of small scopes that you place into the incisions?

Qureshi: It depends on the type of case, but yes, it's usually a series of little dilators, guide wires, and imaging technology that is so critical.

I use something called "three-dimensional navigation" intraoperatively. It's almost like you're playing a video game where you're placing something on the patient's spine. It shows up on the screen as a CT model of their spine, and in real time, you can watch in three dimensions where you're placing things. You don't need to have a giant exposure just to be able to see the areas where you're putting these things, because the imaging technology allows you to have that visualization without removing skin, muscle, ligaments, and other things.

Collaborative Efforts

Medscape: What type of team are you currently working with at HSS?

Qureshi: We have very busy clinical and translational programs focused around minimally invasive spine surgery, and a pretty large research group helped greatly by my research coordinator Katherine.

I have international research fellows who come to spend some time with me from around the world. Currently we have some very bright people, including those from India, Japan, and the Middle East. They're dedicating their careers to spine surgery and spending anywhere from 1-2 years with us, looking at the clinical outcomes in minimally invasive surgery.

Medscape: I'm curious about how you work with the neurosurgeons. For example, if you discover a nervous system issue during surgery, do you bring in a neurosurgeon at that point?

Qureshi: We handle it ourselves. We have a very nice collaborative relationship with our neurosurgical colleagues, of course, but spine surgery is one of these fields now where several of our fellows are neurosurgeons. They go through a neurosurgical residency but come and do spine fellowship with us.

Nowadays as a spine surgeon, it's really a question of which highway you took to get to the same beach. Once you're at the beach, everybody sort of does the same stuff if their practice is really dedicated to spine surgery.

Creating More-Informed Patient Expectations

Medscape: What research projects are you involved in around minimally invasive surgery?

Qureshi: Our focus is on looking at what problems people are coming in with, by using patient-reported outcomes measures, which are essentially questionnaires that have been validated in spine surgery. In a sense, they assign people a certain number in terms of the severity of their problem, which we then use to see whether we can predict who is going to improve with surgery versus without surgery. It also allows us to compare the effectiveness of different procedures, so we can see what might help one set of patients versus another and whether there are certain advantages in how quickly people can return to function.

It's always surprising to patients that we don't have a very good answer right now about their projected recovery. If they were going to have surgery tomorrow and asked when they could return to work, we don't have a great answer for that very important question that affects peoples' lives.

We're trying to be the first to really look at that not just anecdotally, but scientifically. For example, if you have a herniated disc at L4-5 on the left side that's causing this amount of pressure on your nerve and we do this particular operation minimally invasively, we want to be able to say that after the procedure you'll be at this level of pain, you're going to be able to walk a certain distance, or you should be able to drive, all at specific time points. It's about giving people a realistic and appropriate expectation so that they can be more educated in their decision-making.

Oftentimes with traditional spine surgery, because the recoveries are so long, the mantra is that we'll delay surgery until you're absolutely miserable. However, with minimally invasive procedures, we're really turning that on its head by saying, actually you should have this done before you're miserable, while we can still do something that is minimally invasive and prevent you from ever getting to that point. That is really going to allow you to have the best result.

Medscape: You got into this field because of your interest in sports. Are you still actively playing sports?

Qureshi: I'm an avid exerciser. I do Barry's Bootcamp as often as I can, because I have to do things now that don't require teams. But I did run my first 5K this past Saturday and came in first in my age group, so I was pretty psyched about that.

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