The flagship of Dr. Melamed's minimally invasive practice is Biportal Endoscopic Spine Surgery (BESS) — two sub-centimeter incisions, one for a camera and one for fine instruments, with saline flowing to keep the view crystal clear. Depending on the case, he also uses tubular retractors and other muscle-sparing techniques that spread tissue rather than sever it.
Across all of these, the principle is the same: reach the target through a narrow corridor, remove or repair only what needs it under magnified vision, confirm the nerve is free, and close. Because the working field is so controlled, many of these procedures are done on an outpatient basis.
Dr. Hooman Melamed offers multiple types of minimally invasive surgical techniques, each tailored to the unique needs of the patient. Below are just a few of the procedures he offers.
Biportal Endoscopic Spine Surgery (BESS)
Biportal Endoscopic Spine Surgery (BESS) represents a significant leap forward in the field of minimally invasive spine surgery. This groundbreaking technique offers patients a less invasive yet highly effective alternative to traditional open spine procedures.
At the core of the BESS procedure is its innovative use of two small portals, each carefully positioned to maximize surgical precision and minimize disruption to surrounding tissues.
- One portal serves as the entry point for a miniature camera, known as an endoscope, about 4mm. This advanced optical instrument provides the surgeon with a clear, magnified view of the spinal anatomy on an external monitor. This magnified view allows for intricate visualization of nerves, discs, and bone structures, far surpassing what is typically visible with the naked eye in open surgery.
- The second portal is utilized for the insertion of specialized surgical instruments. These micro-instruments are meticulously designed for delicate work within the confined spaces of the spinal column, enabling the surgeon to precisely remove problematic tissue while avoiding damage to healthy structures.
This dual or bi-portal approach provides an unparalleled level of control and visibility, allowing the surgeon to navigate the complex landscape of the spine with exceptional accuracy.
BESS is particularly effective for addressing a range of spinal conditions that cause nerve compression and pain, including:
- Herniated Disc Material: When the soft inner material of a spinal disc protrudes and presses on a nerve, BESS can precisely remove the offending disc fragment, relieving pressure and alleviating symptoms.
- Bone Spurs/Calcifications: Over time, abnormal bone growths (osteophytes or bone spurs) or calcium deposits can form on the vertebrae, narrowing the spinal canal and impinging on nerves. BESS allows for the precise removal of these bony obstructions.
The advantages of BESS over traditional open spine surgery are numerous and significant for patients:
- Less Postoperative Pain: By avoiding the need for extensive muscle cutting and bone removal, BESS dramatically reduces tissue trauma, leading to significantly less pain after surgery.
- Faster Recovery: Because the procedure causes less disruption to surrounding tissues, patients often experience a much quicker recovery period, allowing them to return to their daily activities sooner.
- Reduced Risk of Complications: BESS’s minimally invasive nature translates to a lower risk of complications such as infection, blood loss, and nerve damage compared to more invasive open procedures.
- Preservation of Spinal Stability: Unlike some traditional surgeries that may require the removal of significant bone, BESS aims to preserve as much natural spinal anatomy as possible, contributing to long-term spinal stability.
- Smaller Incisions and Minimal Scarring: The small portal incisions result in less noticeable scarring, which is a cosmetic benefit for many patients.
- Avoiding much bigger operations: BESS has helped many patients avoid much bigger operations such as fusion and artificial discs thus preserving patient’s own natural discs and anatomy.
For those seeking an advanced, patient-centric approach to spinal care that prioritizes minimal invasiveness and optimal outcomes, BESS offers a compelling solution. To delve deeper into the BESS procedure and understand the specific conditions it can effectively treat, further information is readily available.
Minimally Invasive Lumbar Micro-Discectomy and Microdecompression
A minimally invasive lumbar discectomy may be used to treat a herniated or bulging disc or bone spurs in the lower back that’s pressing on a nearby nerve for patients that are not candidates for BESS. Using guided imaging, a small incision, and specialized tools, the surgeon removes the damaged portion of the disc or excessive bone spurs and calcifications without cutting surrounding muscle or bone. It may be considered after conservative treatments, such as physical therapy or corticosteroid injections, have failed to provide adequate relief.
This is typically done microscopically, about an inch incision utilizing the microscope from the skin incision all the way through placement of the last stitch for skin closure, allowing a minimally invasive approach, which is typically done as an outpatient procedure. Recovery is much faster than the traditional open approach, with many patients returning to office work within about a week and driving after a few days.
Minimally Invasive Artificial Disc Replacement
Beyond fusion, minimally invasive artificial disc replacement stands as a sophisticated and effective treatment offered by Dr. Hooman Melamed. This groundbreaking procedure involves meticulously replacing a damaged or degenerated spinal disc with a state-of-the-art artificial disc, all performed through a remarkably small incision. The primary objective is not only to alleviate debilitating pain but also, crucially, to preserve or even restore the natural motion and flexibility of the spine, a significant advantage over traditional fusion surgeries.
Artificial disc replacement is typically indicated for patients suffering from degenerative disc disease, a condition where the discs between the vertebrae wear down over time, leading to chronic and often severe back or neck pain and, at times, radiating shooting pain down their arms and legs as well. Ideal candidates are those who have experienced persistent pain that significantly impacts their quality of life and have not achieved lasting relief through more conservative treatment approaches such as physical therapy, medication, or injections. Dr. Hooman Melamed carefully evaluates each patient’s unique circumstances, including the location and extent of disc degeneration, overall spinal health, and lifestyle, to determine if minimally invasive artificial disc replacement is the most appropriate and beneficial solution. This personalized approach ensures that patients receive the most advanced and tailored care for their specific spinal condition.
Minimally Invasive Lumbar Fusion
For patients with spinal instability due to degenerative disc disease, spondylolisthesis, or other structural issues, lumbar fusion may be necessary. Minimally invasive lumbar fusion techniques use small incisions and advanced instruments to stabilize the spine while preserving surrounding muscles and tissues.
For individuals experiencing persistent back pain and neurological symptoms stemming from spinal instability, lumbar fusion can be a life-changing surgical solution. This procedure is often deemed necessary when conservative treatments fail to alleviate discomfort caused by conditions such as degenerative disc disease, instability, spondylolisthesis, or other complex structural issues within the spinal column.
Spinal instability refers to the abnormal or excessive movement between two or more vertebrae, which can lead to nerve compression, pain, and a decline in overall function. Degenerative disc disease, a common culprit, involves the natural breakdown of the intervertebral discs that cushion the vertebrae, leading to loss of disc height and potential instability. Spondylolisthesis, on the other hand, describes a condition where one vertebra slips forward over the one below it, directly causing instability and often impinging on nerves.
Traditionally, lumbar fusion involved extensive open surgery, requiring large incisions, significant muscle dissection, and a lengthy recovery period. However, advancements in surgical techniques have led to the widespread adoption of minimally invasive lumbar fusion. This modern approach revolutionizes the procedure by utilizing small incisions and sophisticated advanced instruments and imaging technologies, including live image-guided CT navigation.
The core principle of minimally invasive lumbar fusion remains the same: to stabilize the spine by permanently joining two or more vertebrae together, effectively eliminating unwanted motion at the unstable segment. This is achieved by inserting bone graft material, often augmented with screws, rods, or cages, between the vertebrae. The bone graft then fuses with the surrounding bone over time, creating a solid, stable segment.
The key aspect and most important end result of the surgery, which is very often missed by many surgeons and not done, is restoring proper alignment to the spine. The human spine has a very unique alignment, and every segment/level of the spine has its own unique alignment. Many fusion procedures do not take this into account, and the patients are then fused in the wrong alignment. This causes the surrounding levels to hypercompensate, thus leading to much earlier degeneration.
The key advantages of the minimally invasive technique are numerous and significant for patient recovery and outcomes. By employing smaller incisions, surgeons can access the spine with minimal disruption to the surrounding muscles and soft tissues. This preservation of musculature translates to:
- Reduced Post-Operative Pain: Less tissue trauma leads to less pain after surgery, often requiring less reliance on strong pain medications.
- Faster Recovery Time: Patients typically experience a quicker return to their normal activities and a shorter hospital stay compared to traditional open surgery.
- Smaller Scars: The smaller incisions result in more cosmetically appealing scars.
- Reduced Blood Loss: Less tissue disruption generally means less blood loss during the procedure.
- Lower Risk of Infection: Smaller incisions can also contribute to a reduced risk of surgical site infections.
Minimally invasive lumbar fusion can be performed using various techniques, including transforaminal lumbar interbody fusion (TLIF), Anterior Lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), extreme lateral interbody fusion (XLIF), Anterior Cervical Discectomy and fusion (ACDF), among others. The choice of technique depends on the specific condition being treated, the patient’s anatomy, and the surgeon’s expertise. Regardless of the specific approach, the overarching goal is to achieve successful spinal stabilization while prioritizing patient comfort and optimizing recovery.
In summary, minimally invasive lumbar fusion represents a significant leap forward in the treatment of spinal instability. By strategically stabilizing the spine while diligently preserving surrounding muscles and tissues, this innovative approach offers patients a highly effective and less invasive path to long-term pain relief and improved quality of life.
