The Practice of Medicine will always be an Art, based on science, but rigid concepts in medicine, judged by key opinion leaders with emphasis on scientific publications, are affecting the medical literature through strict adherence to Cochrane criteria and “evidence based” concepts in order to be accepted for publication and reimbursement. Payers of Insurance re-imbursement does not recognize expert opinion but requires methods proven with level I or 2 evidence based studies [1]. Even if the result is warranted, insurance reimbursement to honor contracts that does not meet the arbitrary criteria of the insurance carrier needs reform. The ability of level five expert EBM opinions to get information to the scientific audience can also be difficult for most researchers because they either need institutional or NIH funding, or must pay publishing fees to get their work published by open access Journals. The best level I studies are sometimes ignored when the business of spine adversely determines the procedure’s ultimate fate. Chymopapain is one such example

Anthony T. Yeung M.D., has reported his 5-10-year results in a preliminary review of endoscopic transforaminal of isthmic and degenerative spondylolisthesis decompression causing sciatica and back pain at international spine meetings. Fifty-five patients from January 2002-December 2012 served as the database for the clinical presentation in patients who specifically chose to stage Yeung’s endoscopic transforaminal decompressive procedure over fusion. The patients were specifically evaluated for endoscopic spine surgery in a shared clinical decision.

This more focused article is subdivided with stratified indications to degenerative spondylolisthesis only, omitting isthmic spondylolisthesis since isthmic spondylolisthesis is traditionally the surgical option of choice for patients who elected to undergo surgical intervention as the standard surgical option versus continuing with non-surgical care. Disc protrusions associated with degenerative spondylolisthesis, disc herniation, patients with concomitant stenosis, who did well with the first study on both degenerative and isthmic spondylolisthesis were analyzed from the first database and stratified for degenerative spondylolisthesis.

Abstract

In the United States and in industrialized countries, new procedures for back pain tend to “follow the money” aided by industry. In Asian and OUS countries, there is more acceptance of traditional non-surgical treatment from thousands of years of medical treatment history. New and non-traditional treatments based on evolving science, are being made readily available in the information highway by Open Access Journals where researchers can publish their Level V evidence-based concepts for interested parties and other scientists.

Anthony T. Yeung’s work focuses on the surgical treatment of the pain generator in the lumbar spine. Patient selection is aided by using diagnostic and therapeutic injections, to identify the likelihood of surgical success when the pain source is targeted. This article focuses on the details of Yeung’s 27 years’ experience on identifying and treating the pain generators in the lumbar spine by an endoscope and combined with an endoscopic system that he has trademarked the Yeung Endoscopic Spine System (YESS™).

Introduction: Endoscopic spine surgery has attracted both surgeons and nonsurgeons in increasing numbers as endoscopic spine systems, a variety of spine endoscopes, and new and evolving surgical instrumentation are developed. The procedure, using fluoroscopically guided percutaneous techniques, are getting more standard, easier, safer, readily reproducible, and more cost effective. It has also been an avenue for surgeons and a few appropriately trained and certified non-surgeons to participate in a minimally invasive, procedure oriented health care delivery platform that provides cost effective results after failure of nonsurgical methods. Such a multidisciplinary team has been established at the University of New Mexico through a donation to the University by the first author.

Discussion: Asia, especially China and Korea, has seen adoption of endoscopic spine surgery grow exponentially in the past few years, recognizing that endoscopic spine surgery may be the answer to delivering cost effective spine care to their working and aging population. Two basic methods are the mainstay of current endoscopic techniques. The least invasive techniques in the lumbar spine are transforaminal, but translaminar endoscopic approaches are better accepted and easier for endoscopic surgeons to grasp.

Conclusion: Endoscopic spine surgery has great promise in countries with looking for cost effective delivery of health care to its population. Endoscopic surgery is the least minimally invasive surgical platform that will facilitate a move away from fusion as a first line of surgical treatment, delaying or eliminating fusion for patients who may have indications for decompression and fusion, but do well with an earlier and staged procedure that will mitigate the need for open decompression and fusion by 75%, derived by large individual and group databases known to this author.

Background/purpose: Operating under local anesthesia allows the patient to respond and provide feedback during surgery that is invaluable for patient safety and for the assessment of the pain generators and ultimately understanding of the source of pain that the surgeon is targeting. Over 10,000 case studies make up the database for information gleaned from patients reporting the pain experienced and relieved during translaminar and transforaminal endoscopic decompression.

Method: The patient is provided mild sedation with versed and fentanyl unless no sedation is requested. Patients requesting no sedation are usually anesthesiologists and other spine surgeons who opt for decompressive surgery, but wanted some measure of surgical participation and control. The anesthesiologist titrates the patient with 1-2 cc of fentanyl and versed pre-op with titration during surgery. The average total amount is 4-5 cc for most procedures. 1% lidocaine is utilized for the local anesthetic. An average of 10-20 cc is used for local anesthesia, titrated as needed during surgery.

Results: The results of decompression can be predicted by a combination of pain relief reported during, immediately after, and augmented by visualization of the targeted patho-anatomy. Such visualized pathology visualized includes annular tears, decompressed spinal nerves, and visualization of the axilla between the traversing and exiting nerve.

Conclusion: Observations provides level 5 EBM (Expert opinion) for surgical intervention. Evidence based medicine usually starts with level 5 “expert” opinions. With the ability to evoke pain in conscious surgical patients, with endoscopic images of the patho-anatomy that correlates evoked pain production with subsequent pain resolution following visualized endoscopic decompression. Along with comparison of pre-and post op images, a new and different and level of EBM may emerge and need to be considered in addition to the traditional Levels 1-5 EBM guidelines.