Full endoscopic spine surgery by multiple approaches as a safe, effective, and cost saving technique for surgical spine care
This update is very timely, especially with the Covid-19 virus changing the landscape of health care and the global economy. The affordable health care crisis world-wide is upon us.
I have included two reports by Robin Young and Walter Eisner of Orthopedics This Week summarizing their attendance of the IITS sponsored meetings in 2007 and 2009.
Surgical dependence just on traditional open surgical techniques or nonsurgical pain management must be re-evaluated even though results have had extensive validation by the stakeholders “protecting their turf” in the spine literature.
The advent of endoscopic spine care is validated by current clinical research and statistical analysis techniques, such as Kaplan Meier, and MCID (minimal clinically important difference) analysis. It is an answer to the cost effective concept of “surgical pain care” and an answer to surgical spine care without dependence on opioid pain killers.
Most western key opinion leaders (KOLs) in spine care focus on fusion and implants to aid fusion, and others for biologics for combating aging. After recognizing that the endoscope provides images of treatable patho-anatomy that focuses on endoscopic documentation of the patho-physiology of pain, endoscopic visualization allows for a “staged” endoscopic spine surgery that addresses the patho-physiology of spinal pain early in the disease process, and focuses on individual patient needs.
Starting with toxic annular tears, herniated lumbar discs, and expanding to foraminal stenosis, deformity, trauma and neoplasm, endoscopic spine surgery has evolved into a safe, cost effective surgical spine care technique by highly skilled, motivated, and dedicated spine practitioners.
“DIRECT” VISUALIZATION OF PAIN PATHO-ANATOMY IS THE KEY
The two main advantages of spinal endoscopy have mostly gone unnoticed by a majority of traditionally trained spine surgeons as well as non-surgeons. In China and Southeast Asia, with thousands of years of history, endoscopic spine surgery bridges the gap between traditional medicine and Western techniques.
First, the ability to reduce the surgical indications and the plan of care to STAGE the endoscopic treatment and focus on pain generators, even in a multimodal problem may be the answer. Second, the ability to directly visualize areas not just inside the intervertebral disc, but also in the epidural, foraminal and extraforaminal space opens the door to analysis of pain generators residing within a spinal motion segment that can escape traditional spinal imaging and surgical access. Other means to identify pain generators are needed.
Organizing endoscopic spine care by grouping it around identified pain generators implies to ignore other structural problems which may be implicated or unrecognized by history and physical examination alone. Even with advanced imaging studies such as MRI, CT scan, or CT reconstruction, identification of the correct source of axial facet joint pain and sciatica, for example, in multilevel degeneration may be even more difficult in the absence of a radicular component.
The staged management approach is helpful for the endoscopic treatment of clearly identified pain generators.
A newly published, focused issue in Journal of Spine Surgery (JSS) Jan 2020 Vol 6 Suppl 1 by guest editors Kai Lewandrowski and myself, updates the role and future of endoscopic spine care. New terms such as “risk stratification” and “cost stratification” is a new evolving concept in spine care. I hope to lead IITS to become mainstream in surgical spine care and open it to well trained providers for the sake of our patients.