Nine spine specialists debate which physicians should and should not be able to perform endoscopic spine surgery.
Ask Spine Surgeons is a weekly series of questions (published at Beckers Spine) posed to spine surgeons around the country about clinical, business and policy issues affecting spine care.
Note: The following responses were edited for length and clarity.
Question: What is your opinion on pain management physicians performing endoscopic spine surgeries?
Tony Mork, MD. Newport Beach (Calif.): My opinion is that pain management physicians could perform endoscopic procedures outside of the spinal canal with proper training and mentoring. Since so many pain generators/facets in the spine are located outside of the spinal canal, endoscopic spine surgery is synergistic with a pain management physician's scope of practice.
The endoscopic approach to pain offers society, government and the insurance industry a proven therapy to decrease the use of opioids, by 'curing' spine pain rather than managing it. For example, endoscopic techniques offer the low-risk possibility of a 'cure' of facet syndrome pain. There is not much a spine surgeon can offer for facet syndrome except a spinal fusion, which is too much treatment for the patient and too costly for payers and the government.
Sensory nerves can be visualized directly with endoscopic surgery and divided. Because the nerve sheath is divided and not left intact, nerve division offers permanent relief as opposed to the temporary relief provided from radiofrequency.
The pain management physician is usually the practitioner who confirms the diagnosis of facet syndrome with needle injections and is very familiar with the anatomy of the facets, so, therefore, is there really much difference between a 1 mm needle to diagnose the facet problem and a 7 mm endoscope to treat it definitively? Given the previously developed expertise with the 1 mm needle, I believe the pain management physician, if given the proper training, could successfully perform endoscopic procedures.
Issada Thongtrangan, MD. Microspine (Phoenix): This is a tough question. As a fellowship-trained spine surgeon who adopted this technology and has been doing more endoscopic spine surgery in the past 3-4 years, I can say that it's not easy. I feel that we must put the patient's best interest as the first priority. I would say it is OK for a well-trained pain management specialist to perform an endoscopic spine surgery if they can take care of the complications or have a well-trained spine surgeon scrub in the case. Another area is how well they can select the appropriate patients who have solid indications as most of the pain specialists are likely trained in the different aspects of spinal disorders.
Fred Naraghi, MD. Comprehensive Spine Center (Klamath Falls, Ore.): I don't think it's a good idea. Endoscopic spine surgery has a steep learning curve and may be associated with significant complications. Spine surgeons are better trained to treat the possible complications of endoscopic procedures. Ultimately, patient safety and improved outcome is the goal.
James Chappuis, MD. Spine Center Atlanta: Any physician who is well trained should be able to conduct procedures that they are trained in as long as they can handle the complications that could arise from that procedure. Currently, in our practice, endoscopic spine surgery is only performed by board-certified, fellowship-trained spine surgeons. This doesn't mean it will always be this way. This is just what I am comfortable with at this time for the best interests of our patients.
Brian Adams, MD. Spine Center Atlanta: As an interventional spine pain management physician, I am intrigued about the utilization of endoscopic surgery. Since this is largely an image-guided technique, I feel that it is a tool that can be safely incorporated into an advanced interventional spine practice. While I think there are certain limitations to what procedures are appropriate for an interventional physician, the most important consideration is a good symbiosis between interventionalist and surgeons. This is probably best utilized in a practice with both interventionalists and surgeons working together under one roof.
Noam Stadlan, MD. NorthShore University HealthSystem (Evanston, Ill.): The optimal care of spine patients requires the expertise of a number of specialists: surgeons, pain management specialists, physical and occupational therapists, pain psychologists, radiologists and more. Patients will benefit most when all specialists do what they do best and collaborate with others who have different areas of expertise.
Spine surgeons spend many hours during their residencies developing the experience and diagnostic skills to make the clinical diagnoses that are fundamental to the success of any treatment. Pain management physicians who are performing endoscopic surgeries are best served by working with spine surgeons who can provide expertise in the diagnosis and radiographic interpretation, as well as complication management when they occur. Performing these surgeries without the integration of spine surgeons in the decision-making process and postoperative management, when necessary, can result in less than optimal results.
Harel Deutsch, MD. Rush University (Chicago): While pain management physicians are billing for these procedures and want to get the higher valued codes, the procedures they do are not effective or equivalent to spine surgeries done by neurosurgeons and orthopedic surgeons.
Christian Zimmerman, MD. Saint Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): This topic begs the fundamental premise of training, ability, and accountability. My rebuttal is centered on complication management and one's ability to administer care in the likelihood of that situation arising. The actual dissent and friction of this extraneous practice surround the efficacy of such procedures, where both radiologists and surgeons alike, cannot measure or detect the actual surgical interventions of these 'surgical procedures' on CT or MRI scanning. The determinations for these procedures markedly exceed the indications, characterizing the process as deluding.
Recently, a patient was seen in my office after having a 'decompressive' operation performed in a pain clinic where neither the symptoms were changed nor was there any radiological evidence of the surgery. This patient had been charged an additional fee on top of their insurance allowable making this procedure at its least derivative, a holistic failure, and financial overextension. Granted, the management of chronic pain is difficult and at times empirical. Adding to the empiricism with additional risk and fewer control mechanisms seems foolhardy at best.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: In general, I think if you cannot fix a complication from a procedure you are performing, you should not be doing it.