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?
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.
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.
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.
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.
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