From endoscopic spine to cervical laminoplasty, spine surgeons discuss the procedures that they want to see gain prominence.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker’s invites all spine surgeon and specialist responses.
Next question: What’s the most controversial trend in spine surgery today?
Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Tuesday, June 17.
Editor’s note: Responses were lightly edited for clarity and length.
Question: What is an underrated spine procedure in the field? What will it take for that procedure to grow?
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Spinal endoscopy remains one of the most underrated procedures in the field. As I do more and more cases I am very excited about its potential. But like with every technology, it has limits. Strong advocates for endoscopy remain vocal, I urge surgeons to not be a hammer looking for nails everywhere they look. Sometimes we need to be able to get through a mini-open or even fully open surgery to take the best care of the patient.
Arthur Jenkins, MD. Jenkins Neurospine (New York City): Cervical laminoplasty. It will take surgeons collectively saying, “I’d rather do a procedure with fewer long-term problems and better results than one that I get paid more to do” (i.e., compared to multi-level decompression and fusions, ie, a 2-, 3- or 4-level ACDF or laminectomy/fusion).
Choll Kim, MD, PhD. Excel Spine (San Diego): I am probably going to sound like a broken record, but the most underrated, and under-utilized spine surgery is by far…endoscopic spine surgery! This is not a new procedure, and despite being widely adopted in Asia, especially Korea, and parts of Europe, it is still markedly under-utilized in the U.S. This is my favorite procedure, but the “forces of evil” remain strong. To make this procedure grow in the U.S., we must attend to the 2 greatest obstacles to adoption. First and foremost, is the difficult learning curve. It is not enough to simply have more training opportunities. We must have better training programs designed to “make the first case go well.” The second obstacle is the terrible reimbursement landscape. We need stronger advocacy from thought leaders and societies that take into account the value of minimally invasive, endoscopic care, especially as more spine surgeries are performed in the ASC setting where other specialties such as sports medicine, urology, GI, and abdominal surgery have already gone endoscopic. Endoscopic spine surgery isn’t the future – it’s already here. We just need to catch up.
Michael Oh, MD. UCI Health (Irvine, Calif.): Lumbar interlaminar stabilization is an underrated spine procedure. Coflex is often confused with interspinous process spacers like X-stop or it is confused with spinous process fusion. It is neither of those; rather, it is used in a procedure that involves direct decompression of central, lateral recess, and foraminal stenosis. The procedure is a non-fusion stabilization device for patients that have a grade 1 spondylolisthesis. I use Coflex both as a laminectomy plus device and a fusion minus device. What I mean by that is if I am considering fusing a patient with a grade 1 lumbar spondylolisthesis, I would consider Coflex as a non-fusion alternative to provide stabilization following a decompression. For lumbar stenosis, rather than doing a complete laminectomy, I now skip laminectomy with placement of a Coflex device if I think the patient has mostly foraminal stenosis and significant back pain.
In order for this procedure to gain wider adoption, I think education regarding skip laminectomy with the aid of spinous process distraction is important as complete laminectomy is rarely necessary when performed in conjunction with an interlaminar stabilization device. In addition, physician reimbursement that is more than laminectomy, but less than a fusion, will lead to wider adoption of this underrated procedure.
Noam Stadlan, MD. Endeavor Health Neurosciences Institute (Skokie and Highland Park, Ill.): Artificial discs, more so lumbar than cervical, are underrated. They produce excellent results with proper patient selection and meticulous technique. The procedures will grow when more robust data regarding their superiority are available and when reimbursements equal or exceed the fusion alternative. Frequently, insurance companies place additional obstacles in the way of disc replacement. That also is a situation that needs to be addressed and resolved.
Roy Vingan, MD. New Jersey Brain and Spine (Paramus): I believe that an underrated surgical procedure that could be adopted in a more significant way would be the lateral access procedure for lumbar fusion. From my understanding, only about 20% of spine surgeons consider themselves efficient and comfortable with performing lateral access procedures, whether in the lateral or prone lateral position. As someone who has been performing these procedures for 19 years, certainly there is a component of a learning curve, but consistency with the educational process and more consistent training in residency and fellowship would, I believe, allow a majority of spine surgeons to become experienced and confident in the value and benefit of these techniques.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Altruistically speaking, a proper lumbar laminectomy remains indispensable in the foray of complex spinal surgical tools, especially in terms of progressive neurogenic claudication or as a prelude to any posterolateral lumbar fusion procedure. The sheer fact that insurers bundle this procedure based on involved levels or partition it a higher code remains mysterious to many. With reference to necessitated adjacent level failures, salvage operations and the inadequacy/shortcomings of minimally invasive decompressive surgery, demonstrable stenotic levels and symptomatic relief can be delivered with targeted intervention. Actualizing its traditional efficacy and appropriate application to symptomatic elements, its exercise role may be further utilized.
