Dr. Tony Mork: Reimbursement, lack of training shackles progress of endoscopic spine surgery

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Tony Mork, MD, is a Newport Beach, Calif.-based endoscopic spine surgeon who is cofounder of Microspine and founder of the Endoscopic Spine Academy.

Here, Dr. Mork discusses his 21-plus-year experience in endoscopic spine surgery and how reimbursement and lack of training prevents the technique from becoming more prominent in the U.S.

Note: Responses are edited for style and clarity.

Q: When did you began exclusively practicing endoscopic spine surgery?

Dr. Tony Mork: 1998. In the beginning there was nothing that was commercially available, so I used a small version of what they call METRx tubes now. I had my own version made and began using that. In 2001, I purchased my first commercially available endoscope, which was for lumbar discectomy. It was a Richard Wolf/Tony Yeung product. Over the years I learned how to do endoscopic cervical, thoracic and lumbar spine surgery. 

Q: What are the most common endoscopic procedures you perform in your practice?

TM: Around 35 to 40 percent of the procedures I perform are cervical. Endoscopic thoracic approaches are rare. The remaining procedures are lumbar that include the typical stenosis, disc herniations and facet syndrome, which is also quite common.  

Q: What was your first interaction with endoscopic spine surgery and what made you decide to incorporate it into your practice?

TM: After I finished my residency in 1982, I was performing mainly sports medicine surgeries. In 1988, a six-man spine group in Long Beach, Calif., asked me to take care of all their non-spine problems. Their focus was open spine surgery and fusions as they were one of the first with FDA clearance for pedicle screw fixation. In 1998, after my 10th year there, I couldn't stand the fact that people were making such big surgical approaches to treat such small problems. I was skilled at arthroscopy, given the large amount of procedures I performed for shoulders and knees. I thought there's got to be a way to apply those arthroscopic and sports medicine principles to spine surgery. 

Q: Do you think surgeons who are trained in arthroscopy are more easily able to adapt to endoscopic spine surgery?

TM: I think there's a steep learning curve. The physician must have an interest and perhaps be thinking that maybe there's a better way to treat back or neck problems than with a fusion. The problem is there's not currently a detailed guided pathway. It requires a lot of practice. If you start with the easy cases and begin developing your skill set, while becoming comfortable with the process, you can master the easier cases, and move on to more difficult ones. If you do some of the more difficult cases in the beginning, you might fall off the horse and not want to get back on. 

Q: Have you any insight as to why endoscopic spine surgery isn't more widely adapted in the U.S.?

TM: I think there's two major reasons. First, there's little to no comprehensive training readily available. As far as I'm aware, the only training program in the U.S. that includes formal training for endoscopic spine surgery is at the University of New Mexico in Albuquerque. The endoscopic approach uses a totally different skillset than open surgery and requires a relearning of the anatomy. When you start to look at the spine through a scope, it's very different at first. Any problems encountered, for example a dural tear or bleeding, must be taken care of through the scope. This takes a little patience and a lot of practice to feel comfortable. 

The second reason is that the reimbursement is not very good. The equipment is expensive: A diamond burr, used for bone work, can cost up to $1,900 per burr. So, if the facility isn't being reimbursed adequately then it becomes a financial issue. Endoscopic spine surgeries are mostly outpatient procedures, so hospitals are concerned because they're not getting adequately reimbursed. Also, it's the physicians that decide between an endoscopic procedure and a fusion for a given condition. So, if the outcomes may be similar, some physicians might do a fusion because the reimbursements are so much better.   

Q: Do you think endoscopic spine surgery will become more prominent in the U.S. in the next decade?

TM: The main thing that holds us back is the reimbursement structure. If it were a little better reimbursed on the facility and physician side, I think it would be tremendously more popular. Because for many patients, it's their best option. I perform all spine surgeries as an outpatient. It's good for treating the Medicare population as well as the younger patients. Your surgery incisions are only between 3/8 of an inch and ½ of an inch. I think it's the ultimate in minimally invasive surgery. 

Find out more about endoscopic spine surgery on Dr. Mork's YouTube channel, which surpassed 1 million views in November.

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