Dr. Raymond Gardocki: Adding endoscopic spine at Vanderbilt & how COVID changed how he performs spine surgery

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In October, Raymond Gardocki, MD, joined Vanderbilt University Medical Center in Nashville, Tenn., where he will help develop the endoscopic spine surgery program.

Dr. Gardocki spoke to Becker's Spine Review about his new position, minimally invasive spine surgery and how the pandemic has changed his practice.

Question: Congratulations on your new role at Vanderbilt. What prompted this move? 

Dr. Raymond Gardocki: It started out with my wife, who is a pediatric surgeon. She was recruited by Vanderbilt and was very impressed with the surgeon-in-chief, Jeffrey Upperman, MD. I knew Byron Stephens, MD, head of orthopedic spine at Vanderbilt, who was a resident at Campbell Clinic. I connected with him and found out that Vanderbilt was looking for an endoscopic spine surgeon. 

Rick Wright, MD, joined Vanderbilt as chair of orthopedic surgery last year. He came from Washington University School of Medicine in St. Louis, where spine surgeons are hyper specialized. Vanderbilt didn't really have a significant minimally invasive offering in the orthopedic department and was looking to add a spine surgeon with a minimally invasive approach who can do more outpatient cases — that's me all over. They only have so many ORs in the hospital and are about to open an ASC, which will provide more ORs for outpatient surgeries. 

Q: What are your goals at Vanderbilt? 

RG: My goal is to operate in the surgery center, not in the hospital, which is very limited now with the COVID-19 pandemic. It's a lot easier to expand with a surgery center, but you have to be able to do the cases there. I'll add another facet of spine — minimally invasive and endoscopic approaches — to the cases already offered at Vanderbilt, which include scoliosis, tumors and revision cases. It's huge for health systems to be able to offer an awake endoscopic procedure, especially now with COVID. The awake component is very appealing to avoid intubation and to not expose staff to respiratory secretions directly from the lung. Plus the patients have less postop complications such as nausea and pain.

Q: How will you strengthen the fellowship program at Vanderbilt?

RG: Adding outpatient endoscopic surgery will be a real benefit to the fellowship program. The surgeons most interested in this type of procedure are the emerging physicians. If you've been doing open surgery for 10 or 12 years, starting over with the learning curve can be a tough pill to swallow. It's the perfect time to learn this during fellowship, because there's a slight learning curve with almost everything you do. So, you might as well learn the least invasive way to perform spine surgery.

Q: Have you managed to get your hands on Augmedics' Xvision Spine system yet? How can augmented reality improve endoscopic approaches to spine surgery?

RG: I've had an opportunity to look at it and thought it was excellent. I can definitely see an application for it with endoscopic surgery. One of the big hurdles for surgeons starting with endoscopic surgery is being able to properly place the needle, especially in the foramen for transforaminal approaches. Surgeons are just not used to driving a needle, so being able to visualize where the needle is and see the foramen would be of tremendous value. Plus, with the Vanderbilt fellowship program, if we're going to allow fellows to perform endoscopic procedures, being able to see where the tip of the instruments and the scope are, instead of having to guess or use an X-ray, would be huge. 

Q: How has COVID-19 affected how you perform spine surgery? 

RG: Since COVID, I've been doing almost all my lumbar surgeries, such as decompressions and discectomies, as an awake procedure. That was one of the benefits of COVID. It minimizes the anesthesia complications, such as nausea, sore throats and urinary retention, especially for elderly patients. As a surgeon, we kind of just accept the complications that can be associated with general anesthesia, because you might think "what other options are there?" That's where awake surgery comes in, but you have to do the surgery in a way that's not very painful or invasive for the patient. 

Q: Will the pandemic accelerate the adoption of endoscopic spine surgery?

RG: I think so. First of all, people just don't want to go to the hospital, which is where the sick people are. If you can do the same surgery as an outpatient, that's a win, and it's beneficial to the patient. If you look at infection rates, it's much safer in the surgery center than in an inpatient facility. With the endoscope, you have the ability to do decompressions and not induce instability, so there are patients who can have a decompression and avoid fusion, which is also better because there are issues with fusions, such as adjacent segment disease.

That's part of the reason why Vanderbilt wanted to move some procedures to its outpatient center, because the patients are demanding it. You've seen that a lot with total joints and now you're starting to see it more with spine. Just like total joints, I think the pandemic will accelerate spine procedures moving to the outpatient setting. Bundled payments will also contribute to this as they become more prevalent in spine.

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