Downers Grove, Ill.-based DuPage Medical Group opened its third ASC this year as part of its musculoskeletal institute.
Ashish Patel, MD, an adult and pediatric spine specialist, launched an endoscopic spine surgery program at DuPage in May, performing the ASC's first endoscopic microdiscectomy on a patient with a disc herniation.
Dr. Patel spoke to Becker's Spine Review about the program's launch and how he sees endoscopic spine surgery developing in the field.
Q: What were the most important steps to take when planning this endoscopic spine program?
Dr. Ashish Patel: We had been thinking about providing this type of solution to our patient population for a while. One of the things that had to happen was we had to be in our own facility, so we built this Westmont ASC, which is an orthopedic, joint and spine facility. Having that control over the facility and what kind of solutions we provide was a very important step. For the department as a whole, as we gravitate toward new technology, there was a lot of back-end work that went into educating ourselves so we could put this into practice — several cadaver labs, a lot of research and syncing up with providers who have experience with endoscopic spine surgery, etc. Endoscopic spine surgery is growing and we feel that we should be at the forefront of this.
Q: How would you describe the learning curve for endoscopic spine surgery?
AP: The learning curve is real; it's a different skill set. Orthopedic spine surgeons have this comfort with arthroscopy. Being able to use a camera through a small incision has been part of my training in orthopedic surgery. My learning curve will consist of doing the more straightforward cases first. Once I've mastered those, I will push myself to do the more complex cases. The straightforward, most accessible cases would be disc herniation cases at L2-3, L3-4, L4-5. Once you've mastered those, you proceed to L5-S1 and perform disc herniation cases that have gone into the foramen or the far lateral region to do more central disc herniations. After you master these and feel comfortable with all disc herniations in the lower back, you then move onto lumbar stenosis cases, which would be more of a midline approach using slightly different equipment. Then, you can move on to cervical cases, such as laminoforaminotomies or thoracic cases. Once you have a comfort in that, you then proceed to what surgeons are now working toward, which is lumbar fusions through the endoscope.
Q: As outpatient migration accelerates, will payers recognize the value of endoscopic spine surgery?
AP: Reimbursement is restricted now, but there are dedicated societies toward the advancement of endoscopic spine. When you have teaching institutions with continued education and mentorship and labs set up to provide this type of education to the masses, there will inevitably be movement from insurers to appropriately reimburse this, so more practices can offer endoscopic spine surgery to their patients.
Before, I think endoscopic spine surgery has faltered because of its steep learning curve and lack of adequate compensation. But what's happened over the last 15 years or so, is sports medicine made the leap from open cases to arthroscopy cases. Spine hasn't had that opportunity, but now with improved technology, a better understanding of the anatomy and dedicated teaching programs advocating for the advancement of endoscopic spine, these shackles will be breached and providers will adopt this more rapidly.
Q: Outside of endoscopic spine surgery, what technology excites you in the field today?
AP: I see both pediatric and adult patients for spine conditions, from very straightforward disc herniation cases to more complex scoliosis cases. For pediatric scoliosis, vertebral body tethering is gaining significant interest. If we're talking about assisted-surgery through navigation and robotics, we have the ability to be more accurate with our instrumentation placement and reduce radiation exposure for the patient and surgeon. If we're talking about endoscopy, we have the ability to minimize morbidity with the muscle dissection that we do with that technology.
Something I'm particularly passionate about is single-position spine surgery. To accomplish certain cases, we have to flip the patient several times; from laying on their back to their belly, or laying on their side to their belly. We are now working on processes where we place the patient just on their side or their belly, so we can complete the whole surgery from one position. This avoids the flip. In terms of surgical efficiency, cases moving to the ASC and reducing the complexities around surgery, this is going to be a huge opportunity for us to bring more cases from the hospital to the outpatient setting.