1. Complete a spine surgery fellowship. Physicians electing to perform endoscopic spine surgery should be fellowship-trained spine surgeons, or they should perform the procedures under the supervision of a fellowship trained spine surgeon due to the potential for complication this critical area, says Bryan Massoud, MD, a spine surgeon with Spine Centers of America in Fair Lawn, N.J. The spine fellowship provides the surgeon with experience in open spinal procedures, giving them intimate knowledge of the back’s anatomy. This knowledge is imperative for physicians as they begin using the endoscope because the physician can’t see the spine beyond the view provided by the endoscope.
2. Enroll in a cadaver course. Choll Kim, MD, PhD, a physician with the Spine Institute of San Diego, says some practicing physicians will not perform minimally invasive spine surgery because they are uncertain about their ability to complete the procedure accurately and safely. This fear leads to practicing obsolete surgery methods and ultimately increased patient discomfort. “Minimally invasive spine surgery is not a small difference in technology; this is a major leap in being able to take care of our spine patients,” says Dr. Kim. “We need to be able to provide resources for our patients and we don’t want to let a lack of education prevent us from doing that.”
While some physicians learn procedures by watching their mentors perform them in the lab environment, Dr. Kim says the best way to learn is by actually performing the surgery, skin-to-skin, at a cadaver lab modeled after the operating room setting. “Physicians have this surgery with a lot of great benefits available to them but the problem is that they didn’t cover it in their formal training,” says Dr. Kim “At some point you need to mimic exactly what the OR situation is going to be. You need to make sure you can do the procedure from start to finish. Our education program is designed to provide the physicians with this experience.”
By participating in the program, physicians gain experience and become knowledgeable about performing minimally invasive spine surgery in an operating room environment. This experience builds confidence in the surgeon which can lead to fewer complications during first surgery.
3. Train with the endoscope. Physicians access the spine through a small incision (about 5 millimeters) and dilate the muscles instead of cutting them, as is done during open procedures. The physician then inserts micro-instruments, including a small camera, into the natural spine opening. The endoscope placed directly on the site allows for the physician to view his or her actions during the procedure.
The biggest difference between performing open surgery and minimally invasive surgery is how the physician navigates the patient’s anatomy. During open surgery, the skin and muscles are peeled back, allowing the physician full view of the damaged area. When performing a minimally invasive procedure, the physician is guided by the MRI and other imaging equipment, such as the endoscope, placed over the damaged area. This means the physician navigates through the procedure using a projected image instead of the actual anatomy.
4. Follow a mentor. Following and observing a mentor can help physicians overcome the challenging learning curve and give the surgeon an advantage over others. Dr. Massoud followed Martin Knight, MD, an English physician, and learned his technique. “Because it’s an emerging field, the different surgeons learning and performing endoscopic spine surgery have their own techniques they developed over time,” says Dr. Massoud. “Taking the experience of a mentor physician who has actually done a number of cases can move the training physician higher on the learning curve before tackling his or her own cases.”
The mentor is also helpful when the surgeon is first performing the procedures because he or she serves as an expert in the room if the surgeon has questions during the procedure. The mentor can also help if complications arise. Dr. Massoud is willing to speak with and mentor spine surgeons aspiring to learn endoscopic technique. He has been performing several techniques at his practice, including cervical endoscopic discectomy and cervical endoscopic laminotomy.
5. Gain experience first with lumbar and thoracic endoscopy before learning cervical procedures. Since the cervical spine is one of the most sensitive areas of the spine, most spine surgeons don’t begin learning cervical spine surgery until after they are familiar with the technique elsewhere on the spine. Performing surgery on the cervical spine has the potential for more severe injury than procedures on other areas of the spine because there is less space and more major structures to navigate through. The cervical spine is located near the trachea, esophagus and carotid artery, which are three major structures the surgeon must avoid when performing surgery on the cervical spine.
“Before a surgeon starts tackling cervical endoscopy, they need to be very familiar with spine surgery and have gained experience in lumbar and thoracic endoscopy,” says Dr. Massoud. “The cervical spine is much more sensitive to injury than any of the other structures, so before attempting a cervical endoscopy, the surgeon should be a board certified orthopedic or neurospine surgeon and needs to have significant experience in lumbar endoscopy and have mastery over the endoscope and associated instruments we use.” Significant experience with lumbar endoscopy means successfully performing more than 300 cases before beginning to learn the endoscopic cervical procedure.
6. Educate referring physicians on the procedure. To increase patient volume in a practice, specialists should form a good relationship with primary care physicians responsible for the initial identification and referral of future patients, says Jimmy St. Louis, Chief Corporate Operations Officer of Laser Spine Institute. All the procedures done at Laser Spine Institute are endoscopic. Laser Spine Institute has hired representatives to seek out medical professionals such as primary care physicians, physical therapist, chiropractors, etc., for mutual partnerships where the primary care physicians would refer patients to practice and practice surgeons would refer the appropriate individuals back to the primary care physician. These partnerships expand the practice’s relationship within the medical community while also increasing patient volume.
