NASS President Dr. Jeffrey Wang: Opioids, regenerative medicine & endoscopy in spine

Written by Alan Condon | August 29, 2019 | Print  |

Jeffrey Wang, MD, is co-director of the USC Spine Center at Keck Medicine of USC in Los Angeles and president of the North American Spine Society.

Dr. Wang talked to Becker's Spine Review about the future of endoscopic spine surgery in the U.S., emerging trends in regenerative medicine and the opioid crisis.

Note: Responses were lightly edited for style and clarity.

Question: How do you see endoscopic spine surgery developing in the U.S? 

Dr. Jeffrey Wang: Endoscopy is in its infancy in the United States but is enormously popular worldwide. There is some merit to endoscopic approaches, but it must be based on proper education. The reason it has not become popular in the United States is multifactorial, in my opinion. We need to have the proper evidence to show the advantages, but perhaps more importantly, we need to understand transparently the potential disadvantages and potential complications. 

I have seen endoscopic weekend courses, where it is touted as the greatest procedure invented and all the talks are advocating for its use, but potential disadvantages and complications are perhaps not presented in detail. I am not blaming these courses, as the faculty are experts and likely have minimal complications, but we need to teach these techniques in a balanced and evidence-based manner. 

NASS has taken the first steps by having multiple domestic and international endoscopic courses, where we believe the techniques are presented in an appropriate manner, with balanced discussions of the advantages and disadvantages of the techniques. We need to base this education on the evidence, and we need more research in this area with evidence to show the efficacy. I believe we will get this evidence and understand the appropriate education. I think we will see more adoption of these techniques in the next five years, with the integration of endoscopic techniques into our academic teaching programs. I am optimistic that there is an appropriate role for endoscopic surgery — we just need to educate our surgeons in the most appropriate manner.

Q: Is there anything particularly innovative you see on the horizon for regenerative medicine in spine?

JW: The most innovative thing one could do for regenerative medicine is to gather the "real" evidence and educate practitioners, patients and the public on the real story. The area of regenerative medicine is an area of my own personal research focus, and for my entire career, my research lab has focused on this area for both spinal fusion, disc regeneration and biologics. 

However, the current marketing is mostly based on patient interest, marketing and practitioners using this for a competitive advantage. Unfortunately, very little is based on the actual evidence, "real" research and proven results. Throughout my career, I have seen spine practitioners use these buzz words to market their services, and the area of stem cells is the latest marketing craze. In the past, it was anti-inflammatory injections that were "patented," which could help patients avoid surgery. Or it was marketing that one used a laser during surgery, which conveyed to patients that their doctor was special. Now, I see similarities with the use of stem cells. 

What we really need is to demand that there be prospective clinical studies and good basic science pre-clinical studies that show a treatment actually works. The vast majority of stem cell treatments or biologics that are being used and marketed to patients and spine practitioners do not have any real data to support their efficacy. They rely on a few facts that are common to many past treatments that attracted patients. These facts are that most patients are afraid of surgery and will do whatever they can to avoid surgery. Someone offering them a stem cell injection as an alternative to spine surgery is extremely attractive to them. The other fact is that there are buzz words that attract patients and the current area is the use of stem cells. These patients are afraid of surgery and want the latest technology, which makes many susceptible to some of these marketing efforts.

Q: The opioid crisis is a hot topic at the moment. What can physicians and healthcare organizations do to help tackle the issue?

JW: This is a real problem, and the word "crisis" is a great description. The problem that we all realize as physicians and practitioners is that the issues are complex. The crisis is multifactorial. The crisis does not solely exist because of bad physicians or pharmaceutical companies. It does not solely exist because of our patients or our government. And the crisis does not solely exist because of the general public. The crisis exists because of problems in all these areas. 

The new government regulations on the restriction of opioid medications and the new laws governing the prescription of opioids was a great first step. However, it will not be solely solved by this. Having pharmaceutical companies pay billions of dollars in penalties will not alleviate the crisis. If you really want to completely solve the problem, you have to address so many topics, many of which on the surface do not seem to be issues. I have seen our pain management colleagues suffer because of the way medicine works in today's society. I have seen colleagues who care deeply for their patients try to limit opioids in their patients of concern, only to have these same patients write scathing reviews on the internet because they are not getting their opioid medications. These same colleagues then get punished by their institutions for negative reviews, which affects their careers in enormously negative ways. These negative reviews [are]read by other patients [and] hurt the practitioner's practice, causing them to lose patients, lose their academic standing and receive penalties for negative reviews by their institutions. 

In addition, the government may withhold Medicare payments from these institutions for these negative reviews. I am describing one small aspect of a much larger problem, but the closer you look, the more you realize that this is a complex problem. Maintaining patient safety is the primary concern, and I do believe we are moving in the right direction.

More articles on Q+As:
Robotic-assisted spinal fusion and emerging trends in outpatient spine surgeries: Q&A with Dr. Richard Chua
Changes in spine care Dr. Dalip Pelinkovic wants to see and future trends in the field
The effect of baby boomers on the evolving patient population in spine: Q+A with Dr. Camden Burns

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