This article is a portion of a book titled "Challenges, Risks and Opportunities in Today's Spine World " edited by Stephen Hochschuler, MD, Frank Phillips, MD, and Richard Fessler, MD. You can find links to the previous chapters at the end of this article.
Introduction:
Painful spinal conditions represent one of the two most costly health conditions worldwide, especially in industrialized countries. Endoscopic spine surgery is poised to become mainstream as a safe and cost-effective option which will help mitigate the affordability crisis within healthcare, especially in surgical spinal care. A spinal condition can be the most expensive medical condition as well, given the myriad of treatment options utilized by back pain patients. This effects patient productivity worldwide, even if the condition is not life threatening. When comparing spine care in North America and Canada, there is a three-fold difference between New York spine procedure volume and cost, compared to Canada.
Unfortunately, spine care has become so expensive to treat because new advancements in spine surgery come with an increased expense. The total cost of surgical care for the spine is becoming unsustainable. There are many stakeholders involved in a spine care episode, and often, each is trying to maximize their profits. The advent of endoscopic spine care and treating the pain generator in mainstream surgical spinal care is cost effective, as validated by statistical analysis. Adopting this philosophy and technique will help lessen the increasing costs in spinal care, especially in industrialized countries.
The modern age of endoscopic surgical spine care began in the early 1990’s with the introduction of Kambin’s arthroscopic microdiscectomy. At the time, many key opinion leaders in spine discussed more traditional surgical spine methods focusing on fusion and implants to aid in fusion. I began reviewing and staging my endoscopic findings to allow for “staged” endoscopic spine surgery. I wanted to address pain on a more individual patient basis after recognizing the endoscope provided images of treatable patho-anatomy that supported the patho-physiology of pain, which I felt was not recognized by traditional open surgery spine surgeons.
Starting with herniated lumbar discs and expanding to foraminal stenosis, deformity, trauma and neoplasm, endoscopic spine surgery has evolved into endoscopic spine care by highly skilled, motivated, and dedicated spine practitioners. Endoscopic spine surgeons often provide a warranty for their recommendation once they are able to vet their patients. This concept may be needed in a capitalistic “free market” like other free market concepts of capitalism.
Over the last 40 years, open traditional spine surgery has established a track record which is currently accepted and used as a standard that we use for comparison of results.
When compared to traditional endoscopic surgeries for common and complex musculoskeletal conditions, traditional advances have added to the costs by stake holders who focus on maximizing profits, thus creating an affordability crisis. With endoscopic surgery, however, there is increasing and convincing research with statistical evidence that endoscopic spine care will reduce expenditures up to approximately 50%, or more, from other current surgical and nonsurgical cost models. Regulation and payer issues have also aggravated affordability.
This problem is also exacerbated by patients with treatable spine conditions considered either too young, too old, or who have too many co-morbidities to warrant surgery. These patients often have to continue dealing with their pain due to higher surgical risk, and cost of traditional spine surgery.
“DIRECT” VISUALIZATION OF PAIN PATHO-ANATOMY IS KEY
The two main advantages of spinal endoscopy have mostly gone unnoticed by a majority of traditionally trained spine surgeons. First, the ability to reduce the surgical plan of care, to stage the endoscopic treatment. By focusing on one or two major pain generators, in an otherwise complex and multimodal problem, may be the answer. Second, the ability to directly visualize areas, not just in the intervertebral disc, but also in the epidural and foraminal space. This opens the door to analysis of pain generators residing within a spinal motion segment that can escape traditional spinal imaging and surgical access.
STAGED MANAGEMENT
Organizing endoscopic spine care by grouping it around identified pain generators implies to ignore other structural problems which may be implicated or unrecognized just by history and physical examination. Even with advanced imaging studies such as MRI or CT scan and CT reconstruction. Identification of the correct source of axial facet joint pain and sciatica, for example, in multilevel degeneration may be even more difficult in the absence of a radicular component.
For the endoscopically trained spine surgeon, the question of what to treat and what to ignore is a day-to-day decision-making process. It requires attention to detail as well as precision in the diagnostic work-up to indeed arrive at a plan of care that will significantly reduce disability and pain and improve function. The staged management approach is helpful for the endoscopic treatment of clearly identified pain generators. By embracing Kambin’s initial premise to stay inside the disc, but adopting surgical tools such as laser to aid endoscopic decompression, better results are obtained. The use of laser allows visualization to the inside of the disc. It also helps to control bleeding, ablating soft tissue, recognizing that residual intradiscal and annular scaring, may help intradiscal denervation, as well as, decrease destabilization of the spinal segment following mechanical discectomy.
Recognizing the value of endoscopic visualization, I review accumulated data from my surgical cases every five years. That number is now over 11,000. I also altered my patient selection process as the surgical technique evolved.
I correlated clinical diagnostic tests such as intra-operative chromo-discectomy by staining and labeling the degenerative disc with dilute indigo carmine, combining endoscopic discectomy with chymopapain for selected clinical cases of extruded HNP, and evolving the endoscopic technique with custom as well as new instruments, endoscopes and endoscopic technology. I operated on over 300 extruded HNP patients using low dose chymopapain of 500 units / disc and obtained a 10% better result than with mechanical discectomy alone. I had no complications using chymopapain.
Possible Solutions
Deregulate and support the free market in healthcare. An accomplished surgeon or provider will be comfortable providing a warrantee of the result for his recommendation for a fixed period of time, or subsequent treatment will not be born by the patient more than reasonable while resolution will fall back to the surgeon’s recommendation and projected time frame for pain resolution.
The following recommendations must be transparent and may have to be addressed:
a. Surgical spine care will have to be stratified.
b. The future should allow providers to compete in a free market and must be guaranteed by regulations to receive government and payer allowable insurance payments in exchange for a warranty.
c. A multidisciplinary team offering a team approach with financial risk in the free market will help limit expensive non-surgical, as well as, surgical options as a stratified group decision on the efficacy and cost of care. It will decrease cost of overutilization of individual groups protecting their “turf” and encourage more multidisciplinary groups who will be incentivized to be cost effective.
d. Create an atmosphere of integrity for providers to “warrantee” their recommendations.
This is a personal opinion based on my extensive experience in endoscopic spine care.
Previous chapters:
Challenges, risks and opportunities in today's spine world
Spine care - Balancing cost with innovation
What are big data and predictive analytics
Predictive Analytics and Machine Learning
The HSS Spine Care Model, Part 1
The HSS Spine Care Model, Part 2
The History of Texas Back Institute
Private practice vs. hospital employee: Where we are today and why
Episodes of care and bundled payments
Episodes of care and bundled payments, a sustainable approach
Dr. Scott Blumenthal on specialty hospitals