How did I get started? Conclusion
“Can Endoscopic Spine Surgery be considered a specialty ?”
When I began to do endoscopic spine surgery in the late 90’s, I treated painful conditions that could be seen on the MRI such as disc herniations and stenosis. The big difference for me was the use of the tubular retractor that reduced the size of the skin incision, collateral soft tissue damage and post operative pain. The use of the tubular retractor eventually became known as “minimally invasive” with greatly reduced post op pain; less post op pain opened the door to outpatient spine surgery.
The same problems treated endoscopically were the same problems that were treated with traditional “open” surgery. One aspect of the endoscopic approach that was really different from open surgery was the decreased ability to “explore”. The smaller the tube was, the more difficult it was to move the tube away from the area of planned surgery. This decreased ability to explore meant the diagnosis had to be more accurate in order to accurately place the tube.
The most common reason I treat patients from around the world is pain. The most common reason for this continual pain is treatment without an accurate diagnosis. Anyone who deals with pain in the back or neck knows that there are several pain generators and not all of them show up on an MRI scan. Common examples would be facet or disc pain.
Early on, it became obvious that an accurate diagnosis was the key to successful endoscopic treatment of the pain causing problem. The smaller the instruments, the more accurate the diagnosis had to be and this meant that I had to get more involved with the “diagnostic aspect of spine pain”. I needed a clear understanding of where the pain was coming from (pain generator) in order to place the tube accurately. Diagnosis of spine pain is within the wheelhouse of Pain Management practices. I’ve rarely, if ever, seen a neurosurgeon or ortho spine surgeon do any diagnostic work to help identify a specific pain generator that could be treated with anything but the traditional approaches.
The major factor that distinguishes my endoscopic practice from a typical spine surgery practice, is that I do my own diagnostic workup. This is a huge difference between my endoscopic practice and a typical spine surgery practice. These diagnostic workups are painstaking and can require a lot of time. I have found that the diagnostic workups or “pain mapping” can be essential to a good result.
As I got more comfortable with identifying and prioritizing the various pain generators, I began to identify problems that the MRI couldn’t identify such as annular tears in the discs and painful facet joints. I began to realize how important it was to make the correct diagnosis with the help of diagnostic blocks or injections. Understanding what structures could generate pain was critical to limit surgery and eliminate pain.
As I mentioned above, the most common reason people come to my office (and I’m rarely the first person they see) is for pain, often without a good diagnosis. The most common story I hear is “I went to the spine surgeon who didn’t see anything on the MRI and told me to go to physical therapy or pain management”. This demonstrates the need for a good diagnosis !
My opinion is that pain management doctors know more about the sources of spine pain than most spine surgeons because of the injections and blocks they perform on a regular basis. They can make a much better diagnosis because they “don’t have to see it on the MRI”. The problem is that they don’t usually have the tools needed to treat the source of pain definitively after they make the diagnosis. And most of these pain generators are not in the spinal canal !
In my opinion, the doctors who are the best diagnosticians and can figure out where the spine pain comes from when the MRI is “negative” are the pain management doctors. I’ve also discovered that the majority of chronic low back pain comes from “invisible” sources. It is my strong belief that pain management doctors need specific surgical tools to take their treatment to the next level. These tools are a 7 mm endoscope and the instruments that can be passed through it.
After 23 plus years of a 100% endoscopic spine practice, I now think that Endoscopic Spine Surgery is a specialty of its own. It’s a specialty that can treat a huge number of painful spine problems, as an outpatient with minimal risk or complications.
In fact, I believe that endoscopic spine surgery should be the first line treatment for the majority of painful spine conditions. The reason I created the Endoscopic Spine Academy was to give pain management doctors the tools to definitively treat the “invisible” as well as the visible causes of back and neck pain and help their patients avoid a fusion.
Thanks for sharing in the story of how I got started.