How did I get started? Part Two

So what did I do ?

“Are fusions really necessary for so many patients with back pain? ”

The spine surgeons that I worked with were some of the best in the world, but the longer I worked in that practice, the more I became motivated to try a new approach to solving back and neck pain. 

What kind of approach would this be? 

Of course it had to be an endoscopic approach, since it worked so well on knees and shoulders – why not the back? 

My ideas for a new approach resulted from day-to-day observations while working in a busy 6-man spine practice for 10 years. This spine practice had an emphasis on fusion surgery. I observed that fusions were not a panacea for back pain and sometimes caused more pain than the patients started with.           

My “new” approach would incorporate two constraints. One, surgery would be performed with an endoscopic approach to minimize collateral soft tissue injury. Two, I would not perform any fusions. It seemed to me that the spine was supposed to move like the other joints in the body. 

There were clear indications when performing a fusion made real sense, like fractures, deformity, gross instability and tumors, but I didn’t see these as the most common causes of back pain. In many cases, I wasn’t sure what was causing the pain. It was easy to point to something on the MRI, but imaging studies image; they don’t tell you what hurts. I noticed that fusions for anything other than the “clear indications” were unpredictable and didn’t always follow the concept of “no motion, no pain”.

I could see there were obvious problems causing back and neck pain, these problems were often small in size, but causing big pain. I was reminded of how much pain something as small as a rose thorn in my thumb could cause. A thorn that was so small that I could barely see it, could cause riveting pain. 

I observed similar things in the back. Sometimes a small disc herniation or spur would cause disabling pain. MRI scans were just coming into general use and the ability to see soft tissues was a revelation. I was able to discover various causes of back pain, but the MRI didn’t see everything. 

It was 1998 and I didn’t have a name for this new approach to solve back and neck pain, but eventually people called it “minimally invasive”. The term minimally invasive refers to the surgical technique of placing a hollow tube over a dilator after making a skin incision. The purpose of the hollow tube was to retract the skin and soft tissues instead of using standard retractors. Retracting the skin and soft tissues with a hollow tube allowed the skin incision to be smaller and protected soft tissues that would normally have been cut. For some reason, the use of tubular retractors was considered revolutionary for spine surgery, even though this technique (arthroscopy) for knee and shoulder surgery had been around for decades.

When I started there was no formal name for what I was doing and more importantly, there were no commercially available instruments. The first order of business was to create and develop some instrument trays. The hollow tubes were the first thing that I had made at an aerospace machine shop located in the aerospace corridor of southern California. I started with a solid rod or obturator with sequentially larger tubes pushed over each other until the tube diameter was 14 mm. 

 The reason that the tube had to be so large (as compared with a knee arthroscopy 7mm) was to accommodate an endoscope, some instruments and a suction tube.

This is how minimally invasive endoscopic spine surgery began before anything was commercially available. Of course, better instruments were going to become commercially available over the next couple of decades and Germany was the country that was going to supply them.

One thing changed immediately with the introduction of tubular retractors. 

Tune in next week for Part 3