Why stay out of the Spinal Canal? 

Guy with neck pain

I am often asked…

Why stay out of the spinal canal ?

 I’ve had a 100% endoscopic spine practice for over 23 years and have performed over ten thousand procedures on all areas of the spine from C2-3 to the coccyx. In the 10 years prior to doing any endoscopic spine surgery, I was a sports surgeon in a high volume spine office with 6 spine surgeons and a fellowship program. 


I encountered the good, bad and the ugly in a very busy spine practice. I was able to observe how spine pain was evaluated, assist in surgery on hundreds of patients, deal with complications, make rounds and even admit on weekends. I gained a lot of insight into the traditional approach to spine pain over a ten year period and its shortcomings. Coming from the point of view of a sports surgeon doing arthroscopic knee, shoulder, hip, ankle and elbow surgery, these spine procedures gave me pause. 


Open spine surgery was frustrating to watch with the commonly used large surgical approaches and their collateral damage to the soft tissue envelope, even when treating relatively small problems. That frustration, coupled with my extensive experience with the endoscope, led me to consider treating back and neck pain with endoscopic techniques.


Over the years I have noticed three things: one, how much better the pain management doctors are at diagnosing the sources of pain in the spine. Two, that spine surgeons don’t really have any good answers or treatments for problems that aren’t seen on an MRI (Facet syndrome, annular tears etc.). Three, that pain management doctors generally don’t have the tools and training to definitively treat these smaller “invisible” problems. In other words, there are a huge number of pain generators that are not being treated by the spine surgeons and only “managed” by the pain physicians.


Endoscopic spine surgery is just now coming into its own and like all new technologies, it can seem a little threatening to some, gimmicky to others, and maybe just “too challenging” for others. I believe a lot of the confusion and uncertainty arises from the fact that very few people in the spine world have ever used an endoscope in their training or practice. I believe unfamiliarity with the endoscope is the primary reason that endoscopic spine surgery has not really caught on, or found in training programs.


The reason that I created the Endoscopic Spine Academy is to fill the gap that exists between a valuable existing technology (endoscopic spine surgery) and a training program to implement the endoscopic technology into a practice.  


Endoscopic spine surgery is a movement that is in its infancy and could be derailed by strong opposition, particularly spine surgeons. I am looking for acceptance of this technology to move things forward. There are many steps to getting this technology into the mainstream, but one of the first is steps to address credentialing.


My approach to credentialing is based on an expansion of existing privileges and skills. The placement of needles into facet joints or discs is very much in the realm of a pain management practice. It isn’t too much of a jump to go from placement of a 2mm needle to a 7 mm endoscope outside of the spinal canal. I have been helping some of the graduates of our ESA Lab Intensives to craft these applications for privileges and seem to be making good progress.


Once the basic skills of endoscopic spine surgery are mastered and safety can be demonstrated, I’m certain that some doctors will continue to advance their skills. This “time to adopt” will allow surgeons and facilities to become more comfortable with this technology and its benefits. It will be an evolving technology for the treatment of back and neck pain.


Over the years, I have been a department chair for credentialing (5 years at a large California community hospital) and have applied for privileges in surgery centers and hospitals in California and Florida. This experience has given me a sense of what privileges are deemed “acceptable” to request.    


I can’t think of any hospital or ASC, that is not self-owned, in any metropolitan area that would grant spine privileges for a laminotomy/laminectomy (endoscopic or not) to a pain management doctor without surgical spine training. Procedures performed inside the spinal canal have a lot more exposure to risk and complications, even if you know what you are doing. If you do enough of these procedures, it’s not a matter of if, it’s a matter of when you will have a significant complication.


I would not encourage beginners to start in the spinal canal. I would consider it irresponsible to recommend and encourage beginners to start with endoscopic surgery inside the spinal canal with the power equipment needed for these techniques. You run the risk of derailing a great movement in the treatment of back and neck pain.


Surgery in the spinal canal is not the place for beginners to start. Of course with a lot of experience and proper training, it might be the natural progression. However in the beginning, why expose yourself to credentialing issues, malpractice coverage issues, and alienation of the spine surgeon community ? 

Also consider that the endoscopic instrument companies might have second thoughts about who they sell instruments to if there were any significant problems to arise – it might only take one lawsuit.