The State of Minimally Invasive Spine Surgery: Q&A With SMISS President Dr. William TaylorWritten by Laura Miller | February 21, 2012
William Taylor, MD, a spine surgeon at UC San Diego Health System, is one of the pioneers of minimally invasive spine surgery in the United States. He helped found the Society for Minimally Invasive Spine Surgery — which has grown tremendously over the past five years — and now serves as its president and executive director.
"Transitioning to minimally invasive spine surgery has been a long, slow process," says Dr. Taylor. "About 20 percent of the spine surgeons in the United States are performing minimally invasive surgery now, and that number will continue to increase. The demand comes from patients, doctors, hospitals and insurers. Minimally invasive surgery is preferable because there are fewer complications and a shorter recovery time. Most surgical specialties have adopted minimally invasive technique; however, spine has been a bit slower."
Dr. Taylor discusses the evolution of minimally invasive spine surgery and where the field is headed in the future.
Q: Minimally invasive spine surgery has been around for several years and some procedures indicate a clear advantage for patients over the open technique. Why have many surgeons been reluctant to adopt it?
Dr. William Taylor: If you compare spine surgery to other specialties — general surgery — spine surgeons have been relatively slow in adopting the technique. You won't see a surgeon perform an open gull bladder surgery instead of laparoscopy; surgeons who do seem like they are behind the times because patients have gravitated toward minimally invasive procedures. Spine surgery hasn't followed suit as quickly as other specialties. I can't understand the exact reason, but there are barriers in training, education and resources. Most surgeons who are currently practicing spine surgery didn't learn minimally invasive techniques in their residencies and it takes a great deal of extra training to become expert with the procedure.
Another potential barrier is the lack of standardization for minimally invasive spine surgery. For example, there is one way to perform an appendectomy and if you need that procedure, every surgeon will follow the same steps. However, when patients need a spine surgery for something like L4-L5 spondylolisthesis, there are many different acceptable procedures surgeons can do — there isn't just one agreed upon standard.
Q: What factors will play a role in further spreading minimally invasive surgical technique?
WT: Right now, residents going into fellowship programs want to learn minimally invasive techniques for spine surgery. It's growing more quickly in academic settings and private practices than in large medical centers. More people are learning about minimally invasive surgery every year. Its growth clearly depends on surgeon, patient and insurer preference.
Minimally invasive spine surgery is a harder technique to perform and it occasionally takes longer in the OR until you overcome the learning curve. We also sometimes have difficulty receiving reimbursement for the minimally invasive procedures, all of which make them occasionally less appealing than the traditional open technique, despite its value for patients and other stakeholders
I co-founded SMISS with Choll Kim, MD — he's really the driver and standard bearer for the society. We started it five years ago because in the world of academics, there wasn't a place for papers or presentations on minimally invasive spine surgery. Now, other societies are starting to have a bigger interest in minimally invasive procedures, which helps spread the word.
Q: You mentioned one of the barriers to minimally invasive surgery is the lack of standardization among procedures. As the technique becomes more common, do you see a more standardized approach arising?
WT: No, I still think you are going to see a minimally invasive procedure variation. The variation will depend on the diagnosis and surgeon preference. Additionally, where the surgeon was trained, patient population and practice location will all impact this decision.
Q: Despite the variation, is there an umbrella definition surgeons can use to describe a procedure as 'minimally invasive'?
WT: "Minimally invasive" is a definition we have struggled with for a long time. Our definition for SMISS is an approach to the spine which satisfies the physician requirements for outcomes and complications but utilizes normal tissue plans that may avoid unnecessary tissue destruction and allows for outcomes that may be superior to traditional open surgery.
Depending on your technique, the definition could include using an endoscope or other tools to achieve the same goals, as long as the surgeon is minimizing approach related tissue disruption.
Q: There is a big push within healthcare right now to practice evidence-based medicine. Where is minimally invasive spine surgery in terms of proving effectiveness in the literature?
WT: You have to divide that into what we think minimally invasive surgery is now and where we think it will go in the future. It wasn't until the past few years that we knew surgery was better than conservative treatment for spinal stenosis. The Spine Patient Outcomes Research Trial showed, for the first time, this outcome as well as the idea that fusion for spondylolisthesis is better than decompression in the long run. These points have been argued back and forth, but SPORT gave us a foundation for our argument.
We can point to is less blood loss for minimally invasive procedures. There are some studies that don't show this outcome, but the weight of them indicate decreased blood loss, hospital stays, decrease in infection, faster return to work and fewer blood transfusions than with open procedures. In the future, we are hoping to find that outcomes are better for minimally invasive surgery, pain rates are less and patients have a lower risk for adjacent level disc disease.
Q: What are your goals for SMISS over the next few years?
WT: There are three main goals we are focused on:
1. Research — we are trying to prove the effectiveness of minimally invasive spine raining that database for minimally invasive procedures. Surgeons who use it aren't conducting prospective, randomized, controlled studies, but they can mine the database for their research.
2. Education — we try to provide validated training courses for surgeons who would like to learn the minimally invasive technique. Many surgeons are taught by device companies to use their instrumentation; we want to better understand and validate the types and method of the education currently in use and how we can do a better job maximizing these efforts to produce better trained physicians. SMISS also provides educational courses. We have the largest minimally invasive spine surgery meeting every year and at the meeting we have separate courses developed to teach minimally invasive spine surgery techniques. Along with the development of our CORE Curriculum and CME lecture series
3. Advocacy — some surgeons have difficulty receiving reimbursement for minimally invasive procedures. Some procedures don't have CPT codes. Our goal as a society is to make sure surgeons have minimally invasive procedures available in their armamentarium when they are appropriate — which should be available to the patient and the surgeon, not a decision made by the insurance company. For example, the AxiaLIF procedure from TranS1 was developed 10 years ago and has been done 14,000 times — 10,000 times in the United States — but it remains with a T code.
The idea that a procedure that has been done thousands of times over the past decade and proven in the literature still has difficulty getting approvals, reimbursement is disappointing. It means we are not doing enough as a society to ensure options for all patients.
Related Articles on Spine Surgery:
Dr. Stephen Hochschuler: 8 Changes to Ensure a Brighter Future for Spine Surgery
Dr. Frank Cammisa: 8 Top Challenges for Spine Surgeons This Year
5 Trends Impacting Outpatient Spine in 2012: Thoughts From Dr. Thomas Schuler
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