William Taylor, MD, a spine surgeon at UC San Diego Health System and past president and executive director of the Society for Minimally Invasive Spine Surgery, told Becker's Orthopedic, Spine & Pain Management Review, "Transitioning to minimally invasive spine surgery has been a long, slow process. About 20 percent of the spine surgeons in the United States are performing minimally invasive surgery now, and that number will continue to increase."
While minimally invasive surgery may be preferable because there are fewer complications and shorter recovery time, adopting the techniques may still be difficult. Barriers associated with training, education and resources often arise.
Many surgeons who currently practice spine surgery did not learn minimally invasive techniques in their residencies, and it takes a great deal of extra training to become an expert. Another potential barrier may be 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, there may be may not be one agreed upon standard.
According to Brian Massoud, MD, an orthopedic spine surgeon at Spine Centers of America in Fair Lawn, N.J., despite barriers, spine surgeons should train in minimally invasive techniques. "Avoiding minimally invasive techniques will put you at a severe disadvantage when there are other surgeons performing those types of procedures," says Dr. Massoud. "From a medical standpoint, it makes the best sense. In reality and in keeping up with the times, you need to be able to offer minimally invasive services."
Here Dr. Massoud discusses five best practices for beginning a foray into minimally invasive techniques and staying up-to-date within the ever-changing spine care landscape.
1. Begin with the basic stages. According to Dr. Massoud, there are three basic stages to becoming adept at minimally invasive spine techniques. One caveat — it does take several years of dedication. Becoming a minimally invasive capable surgeon should not be something you just dabble in — it needs to become part of standard practice; otherwise, you will not have the proficiency to get good results.
"Phase 1 should be training in a laboratory setting," says Dr. Massoud. "You should not go live on patients until you have the necessary skills to perform the procedure(s)."
Phase 2 is embarking on actual procedure performance. "It is important to pick the correct patient. You want to start with someone who fits the profile for a first good case," says Dr. Massoud. "Ideally someone thin, in good health, and someone who has not undergone prior spine surgeries." Phase 3 involves climbing the learning curve where you find out to handle the predictable hurdles and complications that may arise.
"Basically you are performing the same procedures as before [but] through a much smaller access point. You have a smaller visual field," says Dr. Massoud when describing minimally invasive techniques. The differences physicians must adjust to when performing minimally invasive procedures is part of the learning curve. However, the learning curve is something that becomes easier over time.
"You develop a three dimensional feel over time without having it all opened up in front of you. [That is why] hardware placement is key. In the beginning you might have problem with improper hardware placement which can lead to additional surgery, or you might not be able to always identify neuro structures [through the endoscope] when you first start out. After several years, when you have mastered the techniques and climbed up the learning curve, you come to a place where you and your patients are happy and benefit the most," says Dr. Massoud.
2. Have a plan. It is important to have a plan for your minimally invasive training. "As a surgeon, in general, the last thing you want to do is to disrupt your practice," says Dr. Massoud. New procedures are often accompanied by mistakes — introducing a new procedure could disrupt your practice and put patients at risk.
"You don’t want to come out with a new procedure and have a large number of complications. That is a very scary place to be in because you, as well as your staff, may be questioning what went wrong [if there is a complication], what is happening, what has changed," says Dr. Massoud. The potential for complications and the potential risk to the practice as a result of those complications is exactly why surgeons need a plan to excel in minimally invasive techniques. Start by following the three basic stages.
3. Get to know an experienced surgeon. One of the best ways to grow as a minimally invasive surgeon is to develop a relationship with an experienced minimally invasive spine surgeon. "There are pockets of surgeons across the country conducting minimally invasive procedures," says Dr. Massoud. "The best is to get someone in your community that can assist you in surgery. However, since some surgeons want to protect their territory you may have to travel out of state [to work with a surgeon].”
"At the very least, it is important to have a fellow surgeon to discuss the techniques as you move forward in training and education. A relationship with someone who has already experienced hurdles and pitfalls will be invaluable as you face problems yourself, " says Dr. Massoud. "At Spine Centers of America, for instance, we offer surgeons the opportunity to observe us, to train with us, or to really take it as far as they want to go." Additionally, physician relationships lead to referrals.
"Referrals are easier to achieve if you are performing the most current and effective procedures," says Dr. Massoud.
4. Continue training, education. If you are just beginning to explore minimally invasive techniques, then you may already be immersed in training and education. However, the training and education should continue throughout your career. Several organizations can provide you with current trends, new techniques and a wealth of easily accessible minimally invasive information. For instance, the American Academy of Orthopedic Surgery has educational materials like DVDs and tutorials.
When it comes time to learn under a mentor, travel outside of your state if there is not another surgeon in your area performing minimally invasive spine surgery. "Sometimes traveling out of state to get training is a good idea," says Dr. Massoud. "SCA trains physicians on a regular basis and a majority of them are from out of state. They come to learn, observe and do a training session."
5. Keep minimally invasive surgery handy, but draw upon other techniques when necessary. Finally, minimally invasive techniques should not be all that you work with as a physician. They can be great techniques to utilize but they are just a segment of any physician's care.
"I think of it like a tool bag — what do I have, what can I use to get this done," says Dr. Massoud. "That is how I like to approach treatment recommendations with patients."
With the Internet offering sites like WebMD, many patients arrive at physician offices with a treatment plan in mind. "Patients need to understand that, for instance, the laser, the endoscope and the retractors all are options," says Dr. Massoud. "Some patients come in and they've done a lot of research — they say 'I want this procedure,' or 'what about the laser.' The patient needs to understand that we see what the problem is and have to decide which treatment options in the ‘tool bag’ are best to treat it."
"If a surgeon does not have that mindset, it will be hard to convince the patient. While many patients may have had prior surgeries and an idea of what may work for their syndrome, it's important to design a plan that is right for the patient and not always jump to minimally invasive surgical procedures. I think that it's the best way to customize the procedure to every patient," says Dr. Massoud. "We are realizing that as spine surgeons as we move forward."
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Overcoming Barriers: 5 Best Practices for Beginning Minimally Invasive Spine CareWritten by Kathleen Roney | April 06, 2012
Although many research and journal publications show that minimally invasive techniques for spine procedures are beneficial clinically, the adoption of techniques has been slow.
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