Los Angeles-based Cedars Sinai's endoscopic spine program is less than two years old, and Corey Walker, MD, has played a key role in growing the service line.
He and some other spine surgeons decided to learn endoscopic spine techniques, and the service has been well received, Dr. Walker told Becker's.
Dr. Walker spoke about his experience learning the techniques, growing the endoscopic spine service and the advice that helped empower him along the way.
Note: This conversation was lightly edited for clarity and length.
Question: You learned endoscopic spine after your training. What was that learning curve like? What advice would you have for other surgeons who want to pick up the technique?
Dr. Corey Walker: If you have experience doing any sort of MIS tubular approach, it definitely makes it easy, because you've learned how to navigate the process of landing in an area of the spine without directly visualizing it. I think that's the hardest part about an invasive approach, is you can get lost very easily. In my opinion the procedures are, for the most part, very similar. The anatomy is better visualized because you have this really high magnification scope. At the end of the day the learning curve really comes to figuring out how to use the different tools through a single port. It's not about whether you can see what you're doing better. But it's figuring out how to use the tools to accomplish the same end goal. Especially with uniportal surgery, it's one handed, and that's what took a little bit of time for me.
The one piece of advice I got that gave me a lot of confidence was from Peter Derman, MD. He said, "When I started doing endoscopic surgery, it never felt unsafe. It just felt like I was [working] slower." I think that that's a testament to the fact that your visualization allows you to still be really safe through the process, to still see the anatomy that you're trying to preserve and decompress. It just might take you a little longer when you first start, and I think when you're picking up a new technology, you never want to do something that's going to expose your patient to more risk.
There's a lot of resources available from different companies to help you train and learn. Doing cadaver labs is incredibly helpful, and there is a significant amount of training material through the form of videos, which is unique to endoscopic surgery. One of the things I would advocate for a new spine surgeon trying to learn the technique is to record every case and go back and watch their case video and see where they could have spent less time, [what] made them inefficient, and then try to improve on that next time.
Q: Were there challenges pitching this service line to hospital leaders?
CW: Everyone loves the idea. Everybody wants to have the newest technology, and it's very marketable. Patients want it, but the reality is even with an open, traditional microdiscectomy, the patient goes home the same day. The challenge is why a hospital would spend hundreds of thousands of dollars on new equipment when the patient goes home the same day. It doesn't save the hospital any costs. It just increases their cost. They can pay the same codes, or sometimes some of the endoscopic codes even pay less. So it's a hard sell.
You have to have people who are willing to see the vision and the improvement for the patients. For me it's enormous where we're living in an opioid epidemic, and I'm not needing to prescribe my patients narcotics after surgery. I was giving small amounts of opioids to get them through the first week, and I found that I haven't needed to do that at all. Patients are able to get back to their lives so much quicker, which is great for really young patients. It's really great for older patients and everyone in between. It's great for athletes. It's great for people who you're trying to preserve their anatomy in case you need to do an arthroplasty later.
You have to be able to articulate the benefits, because from a cost standpoint, the hospital won't see it, and that's a hard sell, and the hospital doesn't see the bottom line difference. You're getting people better faster. Some of the return on interest and the return on equity has to come from that investment bringing in people from the outside who are interested in having an endoscopic surgery. I'm getting referred people from all over. People from out of state want to have this surgery because this is my expertise, and other people are not doing it. There's an added volume there that you know will help pay for that.
Q: What's exciting you in endoscopic spine technology? What do you think will push this into the next generation?
CW: I think we're starting to see a critical mass and company interest. The thing that is astounding to me is the granularity and resolution. I can even see blood flowing through the little, teeny capillaries on the top of the nerve. I can see in areas that I couldn't see before. I can look under the nerves with critical, vivid pictures. The cameras and screens are in 4K now, and they allow you to see tissue and pathology better than ever before.
I think that the tools are going to continue to develop and improve. The drills are getting better. They're getting faster and safer. The different tools on which we use to remove bone and dissect are improving, and people are coming up with better tools to use through the endoscope, which I think is going to make the procedure easier.