Anthony Yeung, MD, founder of Phoenix-based Desert Institute for Spine Care, is a pioneer in endoscopic spine surgery. He developed the Yeung Endoscopic Spine System in the early 1990s and has perfected endoscopic procedures over the nearly three decades since.
Here, Dr. Yeung discusses the biggest challenges for endoscopic procedures and where the future is headed.
Q: What have you learned about optimizing patients for endoscopic spine surgery? How do you select the right patient and deliver satisfying results?
Dr. Anthony Yeung: Correctly interpreting the imaging studies and confirming the origin of the suspected pain generator with transforaminal diagnostic and therapeutic injections is critical for patient selection. A favorable response to the diagnostic and therapeutic injections and ease of access to the patho-anatomy will help predict a favorable response to endoscopic decompression that utilizes the same trajectory as the pre-surgical injection.
If the surgeon performs the injections, the way the patient responds to the process of the injection will provide additional information on whether the patient will be a good candidate. Current imaging studies with MRI only provide partial information to guide the surgeon. For instance, a foraminal epidural gram will provide additional information that will augment the interpretation of the MRI with the clinical symptoms. If a patient is not able to tolerate the skin needle injection, there may be other options.
Q: How does endoscopic spine surgery fit into value-based care? How can it be cost-effective?
AY: The endoscopic approach allows for the visualization of foraminal and intra-discal pathology that is not seen or appreciated by surgeons trained using a traditional dorsal translaminar approach. The ability to visualize these patho-anatomic sources of pain that correlates with the patho-physiology of pain will open the door to not just a better understanding of the degenerative process and anatomic pain generators, but will add to the surgical armamentarium of surgical intervention. Patient selection and definitive treatment earlier in the painful disease process is cost effective since it will eliminate or mitigate the many nonsurgical options that add to the overall cost of treatment of common low back pain. I have enough information from reviewing my 10,000 case studies that I can predict the endoscopic decompression result to the extent that I will provide a warranty to patients who pay cash and not depend on insurance.
Q: Where do you see the biggest opportunity for spine surgeons to incorporate endoscopic procedures into their practice? Which surgeons would benefit most from learning endoscopic procedures?
AY: The procedure I developed is not a "see one, do one, teach one" procedure. My technique is not available in most training programs. I started the Yeung Endoscopic Spine Center at my alma mater at the University of New Mexico. After training hundreds of surgeons, I now only select dedicated surgeons who are not just interested, but exhibit dedication to learning as well as certain technical skills during the training process. Most surgeons find it difficult to take the time to learn when they finish their training and are anxious to start their practice. The biggest opportunity is to join a spine group already successful in endoscopic spine surgery.
Q: What should surgeons know about endoscopic technology before deciding to incorporate it into their practice?
AY: They need to understand the philosophy and technique of treating the pain generator. There are different techniques that are promoted by different key opinion leaders. My philosophy and technique is different enough that a dedicated surgeon my have to familiarize themselves with all techniques and choose the philosophy and technique that they want to embrace, like the different styles and techniques of martial arts.
Q: How do you see endoscopic technology evolving in the future?
AY: It will and should evolve slowly since there will be a steep and long learning curve. Training too many surgeons before they are ready may negatively affect the future of endoscopic spine care. I am not interested in training the masses, but only surgeons who come to me and dedicate themselves to learning.
The surgeon will need to learn technical maneuvers to advance surgical cannulas and instruments in an approach and manner that protects normal anatomy and exposes bone or soft tissue requiring decompression. Once the surgeon masters this technique, it will be his or her first favored approach option for decompressing the disc, foramen and epidural space in the lumbar spine in their patients. It will take years before the surgeon becomes comfortable enough to take on transforaminal decompression over the more familiar translaminar approach. Once proficient, they will have a steady stream of patients seeking them out for treatment.