Raymond Gardocki, MD, joined Memphis, Tenn.-based Campbell Clinic Orthopedics after completing a spine surgery fellowship at the Los Angeles Spine Surgery Institute in 2004.
Dr. Gardocki specializes in minimally invasive and endoscopic spine surgery and adapted endoscopy into his practice after performing his first procedure in 2017. In February, he completed his 100th endoscopic spine surgery using Joimax technology.
Although there are some challenges to overcome in the training, Dr. Gardocki maintains that endoscopy is the least invasive, safest approach to spine surgery, which allows for a decrease in morbidity rates and recovery times.
Here, Dr. Gardocki shares his insight on endoscopic spine surgery and the benefits of awake surgery.
Question: Where do you see as the biggest space for innovation in spine?
Dr. Raymond Gardocki: I think the biggest space for innovation and potential impact is endoscopic surgery. It currently is a very small part of the market, but it has the greatest benefit and it's applicable to the largest number of patients. We have technologies yet to be developed in endoscopic surgery that are going to allow us to do lumbar and cervical fusions outpatient in addition to the discectomies and decompressions we can already do. Instrumentation and expandable cages — things that can be applied through a very small portal and expanded — are yet to be developed and I think that's where you're going to see everyday degenerative spine treatment change.
Endoscopic spine surgery is technically challenging because it's not a motor skill that we've learned to do in traditional surgery. The anatomy can be harder to identify because you have less anatomy to orient yourself. We all know the anatomy but it's a point of view that we're not used to seeing. Another barrier is the pressure to see more patients faster, which makes it harder to be more specific with your diagnosis. It takes a lot more time, work and energy to pinpoint pathology. It's easier to say there's three abnormalities on the MRI so we're just going to operate on all of it. In that way the endoscope forces you to be a better clinician.
Q: Endoscopic spine surgery is used in approximately 5 percent of adult spine surgery in the U.S., compared to around 15 percent in Europe and 30 percent in Korea. Have you any insight into why it hasn't been more widely adapted domestically?
RG: It's multifactorial. Endoscopy has been around for a while, but in the early days the optics were poor. I think there were some people pushing endoscopic spine surgery who promised it could do more than it actually can. That left a bad taste in peoples' mouths, especially in the spine community. There's been a number of innovations in spine over the years that ended up not being able to do what was promised.
There's a greater risk of liability in the U.S. than other countries so people don't want to be the first person to do something. I started doing outpatient lumbar fusions in 2008 and it weighed heavily on my mind because I was basically outside the standard of care. If I had any complications, it would have been very hard to defend. But it's slowly becoming accepted now.
Having had that experience, I felt I could tackle the endoscopic aspect. Fundamentally, I think it's better — you either believe it or you don't. It's less invasive, not only intuitively, but there are studies that show inflammatory mediators are lower after an endoscopic approach than even a tubular approach. It's objectively less invasive; it allows us to do surgery on patients that are awake so you can avoid the risk of general anesthesia, which can be significant in the elderly population. You also get instant feedback — you can sometimes tell while the patient is on the table if they're better because you can ask them how their leg feels.
Q: Is there an apprehension among patients when you propose an awake endoscopic procedure?
RG: Surprisingly, no. I thought there would be a lot of patients that would say, 'just knock me out, I don't want to deal with this.' Occasionally a patient will say that, but when I explain to them that it's safer to do it awake because of the area we are operating in, how it's done and the benefits of being awake, I haven't had a patient that didn't want it done that way. Take a transforaminal discectomy for instance, it's a very small area and very easy to put too much pressure on the nerve if you don't get that feedback. It's possible to do it asleep with very good neuromonitoring, but the best neuromonitoring is the patient telling you that you are causing pain in their nerve.
Q: What was the training like in endoscopic spine surgery? When did you decide to incorporate it into your practice?
RG: I did my first case in February 2017. Over the years prior, I had done several endoscopic spine courses through practical anatomy workshops, the North American Spine Society and the Society for Minimally Invasive Spine Surgery. About 10 years ago, I tried a couple of endoscopic spine surgeries and they went poorly and I kind of gave up on it. That's when I started to focus more on the outpatient tubular surgery and started doing outpatient lumbar fusions.
Then I was at a NASS course in Chicago about five years ago and Dr. Ralf Wagner was doing a demonstration. He showed the disc, the pedicle, the traversing nerve root and all the anatomy through the scope, and it clicked. It was like somebody flipped a lightbulb in my head and I got it. I did the training with the Joimax system and the first patient I had, I told him that I'd never performed the procedure in a live person before, but that he was the perfect candidate. He had a contained herniation that was somewhat central. I would have had to do a wide laminotomy and remove a lot of bone to do this from a traditional posterior approach. We did it awake through a transforaminal approach, and he went home the same day and did really well. He even did a testimonial video for me.
Q: Do you think the training has an impact in the lack of spine surgeons using endoscopy? Given the benefits, why do you think more surgeons haven't adopted it?
RK: It's not part of the mainstream training. For instance, if you do a fellowship, you're not going to get a year's exposure to it. You have to learn it on your own so it certainly makes the learning curve longer. I often hear in the hospital, 'we do it that way because that's the way we've always done it,' and I hate hearing that. I think there's always room to make something better and improve it. The easiest way to improve spine surgery is to maintain the fundamental objective of the surgery and minimize collateral damage. That's why we do minimally invasive surgery, and endoscopic spine surgery is the least invasive spine surgery.
Diagnostically, you have to be better to do endoscopic spine surgery. I presented a case a recently where a patient had spondylolisthesis at one level and a disc herniation at the next level. I could attribute his symptoms solely to the disc herniation — he didn't seem to have symptoms attributable to the spondylolisthesis, which he had for a very long time. I was surprised that most of the course participants suggested a two-level fusion. I presented that I did the disc herniation surgery and he improved, and people still pushed back and said he's going to need a fusion later, but he hasn’t needed it yet.
Q: How do you approach the conversation with a patient when you're explaining that they will be your first patient using a new technology? What makes a good candidate for endoscopic spine surgery?
RK: It's surprisingly easy. I'm old enough where I'm not self-conscious about what people think. They can just tell me no. Fundamentally I want to do the surgery that I would want done for myself or my family member. That's why I feel very confident when I look somebody in the eye and say, 'this is the right thing for you.' I try to take what I've learned through the years, picture myself in that situation and decide what I would want if I were the patient.
I don't operate on the MRI; I operate on the patient. You have to be very specific as to the source of the patient's pain. It takes extra time to sort through the physical exam and imaging and really pinpoint to the best of your ability what nerve is hurting. If you can do that, they're a candidate for endoscopic surgery. If they have multilevel pathology and their complaint is very diffuse, then they may not be a candidate. I would say that about 80 percent of the patients we see are probably candidates for something less invasive than a traditional approach.
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