Marc Cohen, MD, is a spine surgeon practicing in New Jersey with more than 20 years of experience in spinal health. He has trained extensively in lumbar endoscopic spine surgery and performed more than 1,000 procedures using that technology. Here, Dr. Cohen discusses the technology and where its' headed in the future.
Q: What has been the most significant technological advancement in spine surgery over the past few years?
Dr. Marc Cohen: Spine surgery by nature is always technically evolving and the current evolution has to do with minimally invasive procedures. Specifically, I am involved in lumbar endoscopic surgery. It's a procedure that's in its infancy in the United States by way of Asia and Europe. I traveled for training and received certificates from programs in Korea, Germany and England. The nature of the surgery is the same procedure and indications you would use for conventional microsurgery patients.
These patients would have gone through treatment with medication, chiropractic care and other non-operative methods and their symptoms would fail to be alleviated. Surgeons must also obtain a neurobiological testing to confirm the physical structural problem and symptoms that didn't evolve. Endoscopic surgery is a direct lateral approach into the spinal canal where you have the technology for a telescope light source and surgical instrumentation.
Q: What are the advantages of the lumbar endoscopic technique?
MC: This procedure takes a lateral approach, and the distinction of the lateral approach into the spine versus traditional surgery is the surgeon isn't compromising the muscles or other joints. They are coming from the side to approach the disc in the spinal canal, minimizing soft tissue damage. I can see the surgical site without a big incision and perform the procedure.
The other advantage is that everything is done under IV and local anesthesia. We are able to alleviate the neurological compression and ask patients whether their legs feel better. This is an outpatient procedure done through a 7 millimeter portal, which allows patient to recoup very quickly. Patients are able to leave the facility without narcotics and given aerobic exercises. Most patients can return to work in two to three weeks, depending on where they work.
Q: The procedure seems to have many advantages. Why aren't more spine surgeons able to perform it?
MC: I think the problem is that the procedure is still in its infancy and continues to evolve. Most academic institutions aren't teaching this procedure. The best training on this procedure for neurosurgeons and spine surgeons would be to go to the facilities abroad where they have been doing these procedures for years and train with the professors in those hospitals and medical centers as though they were in residency. The procedure itself has a steep learning curve; it's a matter of retraining your mind to look at the three dimensional problem where they are operating in a direct visualization.
I spent months abroad and after I felt comfortable learning what I needed to learn in terms of how to approach the problem and the patient, make sure the patient had the right indications for the procedure and learn the procedure technically, I was able to come back to the United States. Throughout the last three-and-a-half years, I have continued to go back to those professors and learned new things that could be done in the field.
There are newer things that are constantly coming out in endoscopic spine surgery to address problems we couldn't approach in the past.
Q: How can young or experienced spine surgeons become trained and proficient with this technology in the future?
MC: The companies that manufacture the product are from Germany — joimax. They have representatives in the United States and they make the equipment available through these representatives. Surgeons also need to teach the OR staff and nursing staff how to use the equipment. There is a period of time where you must work with your staff on the equipment. We do the procedure with local anesthesia and sedation, so you have to have a well-trained, board-certified anesthesiologist who is comfortable with the patient lying on their belly for the spine operation and controlling the air way with the appropriate amount of anesthesia.
The surgeon can also use spinal cord monitoring for patients with general anesthesia. The ancillary staff must be well educated in order to accomplish this procedure at the highest level.
We work in an outpatient ambulatory surgery center, so the facility purchased the equipment for us as a curtsey. Most of the patents do not have morbidity factors, so we are able to do the surgeries and allow them to recoup in the facility for one or two hours before sending them home. After that, patients complete their follow up visits and physical therapy to address residual soft tissue muscle issues.
Q: Are surgeons in private practice able to incorporate the lumbar endoscopic technique into their armamentarium?
MC: Private practice surgeons can help advance the field because there are a huge number of patients out there who have chronic back pain and leg pain who have failed conservative therapy but aren't candidates for conventional surgery. These patients continue to function on medication with chronic pain and don't think they have an option to fix or alleviate their problem.
However, surgeons in private practice can learn this or other proven minimally invasive approaches to fix a structural problem which allows their patients to reduce narcotic medications and return to their families in a higher functioning capacity.
Q: Since this procedure is relatively new in the United States, have you experienced an issues billing for it and receiving coverage?
MC: There are issues we run into with billing and CPT coding where a lot of commercial insurers today look at the procedure and categorize it as experimental because it's new technology. They don't have a track record of effectiveness and use that as an excuse to not pay the bill. Unfortunately, that's an erroneous statement because the procedure has been around for years and in the spine literature many studies compare endoscopic surgery to traditional microsurgery with favorable results.
Endoscopic patients do better because they experience less muscle and scar tissue damage. The insurance companies don't recognize the procedure and classify it as experimental. When the insurance company won't cover it, patients have to pay cash.
Q: Do you see these coverage challenges changing in the future?
MC: I think they will change, but I think most surgeons in academic institutions are open when they see that there is an opportunity to advance the field with spine surgeons who are open to learning new things. It's just a matter of more time where these procedures are presented at conferences and where surgeons can see the outcomes and track their patients.
We spend time documenting outcomes so we can show colleagues these procedures have value in terms of technology and good patient outcomes; often patients will tell you they feel as though they have gotten good results.
Q: What should spine surgeons look out for as the next big development in endoscopic spine surgery in the future?
MC: There are new advancements happening right now where the endoscopic surgery in the lumbar spine is able to treat patients with disc herniation and pathology have evolved to the cervical spine where we are able to address the same types of problems for patients with cervical disc replacements, stenosis and decompression. We are able to use the lateral endoscopic approach to do minimally invasive surgery now; next we will be able to do intradiscal fusions where patients who have the mechanical structural problem that needs some form of stabilization, then patients can have the endoscopic procedure instead of a fusion.
More Articles on Spine Surgery:
5 Tips for Spine Surgeons to Prepare for New Payment Models
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Biggest Coverage Issues for Spine Surgeons in 2013: Q&A With Dr. William Taylor of UC San Diego
Q: What has been the most significant technological advancement in spine surgery over the past few years?
Dr. Marc Cohen: Spine surgery by nature is always technically evolving and the current evolution has to do with minimally invasive procedures. Specifically, I am involved in lumbar endoscopic surgery. It's a procedure that's in its infancy in the United States by way of Asia and Europe. I traveled for training and received certificates from programs in Korea, Germany and England. The nature of the surgery is the same procedure and indications you would use for conventional microsurgery patients.
These patients would have gone through treatment with medication, chiropractic care and other non-operative methods and their symptoms would fail to be alleviated. Surgeons must also obtain a neurobiological testing to confirm the physical structural problem and symptoms that didn't evolve. Endoscopic surgery is a direct lateral approach into the spinal canal where you have the technology for a telescope light source and surgical instrumentation.
Q: What are the advantages of the lumbar endoscopic technique?
MC: This procedure takes a lateral approach, and the distinction of the lateral approach into the spine versus traditional surgery is the surgeon isn't compromising the muscles or other joints. They are coming from the side to approach the disc in the spinal canal, minimizing soft tissue damage. I can see the surgical site without a big incision and perform the procedure.
The other advantage is that everything is done under IV and local anesthesia. We are able to alleviate the neurological compression and ask patients whether their legs feel better. This is an outpatient procedure done through a 7 millimeter portal, which allows patient to recoup very quickly. Patients are able to leave the facility without narcotics and given aerobic exercises. Most patients can return to work in two to three weeks, depending on where they work.
Q: The procedure seems to have many advantages. Why aren't more spine surgeons able to perform it?
MC: I think the problem is that the procedure is still in its infancy and continues to evolve. Most academic institutions aren't teaching this procedure. The best training on this procedure for neurosurgeons and spine surgeons would be to go to the facilities abroad where they have been doing these procedures for years and train with the professors in those hospitals and medical centers as though they were in residency. The procedure itself has a steep learning curve; it's a matter of retraining your mind to look at the three dimensional problem where they are operating in a direct visualization.
I spent months abroad and after I felt comfortable learning what I needed to learn in terms of how to approach the problem and the patient, make sure the patient had the right indications for the procedure and learn the procedure technically, I was able to come back to the United States. Throughout the last three-and-a-half years, I have continued to go back to those professors and learned new things that could be done in the field.
There are newer things that are constantly coming out in endoscopic spine surgery to address problems we couldn't approach in the past.
Q: How can young or experienced spine surgeons become trained and proficient with this technology in the future?
MC: The companies that manufacture the product are from Germany — joimax. They have representatives in the United States and they make the equipment available through these representatives. Surgeons also need to teach the OR staff and nursing staff how to use the equipment. There is a period of time where you must work with your staff on the equipment. We do the procedure with local anesthesia and sedation, so you have to have a well-trained, board-certified anesthesiologist who is comfortable with the patient lying on their belly for the spine operation and controlling the air way with the appropriate amount of anesthesia.
The surgeon can also use spinal cord monitoring for patients with general anesthesia. The ancillary staff must be well educated in order to accomplish this procedure at the highest level.
We work in an outpatient ambulatory surgery center, so the facility purchased the equipment for us as a curtsey. Most of the patents do not have morbidity factors, so we are able to do the surgeries and allow them to recoup in the facility for one or two hours before sending them home. After that, patients complete their follow up visits and physical therapy to address residual soft tissue muscle issues.
Q: Are surgeons in private practice able to incorporate the lumbar endoscopic technique into their armamentarium?
MC: Private practice surgeons can help advance the field because there are a huge number of patients out there who have chronic back pain and leg pain who have failed conservative therapy but aren't candidates for conventional surgery. These patients continue to function on medication with chronic pain and don't think they have an option to fix or alleviate their problem.
However, surgeons in private practice can learn this or other proven minimally invasive approaches to fix a structural problem which allows their patients to reduce narcotic medications and return to their families in a higher functioning capacity.
Q: Since this procedure is relatively new in the United States, have you experienced an issues billing for it and receiving coverage?
MC: There are issues we run into with billing and CPT coding where a lot of commercial insurers today look at the procedure and categorize it as experimental because it's new technology. They don't have a track record of effectiveness and use that as an excuse to not pay the bill. Unfortunately, that's an erroneous statement because the procedure has been around for years and in the spine literature many studies compare endoscopic surgery to traditional microsurgery with favorable results.
Endoscopic patients do better because they experience less muscle and scar tissue damage. The insurance companies don't recognize the procedure and classify it as experimental. When the insurance company won't cover it, patients have to pay cash.
Q: Do you see these coverage challenges changing in the future?
MC: I think they will change, but I think most surgeons in academic institutions are open when they see that there is an opportunity to advance the field with spine surgeons who are open to learning new things. It's just a matter of more time where these procedures are presented at conferences and where surgeons can see the outcomes and track their patients.
We spend time documenting outcomes so we can show colleagues these procedures have value in terms of technology and good patient outcomes; often patients will tell you they feel as though they have gotten good results.
Q: What should spine surgeons look out for as the next big development in endoscopic spine surgery in the future?
MC: There are new advancements happening right now where the endoscopic surgery in the lumbar spine is able to treat patients with disc herniation and pathology have evolved to the cervical spine where we are able to address the same types of problems for patients with cervical disc replacements, stenosis and decompression. We are able to use the lateral endoscopic approach to do minimally invasive surgery now; next we will be able to do intradiscal fusions where patients who have the mechanical structural problem that needs some form of stabilization, then patients can have the endoscopic procedure instead of a fusion.
More Articles on Spine Surgery:
5 Tips for Spine Surgeons to Prepare for New Payment Models
10 Key Factors for Spine Surgeons to Examine Before Signing Hospital Contracts
Biggest Coverage Issues for Spine Surgeons in 2013: Q&A With Dr. William Taylor of UC San Diego