Arnold Feldman, MD, founder of The Feldman Institute in Baton Rouge, La., was originally trained as an anesthesiologist 30 years ago and treated many failed back surgery patients in his office. After an injury left him with chronic back pain, Dr. Feldman began his search for a less disruptive procedure than the traditional laminectomy and discectomy. Here, Dr. Feldman discusses what he found, how he trained on the procedure himself and where he sees minimally invasive surgical technique headed in the future. Q: Why did you decide to learn minimally invasive surgical technique?
AF: I gave nerve blocks to relieve back pain for many people with failed back surgery. There were a significant number of failures early in my practice — these were patients that had good surgeries from good surgeons and healed incisions, but they just didn't do well. The treatment for those patients burgeoned in my practice from epidurals and nerve blocks to implantations of spinal morphine and opioid systems as well as electronic stimulators.
In my view, spine surgery is the only procedure to also have a separate CPT code for failed surgery. Significant subsets of these patients we operate on don't do well, despite our best efforts.
When I became a back pain patient, I didn't want to go through open back surgery. I was respectful of the fact that it could help, but it might not. I waited four years and then found Dr. Anthony Yeung, a very smart and driven man, developed his own minimally invasive procedure to relieve pain. Dr. Yeung performed the surgery for me and I went from four years of pain to feeling better after 15 minutes. That was a game-changing experience; this is a disruptive technology. Yet, it hasn't changed the practice of spine as much as it should have.
Q: With such innovative technology and procedures available, why hasn't this technique made a bigger impact on the market?
AF: It has to do with tradition; we tend to stick with things that work. In medicine, we look at all new technology with amazement and a circumspect glance. The other thing we can improve is training; these types of procedures aren't taught during residencies. After I experienced the procedure, I looked around the landscape and there were no places to train except with Dr. Yeung and a few surgeons in Europe. This became a challenge for me, but I was able to train on the procedure and I feel it can be very beneficial. I've done a few thousand of these procedures with excellent results.
However, the surgeons who pioneered these procedures 15 years ago are now getting older and I don't see this growing like it should. The philosophy was "refuse to fuse," and preserve the normal anatomy. These procedures can also remove cases from the hospital to the outpatient setting, which is a clear cost savings and reduced risk of infection.
Q: How long did it take before you felt proficient with this procedure?
AF: It took me a number of years before I got my comfort level high enough to perform the procedure on a patient. I am very careful; I used to fly air plans and it took me 86 training hours before I decided to solo — most people only require 10. I am still learning and training because you can always learn from other surgeons and refine the procedure I've studied with some of the very best people in the world and I'm comfortable doing endoscopic lumbar spine surgery.
Q: Do you think more surgeons will chose to incorporate this procedure into their practices in the future?
AF: I have my own clinic and I've been passionate about it. I have taught and trained other surgeons how to perform these procedures and been a teacher at cadaver seminars; you are seeing more of these opportunities arise. Procedures tend to succeed or not succeed for a number of different reasons. I find that companies that make this equipment are small companies or small parts of much bigger companies with multiple product lines. For surgeons to train, they must be passionate about it.
Q: Low reimbursements have threatened several new technologies in the past, and continue to do so. How will the downward pressure on reimbursements impact surgeons performing these procedures?
AF: We are seeing a lack of reimbursement, and that tends to kill technology. I think a lot of people are scratching their heads wondering whether the endoscopic procedures are good, but for the right patient, it's like penicillin for the strep throat.
In some case, surgeons are hampering the progress of these types of surgeries because they say the incisions are too small, so they don't consider it surgery at all. However, it is a highly skilled procedure. We need to get over these ideas and think about what is best for the patient instead of our pocketbooks. It's expensive to get started with the equipment, but I think it's a game changing or transforming surgery.
Q: Does this procedure have adequate evidence to survive in the emerging world of comparative-effectiveness research?
AF: The critics will say it's not adequately published, but Sebastian Rutten has published an article comparing this type of surgery to full endoscopic surgery to traditional microdiscectomy, showing this procedure is superior. For someone on the receiving end, it's minimized risk because there is no general anesthesia and the original anatomy is preserved. You can always do more and bigger surgeries if this procedure doesn't work, but if you do the big things first it's hard to go backwards.
The surgeons doing minimally invasive fusions came up with technological ways to fuse the spine with less destruction. In my opinion, this is the best way to perform a simple discectomy.
Q: What opportunities are there for technology improvement in the future?
AF: In the future, we'll be able to take off bone spurs with lasers and endoscope drills. What I find is endoscopic transforaminal surgery is great if you are the right candidate. I've become skilled at the procedure and helped design some instruments, but basically my philosophy is what Mother Nature gave us is better than anything we could put in there. I try to modify instruments and think of ways to help people with the sole purpose of doing minimal procedures. The design of the spine is good and we should work to preserve it as long as possible.
In the future, I think biologics will become a bigger part of the equation. We'll be able to implant something in the disc that will restore a degenerative disc, which is difficult to treat. There is controversy surrounding fusion for degenerative disc disease. I am a firm believer that fusions are over done and I think we should strive to have good back patients, not failed back patients.
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