Although not widely adopted in the U.S., endoscopic spine surgery's benefits have been well-documented, including smaller incisions, less muscle-cutting, the need for fewer opioids and faster recovery.
Here, six spine surgeons discuss whether interventional pain physicians and others who are not surgeons should be permitted to perform endoscopic spine procedures:
Question: What is your opinion on interventional pain physicians performing endoscopic spine surgery?
Tony Mork, MD. Newport Beach (Calif.): I believe pain management physicians are in an optimal position to perform certain kinds of endoscopic procedures. Endoscopic procedures that fall outside the spinal canal provide the pain management physician with a pathway to permanent pain relief, rather than treating it with temporary procedures like radiofrequency or an ongoing opioid prescription regimen. Painful conditions that exist outside of the spinal canal include facet syndrome of the lumbar, thoracic and cervical spine as well as painful degenerative discs. Pain Management physicians are highly qualified diagnosticians for these types of problems, which are usually ignored by spine surgeons. After diagnosis, the pain management physician is the ideal specialist to treat the above mentioned problems with an endoscopic procedure in an outpatient setting.
Ara Deukmedjian, MD. Deuk Spine Institute (Melbourne, Fla.): Endoscopic spine surgery is surgery, and nonsurgeons should not perform surgery. Pain management physicians are not surgeons, and therefore should not perform spine surgery. Less invasive surgery, such as endoscopic spine surgery does not require 'less' skill or training. In fact, it requires more experience and training in surgery than open surgeries. Pain management physicians along with any nonsurgeon physicians (anesthesiologists, neurologists, etc.) should not be allowed to perform any type of spine surgery, as it poses serious safety risk for patient well-being. I would feel very comfortable testifying in court that a complication resulting from a nonsurgeon performing endoscopic spine surgery is below the standard of care and their lack of proper training was the proximal cause of the patient's injuries.
Brian Cole, MD. Englewood (N.J.) Spine Associates: I have been performing endoscopic spine procedures for the last 20 years and it has been a great complement to my surgical practice. I am still continuing to learn with each passing case. These procedures have a steep learning curve, and there is a lack of comprehensive training in our U.S. residency programs. Early on I identified mentors to learn from, and I believe it takes at least 50 cases to develop proficiency in these procedures. Although I know many pain management physicians who are quite capable operators, the two questions I would ask is:
1) What is the nature of their training?
2) Are they able to handle the complications?
Taking a weekend course is not enough to do a service to your patients.
Daniel Lieberman, MD. Phoenix Spine & Joint: The technical and surgical skills of pain management physicians varies tremendously. The key to determining whether endoscopic spine procedures are within the scope of practice for pain management physicians depends on their skill set. Therefore, the ability of pain management physicians to perform endoscopic spine procedures varies tremendously. Who should be given the green light and [who should be] told no?
If a pain management physician feels they have the surgical ability, they should be offered a path to perform endoscopic spinal procedures. Since pain management physicians were not traditionally trained to do endoscopic spinal procedures in their residency training, then the path toward credentialing should involve demonstration of adequate training (likely cadaveric labs and such) as well as observation by surgeons currently performing endoscopic spine procedures. If a pain management physicians' colleagues, training and personal assessment indicate it would be appropriate for them to perform endoscopic spine procedures, then they should be credentialed as appropriate.
Isador Lieberman, MD. Texas Back Institute (Plano): Any surgeon, regardless of specialty, must know the indications, contraindications, potential for complications and how to treat those complications, prior to subjecting any patient to any intervention. As a surgeon you need to know how you can get into trouble and how to get out of trouble. If you can't treat the complication you should not be doing the procedure.
Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): This is a tough question. As a fellowship-trained spine surgeon who adopted this technology and has been doing more endoscopic spine surgery in the past three to four years, I can say that it's not easy. I feel we must place the patient's best interest first. I would say it is probably acceptable for a well-trained pain management specialist to perform an endoscopic spine surgery if they know how to take care of the complications.