Minimally Invasive Spine Surgery

Pioneering medical innovation is not welcome at the more conservative sectors of the medical community that either don’t understand the technology or are unable/unwilling to expend the effort to re-educate themselves. The more convenient option is the criticizing and professional harassment of the innovators. Minimally Invasive Spine Surgery is here to stay and has become an extremely effective tool in the treatment for patients with back, leg and arm pain. The ability to perform these procedures in the outpatient setting has revolutionized the field of spine surgery and will continue to advance the boundaries of minimally invasive spine surgery. The decade long journey has been ferociously fought between the neurosurgeons and the interventional pain specialists with victory on the horizon for the latter group. The central part of their persuasive argument was the critical role of the use of fluoroscopic guidance and interpretation without which these surgeries would be impossibly dangerous. The skills acquired during an interventional pain program more readily equip the IP community with the expertise to competently perform minimally invasive spine surgery. The Spine Turf Wars are the eventual culmination of a decade long battle that was eventually decided by technology which is often the case in medicine, with ofr example the interventional cardiologists practically annihilating the cardiac surgeons with the introduction of the femoral stent. Minimally invasive spine surgery has been definitively shown in numerous studies to result in superior outcomes for most degenerative spinal diseases and it is almost certain that this will now become the standard of care in the US. The associated reduction in blood loss, the quicker recovery and return to normal function were observations I made almost a decade ago when the majority of surgeons in the US were still butchering patient backs as they attempted to locate the painful disc. The minimally invasive management of back, leg and arm pain in conjunction with the use of interventional pain techniques has dramatically altered the publics perception of spine surgery, which can be seen in the increased number of patients undergoing minimally invasive spine surgery. The evolution from general surgery to the specialty of spine surgery began around the early 1980s and the most impressive advances have been witnessed within the last decade, as the techniques of minimally invasive spine surgery have become further refined. That ability to send the patient home the same day was unheard of 15 years ago, when all back surgeries required at least a 5-day hospital stay during which the risk of nosocomial infection was very high. This raised rate was part of the explanation for the exceptionally high incidence of hardware infection. The minimally invasive spine surgical approach completely deleted this risk from the picture, as the patient is discharged the same day as a consequence of very little pain and minimal blood loss, the two main factors that prolonged the hospital stay. The professional battles otherwise known as The Spine Turf Wars have been extensively documented elsewhere on the Internet but basically describe the differences in opinion between the neurosurgeons and the interventional pain community as to who was most appropriately qualified to perform these procedures. The IP community state categorically that because of their superior skills with radiological fluoroscopic guidance and interpretation, which accounts for 90% of the procedure, that they are more qualified to perform minimally invasive spine surgery. The neurosurgeons however predictably disagree and flimsily use the archaic fact that just because they operated on spines with wide aggressive exposures that they are bewilderingly more qualified to competently use the recent skills of minimally invasive spine surgery. The visualization of the human spine for the purposes of operating in a minimally invasive manner requires that the practitioner have an intimate understand of the correlation between the changing fluoroscopic image and the actual anatomical structure. Unfortunately these tempor-spatial skills were never part of either the neurosurgical or orthopedic programs and graduating residents are left to their own devices, which usually involves attending multiple hands on cadaver training courses, in exactly the same way the interventional pain physicians were obligated to do so. A brave new world is upon us in the field of medicine with a large number of moving parts, complicated political agendas and large profits. The fact that nurses in some states of the US are now legally allowed to perform interventional spine procedures is a sign if things to come, and will with time make us, as a brotherhood of physicians wonder

why we spent so much energy fighting each other, when the real enemy was gathering at the gate. I suppose the answer lies fundamentally in the fearful, envious egos of doctors who are unable to see that the carpet has been yanked from under their feet. I don’t blame them, but am generally very disappointed at their complete lack of backbone The medical profession (if that is what one still wants to call it) has been progressively neutered and within the next ten years technology will have subjugated the role of humans in medicine. Nothing ever stays the same, and medicine is no exception. The pathetic downward spiral of a once noble profession, is in my opinion, the result of weak political leadership. Most doctors are scared to strike and will generally not confront the multiple injustices imposed on their profession. Within a short period of time the profession will join the ranks of the teachers, the smart kids will head to any number of metaphorical global silicon valleys, but I am sure minimally invasive spine surgery will survive only another ten years. The only thing to expect is the unexpected.

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