Fluroscopic guidance and interpretation-FGI

The use of x radiation to visualize the bony anatomy of the human body commenced about 100 years ago with cumbersome machines that produced grainy images a far cry from the high definition pictures generated today by advanced mobile radiological units such as fluoroscopic C-arms. The evolution of imaging modalities has played a defining role in the progress of spine surgery and particularly the minimally invasive variety which is now routinely performed in ambulatory or outpatient surgical centers increasingly by physicians trained principally in interventional pain and radiology. The ability of these machines to enable the placement of devices and instruments into the spine requires the physician to be proficient in fluoroscopic guidance and interpretation which simply means interpreting 2 dimensional x ray images into their 3 D anatomical equivalents.

The central neurological skills necessary to process the incoming data and convert to outgoing signals that guide the physician hands are most frequently acquired during the training programs of interventional pain and radiology whose residents repeatedly place needles using fluoroscopic guidance into and around the spinal column. It is this repeated stereotactic training that has optimally equipped this subset of physicians with the most appropriate training for minimally invasive spine surgery in contrast to the blunt surgical skills used by most neurosurgeons for wide tissue dissection open spine surgery. A good analogy exists in the same comparison of the different skills required by pilots who fly only by sight compared to those that are instrument rated and can fly by night.

Medicine is constantly evolving as technology advances but what is antiquatedly referred to as the ‘profession’ of medicine is frequently out of step with the practical application of technological progress which often leads to marked differences of practice opinion. The last decade has seen spine surgery walk out of the healthcare equivalent of the dark ages but not without some professional blood-letting. Ultimately the spine reformation will occur and as with all great steps forward technology has played the dominant role. The spinal visualization that FGI permits is a perfect example of the man-machine synchronicity integral to the fighter pilots of today who are able to rapidly process positional information using internal complex feedback loops that allow sophisticated aerial maneuvers thought impossible even a decade ago, much like minimally invasive spine surgery.

As Nelson Mandela said ‘it always seems impossible until its done’ which could have been written precisely for the changes witnessed over the last decade in minimally invasive spine surgery. Change does not occur without friction and a strong argument founded on scientific reason as was seen twenty years ago in the field of cardiac care with the shift from open heart surgeries performed by cardiac surgeons to the fluroscopically guided catheter procedures now commonly carried out by interventional cardiologists. The interaction of man and machine in these therapies involved the development of the same skills that will five years from now most likely have culminated in the birth of an entirely new speciality devoted purely to minimally invasive spine surgery.

The outcome of medical professional battle commonly known as The Spine Turf Wars that has been raging for the last decade in the US between the neurosurgeons and the interventional pain physicians will be decided by which group harnesses the technological advances in imaging and spinal intervention more effectively. One of the main economic advantages of these enhanced more cost effective procedures will be the ability to effectively treat a wider swath of patients who previously were unable to afford the remedies which ultimately will have a significantly positive impact on a country’s economy. Untreated pain is very expensive in both physical and meta-physical terms.

The arguments supporting the progress of the aforementioned techniques would seem logical and to the observer unfamiliar with the protectionist parochialism of medicine should have almost no opposition. It is therefore entirely understandable that a patient seeking affordable spine care would experience confusion upon learning of the almost anti-intellectual commercially based forces that have attempted to professionally destroy the innovators in this field and thus deny patients the opportunity to access high quality cost effective spine care. But this is the history of western medicine with other almost identical stories being catalyzed by the same factors of technological advances and innovative thinking.

Fortunately for the field of spine and most importantly patients afflicted with debilitating spine pain the professional turf wars, fought most aggressively in the US, have not impeded the evolution of minimally invasive spine surgery or prevented its delivery by physicians from the specialities of interventional pain or radiology who have swiftly recognized the increased global need for their services in regions that encourage and foster innovation. The US healthcare market has marginalized itself with its excessive regulation and out of control litigation that work directly against the advancement of medicine.

The economics of a competitive healthcare system understand the critical relationship between physician behavior and technological development, which for advances to occur must allow physicians to make decisions based on scientific reason and clinical judgement, while mitigating the fear of legal litigation. The society in which we live today is a beneficiary of high risk clinical decisions taken decades previously from which were born therapies that are today taken for granted and for progress to continue it is important not to forget that the battles once fought whether on the military or healthcare field were won by technologies that made our lives better such as Fluroscopic Guidance and Interpretation-FGI

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