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Minimally invasive spine surgery


Pioneering medical innovation is not welcome with the more established sectors of the

medical community that usually don’t understand the technology or are unwilling to

expend the effort to re-educate themselves. The more convenient option is sadly criticism

and professional harassment.

Minimally Invasive Spine Surgery is her 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 were the eventual culmination of a decade long battle that was

eventually decided by technology. This was clearly demonstrated in the 1990s with the

interventional cardiologists practically annihilating the cardiac surgeons with the

introduction of the femoral inserted cardiac stent.

Minimally invasive spine surgery has been definitively shown in numerous studies to

result in superior outcomes for most degenerative 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 public 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 elevated infection rate was part of the explanation for the

exceptionally high incidence of hardware infection. The minimally invasive spine

surgical approach almost completely deleted this risk from the picture, as the patient is

discharged the same day due to the minimal 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 skill 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 skill of minimally invasive spine surgery. The visualization of the human spine

for the purposes of operating in 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 temporo-spatial skills were never

part of either the neurosurgical or orthopedic programs and graduating residents are left

to their own devices which invariably involved attending multiple hands on cadaver

training course 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 of

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 The medical

profession (if that is what one still wants to call it) has been progressively neutered and

within the next ten tears technology will have further subjugated the role of humans in


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, and smart kids will head to the world of nano-technology.

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