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The cutting edge of spine-The cost of innovation

An article published February 2014 in Outpatient Surgery entitled ‘How We’re pushing the outpatient spine envelope”

Describes the practice of a physician in California who has dedicated himself to the performance of increasingly complex spinal procedures in the outpatient setting by analyzing the different components that comprise the performance of outpatient spine surgery.

The story is very familiar one and as anyone who has been following the evolution of minimally invasive spine surgery and the associated Spine Turf Wars will recognize, demonstrates the inevitable advance of fluroscopically guided spinal procedures that commenced using in 2001 and which allowed the performance of the 1st outpatient lumbar fusion in 2005.

When the journey was commenced that would take previously complex spine procedures associated with extensive blood loss, extended hospital stays and muscle destruction out of hospitals into the outpatient setting there were many detractors who thought it would be impossible to correct spinal abnormalities on a same day basis. Understanding the reasons as to why spine surgery had only up to that point been performed in hospitals involved an appreciation of the advances in video endoscopic and fluoroscopic technology. In addition one of the main obstacles to the early discharge of patients was the excessive and uncontrolled pain most patients experienced after an open aggressive procedure that involved the painful destruction of muscle. It was recognized that the usefulness of a post operative caudal epidural injection significantly reduced the post-op pain level and minimized the requirement for opiate medications which are associated with delayed recovery. The minimization of blood loss through the use of muscle sparring techniques eliminated the need for blood transfusion that was often required with traditional open approaches to the spine and was another factor that allowed the surgeon to perform multi-level fusions in 2010 for degenerative scoliosis.

With the advances in spinal technology has come an improved understanding of the relationship between biomechanics and experience of spinal pain. The study and treatment of pain has principally been the pursuit of interventional pain specialists who through their extensive training in fluoroscopic guidance and interpretation have become the experts at placing needles, probes and other minimally invasive instruments into and around the spinal column. The professional battles between the orthopedic, neurosurgical, radiological and interventional pain communities will most likely culminate in the creation of an entirely new specialty whose focus will most likely be the performance of minimally invasive spine surgery in the outpatient setting. The principles however of FGI and pain mapping will significantly direct the education and training of these future physicians.

The increasing utilization of stem cell therapy is predicted to profoundly alter the future landscape of degenerative spine disease and most of the therapies will be administered via a fluroscopically placed needle that will most likely lead to a reduction in the use of pedicle screws and interbody devices. With this new frontier will come an increased focus to completely eliminate X ray and fluoroscopic utilization as infrared and ultrasonic technologies evolve to allow the development of portable imaging googles that will incorporate 3D multi-spectometry software

Medical innovation has historically been associated with forward thinking clinicians able to find innovative solutions to seemingly insurmountable obstacles but not without a cost. The physician in California who can now perform an outpatient lumbar interbody fusion does so on a trodden path that was once, until someone took the first step, never existed.

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