Utilizing “Disruptive” Endoscopic Techniques: The€¦ · –The future will be by combining...
Transcript of Utilizing “Disruptive” Endoscopic Techniques: The€¦ · –The future will be by combining...
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Anthony T. Yeung, M.D., Clinical Professor
University of New Mexico School Of Medicine
Desert Institute for Spine Care, Phoenix, Arizona
Executive director, (IITS.org)
Beckers 17th Annual future of Spine and Pain Management Conference
June 12-19, 2019
Utilizing “Disruptive” Endoscopic Techniques: The Role and Future of Endoscopic Surgery for the
Treatment of Symptomatic Conditions of the Spine( an evidence based concept talk)
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Health Care Cost is in Crisis… No easy answer
• Affected by stakeholders all competing for services or products causing an affordability crisis
• Privilege or Right?
• Free, single payer, or best solved by a Free market?
• What is the Role of health care providers that has to deliver health care , vs government / insurance payers?
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Health Care Affordability is the Crisis
• Affordability is a real challenge without the means to pay for “real quality “
• A growing trend is for hospital and physicians to manage cost-sharing and quality metrics
• What about “disruptive” concepts,
– Treating the pain source surgically with a “warrantee”?
– Ie. surgical pain care with visualized surgical treatment of the pain generator as a staged procedure
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My opinion:
Consider “disruptive” techniques that preserve patient choice and physician
autonomy= free market concepts
Endoscopic Spine Care, 5G, Robotic A.I.
Single payer w/o insurance choice, USPO without FEDEX,
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I am “Conflicted” by 28 years >11,000 Endoscopic Procedures since 1991
• Developed the YESS™ Endoscopic Spine System 1997
– Personal experience with the first Medicare approved Spine ASC
• Over 140 Level IV and V EBM publications
– Now level 3 with like minded surgical collaborators
– All innovations start as level V
Personal observations
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The Background for my “Confliction”
• BACKGROUND: I was a General Orthopedic Surgeon for 20 years, before Spine Fellowship Programs spawned the myriad of fusion procedures considered the “State of the Art”.
• I support current concepts in Spine Surgery, including fusion
– I see the success of fusion for the right indications by my fellowship trained associates at Desert Institute for Spine Care
• After adopting endoscopic spine surgery in 1991, I became passionate about endoscopic spine surgery because it offered greater surgical options, but “disruptive” to traditionalists
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Take home message
• Endoscopic surgery on the pain generators of spine symptoms and pain can be correlated with patho-physiology supported by endoscopic documentation
• The patho-physiology of pain is better understood than just reliance on current imaging techniques alone
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Initial Response by many traditionaliststo “Disruptive” Surgical Platforms
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Why is Endoscopic Spine Surgery ”Disruptive?”
• Eliminates the need for fusion, (the current focus) by 30-
85% (stratified)
– The most costly surgical option
• Decrease the need for more costly Spinal cord stimulation
for FBSS from failed decomoression and fusion
– * I share the DRG neuromodulation method for neuropathic pain
• It mitigates dependence and over utilization of
Opiods by “surgically” treating the pain generator
“surgical pain care”
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Why is Endoscopic Spine Surgery ”Disruptive?”
• Endoscopic decompression accomplished under
local anesthesia by Surgically Trained
Endoscopists as a “STAGED” procedure can
eliminate 70-90 percent of fusions being utilized as
the first option for decompression and stabilization
• Mitigates the fusion solution driving evidence
based medicine studies and 3rd party payment
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Scott Becker’s Thoughts on Health Care Systems
• Scott Becker Outlined the headwinds facing Current Trends in health care delivery
• Scott Becker concludes that current medical doctrine…IS NOT Likely to Work in the Next 10 years
• Are Scott Becker’s “other” Issues “DISRUPTIVE”?
–*Endoscopic Spine Surgery for symptomatic conditions of the lumbar spine is Becker’s “other” issue for more cost effectiveness in spine care
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My Thoughts on Disruptive Health Care Issues under Becker’s “other” platform
• Convert pay for service to pay for “value”
• The provider issues “value warranty” for the requested fee
• Treat surgeons like PROFESSIONAL ATHLETES where only the very best are paid what they command
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My Thoughts on Disruptive Health Care Issues under Becker’s “other” platform
• Educate the next generation of physicians to be competitive in the new era of healthcare by:
– Focusing on what is best for their patient
–Adopting endoscopic “surgical spine care “
– Surgeons offering a “warranty”
• Robotics for endoscopic spine surgery will shorten learning curve, improve results
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Current political Situation in the USA
• ”FREE” single payer “ one size fits all” concept will
provide less quality, less choice, rationing, and greater cost
• Health care providers “gaming” the system will add cost by protecting their turf without improving care will be the demise of universal “free” health care
• The Best solution is still be debatable and must be rationed
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• Oval design as a surgical tool:– Discectomy, Nuclectomy
• Decompression
– Intradiscal Therapy• Decompression
• Thermal annuloplasty
• Disc irrigation
– Nerve Ablation• Intradiscal annuloplasty
• Rhizolysis• Disc and Axial back pain
Facilitate And augment All Surgical Approaches
Wolf Y.E.S.S™. Multi-Channel Spine different systems in the market
Many Endoscope DesignsFor Diagnosis and Treatment:
Identify Painful Patho-anatomy
YESS Endoscope Provides Endoscopic
Documentation of patho-anatomy of pain
generators: A New EBM concept
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The YESS Scope Design: Oval endoscope with Multi-channel flow integrated system ( 1997)
Wolf Award 2017 commemorating 20 years of innovation
NEW 3D SCOPE under development
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Oval endoscope configuration facilitates intradiscal therapy visualization in a
narrowed aging spine
( other OEM endoscopes are round)
Oval shape Enhances visualization by a fluid pump that controls
irrigation flow and pressure to keep the endoscopic field clear
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Surgical pain treatment is a “disruptive” concept
• The endoscope can document patho-anatomy responsible for symptoms and pain from normal aging
• It can correlate the pathophysiology and symptomatology when endoscopic surgery is performed with pt feedback under local anesthesia
Clinical example: Correlation of
epidurography and “evocative”
discograms with the patho-
anatomy of symptom generation
Video of painful anular tear (1.5 min)
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Why is endoscopic spine “disruptive”?Too many stake holders in the spinal care platform
• Surgeons and nonsurgeonswho do not perform endoscopic surgery may have a different opinion about endoscopic spine surgery
• Many are opposed or “agnostic” about it
• Accomplished Endoscopists
requires special surgical training to be proficient
for this “new” concept of “evidence based medicine”
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Why is Endoscopic Spine Surgery ”Disruptive?”
• It will mitigate dependence and over utilization of opiods
and pain management procedures that are easily abused
• Decrease the need for costly Spinal cord stimulation or
nerve and DRG neuromodulation for “FBSS” Pain
• A Yeung owns the foraminal DRG neuromodulation method,
but almost all utilization is by pain management providers
familiar with concepts of Spinal cord stimulation
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This experience provides endoscopic “evidence based medicine” by treating the pain and
symptom generator, with endoscopic documentation of the patho-anatomy.
*Traditional imaging requirements to make clinical decisions is not completely accurate
*Neuromodulation can treat neuropathic pain
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When the visualized “pain or symptom” generating patho-anatomy is correlated with the patient’s response and feedback during
surgery, a new type of “evidence based” validation of the surgical effect, considered “disruptive” can be studied and validated
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The “E” in Endoscopic Evidence Based
Medicine (a new concept)
• E= Evidenced based
• E=Endoscopic Visually Based
• E= Expedient and Efficient Based
• E= Economically Based
• E= EXPERTISE Based
Treat the pain generator, not just the available imaging
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The “disruptive” process provides information on pain generators that is not appreciated by traditional spine surgeons and non surgeons.
A. Yeung’s data base of >11,000 surgical procedures on endoscopic surgery under local anesthesia identifies the best indications for
“surgical pain care”
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The “YESS” endoscopic philosophy and technique
• Appropriate for patients deemed “too Young”, “too old”, “ too pain sensitive”, with “psychologic disorders” or having “too many co-morbidities” to be good candidates for the risks of traditional surgical intervention
Morbid Obesity 350 #
Biportal Endoscopic Technique
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Video example of biportal endoscopic technique
The surgeon and
assistant can
work together
inside the disc
An endoscope
Visualizes the
surgical process
Extruded
herniations
Are pulled back
into the disc
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THE BEST TECHNIQUE, as defined by safety through reduction of complications, efficacy,
and cost effectiveness should be adopted by the best results in each individual surgeon’s
hands
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“Best” Minimally Invasive Surgical Technique is Transforaminal Decompression under local
anesthesia
• It is Safer than traditional open surgery!
• 3.5% published complication rate
• NOW *< 1%-2% endoscopic complication rate after overcoming the learning curve
– A Yeung’s overall CUMMULATIVE case series
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FEATURES of Transforaminal Decompression:
• Clinically Effective, and Cost Effective– Local anesthetic performed with MAC or no sedation
– Outpatient, one hour recovery in ASC, surgical time dependent on case complexity and surgeon experience
– *Neuromonitoring NOT NEEDED ( at cost savings )
– Earlier Surgical Care bypasses less effective nonsurgical methods and more surgically morbid care
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The “Surgeon” factor:
Endoscopic surgeons or nonsurgeon providers must develop critical skills, with appropriate training, and gain competency to perform at a high enough skill level needed to attain the safest and best results
Appropriate training, “turf battles”, “hype”,
unaccepting surgeons, FALSE marketing
CONCERNS
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A systematic review of A YEUNG’S endoscopic database 10,000 cases 1991-2018
• Discogenic pain validated by evocative chromo-discography with intra-operative vital staining
• Progression to contained, then protruded and extruded HNP of various types
• Progression to foraminal decompression and
foraminoplasty
• Statification of endoscopic indications in past 15 years to present evolution in 2019
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Growth of Endoscopic Spine
• ENDOSCOPIC VISUALIZATION ,EXCISION, DECOMPRESSION AND STABILIZATION of the lumbar thoracic and cervical spine Is CURRENTLY BEING PRACTICED WIDELY in ASIA
• Transforaminal Endoscopic Decompression, providing symptom relief is possible for 80%-90% of the Painful Patho-anatomy of each Degenerating symptomatic Spinal Segment
China 2018
Courtesy of Luke Kim
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Endoscopic Spine State of the Art
• A “full endoscopic” approach is first promoted by Sebastian Ruetten and others by combining the Translaminar with a Transforaminal approach
– The future will be by combining all endoscopic approaches possibly staged, aided by Robotic A.I.*
• Endoscopic procedures now BEING UTILIZED for trauma, neoplasm, and instability, including fusion as a surgical option for pain resolution from “FBSS”
* ATY’s A.I. for endoscopic techniques
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A.I. in computer technology for health care
• Assimilation in Asian countries will be at a much higher rate than the West because it is culture and Asian political policy dependent
• Asia (China) has a large population with relatively lower costs, that “insulate” Asia from loss of low level and blue collar jobs at risk in Advanced Western Countries currently in political turmoil
• *Physician A.I. needs a reimbursement platform to innovate, but under attack because of payment headwinds
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Endoscopic Spine as an Academic Endeavor
• The Yeung Endoscopic Spine Center established in 1993 at the University of New Mexico ( Yeung’s Alma Mater) as the
first academic center to create a multidisciplinary program for Endoscopic Spine Procedures. Certification for endoscopic spine surgery graduated it’s first anesthesia trained spine fellow Andrew Roberts, M.D.
• More fellowship trained spine surgeons adopting endoscopic spine to augment their practice
• (D.I.S.C. Phoenix, Arizona)
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Endoscopic surgery augments open “gold standard” surgery by adding intradiscal therapy
• Intradiscal therapy: Endoscopic Selective Decompression, thermal ablation , Irrigation, and neutralization of disc pH
• *Endoscopic visualization of patho-anatomy under local anesthesia with patient feedback during surgery is an important aspect of endoscopic evidence based medicine
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The Exit Zone
Hidden Shoulder
Osteophytes
Inflamed Nerve
Superior Foraminal
Lig. Impingement
Superior Foraminal
Osteophytic Impingement
Impacting Facet
Margin
Tender Capsule
Hypertrophied SAP
Hyper-vascular
Scared SWZ
Inflamed Disc
* Superior foraminal ligament Impingement
* Superior notch Osteophytes
* Dorsal & Shoulder Osteophytes
* Facet Joint Impaction
* Facet Joint Cysts
* Pars Intrarticularis tethering
* SWZ & notch Engorgement
* Ligamentum flavum Infolding
* Disc Pad
* PLL Irritation
* Inter Transverse lig & Muscle Entrapment
*Inferior External Pedicular Tethering
*Annular thinning
*Annular Tears
*Shoulder Osteophytes
*Lateral Osteophytes
*Perineural Tethering
*9 common, 17 endoscopically documented painful
conditions and its anatomic locations in the foramen
The list is still growing, with endoscopic solutions for FBSS
Ie. compressed or stretched scar tissue previously asymptomatic
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9 Common endoscopically visualized Conditions, aided by endoscopic foraminoplasty
• 1. Inflammed disc
• 2. Inflammed nerve
• 3. Hypervascular scar• 4. Hypertrophied SAP, lig flavum impingement
• 5. Tender capsule
• 6. Impacting facet margin
• 7. Superior foraminal facet osteophyte
• 8. Superior foraminal ligament impingement
• 9. Hidden shoulder osteophyte
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Additional endoscopic documented conditions
• Symptomatic scar tissue (from stretching or compression)
• Facet joint soft tissue and bony impingement
• Facet Joint cysts (many unrecognized by imaging
• Pars defect tethering in isthmic spondylolisthesis
• PLL and annular inflammatory irritation
• Annular thinning and tears with chemical inflammation
• Perineural tethering by scar post operative or inflammation
• Foraminal osteophytosis
• Endplate tethering and impingement
( * “YESS” technique)
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Yeung’s KEY PUBLISHED ARTICLES
• Endoscopic Identification and Treating the Pain Generators in the Lumbar Spine that Escape Detection by Traditional Imaging Studies J of Spine
– J Spine April 21, 2017 * (intradiscal therapy and foraminoplasty to access the “hidden zone of MacNab”)
• In-vivo endoscopic visualization of patho-anatomy
in symptomatic degenerative conditions of the lumbar spine II: Intradiscal, foraminal, and central canal decompression. Surg Technol Int 1: 299-319.
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Journal of Spine Yeung and Yeung, J Spine 2017,
6:2 DOI: 10.4172/2165-7939.1000369
Endoscopic Identification and Treating
the Pain Generators in the Lumbar
Spine that Escape Detection by
Traditional Imaging Studies
Department of Neurosurgery, University of New School of
Medicine, Albuquerque, New Mexico
Desert Institute for Spine Care, Phoenix, Arizona, USA
KEY Article for Endoscopy
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2 Basic Endoscopic Techniques
Inside Out Technique
Anthony Yeung
Outside In Technique
Hoogland
Richard WOLFMaxMore
Joimax
Both Target the Patho-Anatomy
Slide Courtesy of Luke Kim
“The gospel according to Luke”
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2 Different Targeting Techniques
Inside Out Technique“SAFEST” Due to
Outside In TechniqueSERIAL DILATION
Hoogland design change
DIRECT VISUALIZATION MaxMoreJoimax
The Best Designed Endoscope= YESS Scope ( personal opinion)
not reflected by Wolf’s Marketing plan
INTRADISCAL THERAPY
YESS
“Gospel of Yoda using a Starwars Theme”
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YESS Technique = “Easy” TechniqueXifeng Zhang, first YESS Chinese spine fellow
Mobile cannulas, direct visualization, local anesthesia
Mobile cannulas
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Similar Approach with “outside in” mobile cannulas
• “Novel” targeted “outside in” approach using Joimaxsystem and mobile retractors loosing appeal due to outside large trephines increasing complication rate
• Hoogland converted his original THessys serial dilation and outside trephines for safer inside reaming (Maxmore)
• Targeted decompression and excision techniques developed for trauma, neoplasms, and stenosis
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• Journal of Spine
Endoscopic Surgery of the Spine as a Subspecialty for Trained and Experienced Providers
Anthony T Yeung1,2*, Christopher A Yeung
Nima Salari, and Justin Field
Yeung et al., J Spine 2017, 6:5
DOI: 10.4172/2165-7939.1000388
The future will have Multi-disciplinary contributions,
working together rather than as competitors
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Trend: “Moving away from Fusion”
• Fusion is not needed if we can treat the cause of pain early
• Natural healing over time will decrease the need for fusion to treat pain
• Fusion will be for deformity or instability
– Endoscopic MIS Fusion and dynamic stabilization is possible
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Moving Away from Fusion by Treating the Pain Generator: The Secrets of
an Endoscopic Master
Anthony T. Yeung* Citation: Yeung AT (2015) Moving Away from Fusion by
Treating the Pain Generator: The Secrets of an Endoscopic
Master. J Spine 4: e121.doi:10.4172/2165- 7939.1000e121
Journal of Spine Spine
> 25 publications since 2015
Appropriate adoption and training will be critical
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Key Important Factors
• Appropriate Training
• Adopters must perform the procedures “really well”,
and evolve their own learning curve
• Transparent pricing ( cash vs insurance)
• Practice good EBM ( Evidenced based Medicine )
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Disc Degeneration, even in asymptomatic patients has a high Risk of eventually developing low back
pain and sciatica in the normal aging process
Little Known or appreciated Premise?
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Common Low Back Pain begins in the disc
• Disc Degeneration in asymptomatic patients increases risk of low back pain
– a prospectively assessment of Southern chinese
– Dino Samartzis, HK University faculty
• New technologies being developed with Yeung involvement*
– Disc shunt
– Imaging ( Nocimed)
– Neuromodulation *( invasive and noninvasive )
– Robotics for endoscopic targeting *
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Primary Pain Source:
The Disc• Current research and interest should be with
intradiscal therapy– Validated by level I EBM
Chymopapain
• New technologies for nucleus augmentation, biologics is still in its infancy, but promising
Disc Anatomy
80 Percent support
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*The demise of chymopapain is a lesson that even level 1 EBM validated studies can fall
victim to over regulation and risk vs profitability over efficacy. Good training also an issue for poorly trained practioners “ruining”or
discrediting the endoscopic procedure
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IS OVER REGULATION AND RECENT PHARMA SHORTAGES and COST THE PROBLEM?
• SHORTAGES OF COMMON INEXPENSIVE ENDOSCOPIC SUPPLIES * SINGLE OR MULTI USE
– SALINE
– WATERSOLUABLE COMPOUNDED STERIODS
• Betamethasone
– VITAL DYES
• indigocarmine
• Methylene blue
– NON-IONIC CONTRAST INJECTIONS
• Iso-vue 300
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Evidence: Evocative Chromodiscography™Specificity> 99% False Positive< 1% (Yeung)
Supported by review literature: Disagrees with Caragee
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Endoscopic Evidence: Toxic Annular Tears Testimony: Wife of Pain Physician on Disc website you and tube videos
www.sciatica.com
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Playlists (U tube) www.sciatica.comDocuments case examples with audio-video illustrations
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Clinical Rationale of Endoscopic Treatment
• Intradiscal Therapy ( lumbar spine )
– Validated by Level I studies ( chymopapain)
• Foraminal decompression: Foraminal Decompression vs Foraminoplasty
– ENDOSCOPIC EXCISION and neuromodulation of patho-anatomy
• Dorsal rhizotomy
• Hybrid Procedures incorporating all three Therapies
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Endoscopic Surgery is the least invasive Surgical Procedure to treat the patho-anatomy of
chronic back pain and sciatica
New Indications are constantly being developed,
aided by new instrumentation and surgical techniques
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• Save Fusion for last, avoiding “ burning bridges” for more invasive procedures as a staged procedure
• Fusion continues to flourish as well, with “new” surgical concepts changing every 10 years
• Many patients want to avoid fusion due to a ”bad” result to or to fear of the paradoxical effects of adjacent level deterioration
FUSION
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Clinical Research validates Both Clinical Rationale
• The research design focuses on Evidence Based Medicine: EBM allows us to rate clinical data into :
• Levels of Evidence, I-V
• Grades of Recommendation
• Current focus on SCS and DRG neuromodulation
should be for “ true” FBSS causing neuropathy
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The Practice of Evidence Based Medicine is the integration of:
–Clinical Expertise ( starting with level V)
–Patient’s personal Needs and Values
–Best Research Evidence
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Evidence Based Medicine
• Almost all physicians feel they are already practicing “Evidence –based Medicine”
–Medical Schools teach and use the scientific method
–Many read medical journals appropriate to their practice
Excerpted from presentation by W. Watters, NASS President
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Surgical Concepts on Expertise and Education: ( NASS past president W. Watters)
• “What you think you may know may no longer be valid or become disproven over time with future research”
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Patient Values are also Important
• Each patient brings a set of personal beliefs and knowledge base to the patient-physician relationship
• Patients rely heavily upon the recommendations of their physician, family, and friends for personal choices
– Different cultures may have varied beliefs based on their cultural biases that will affect their acceptance of recommended treatment
• Physicians offer guidance to their patients for a joint decision on their choice
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The Best Research Evidence
–Reduces bias, which is difficult to overcome, but should be acknowledged
–Promotes ethical clinical decision making and Minimizes outside influences
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• Journal of Spine
Endoscopic Surgery of the Spine as a Multi-Disciplinary Subspecialty for Appropriately Trained, and Experienced Providers
Anthony T Yeung1,2*, Christopher A Yeung1,
Nima Salari1 and Justin Field1
Yeung et al., J Spine 2017, 6:5
DOI: 10.4172/2165-7939.1000388
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In Endoscopic Surgery: Cooperation is neededCross training, communication, shared responsibilities
• Training is different
• Background is different
• Concepts are different
• Experience is Different
Technical abilities
are different, and
disruptive for
colleagues with a different
surgical background
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Decision making and surgical skills are both necessary and go together.
Training, knowledge of indications, and competency is critical.
(My Greatest Worry: Endoscopic Technique discredited by poorly trained non – surgeons with
no training in surgical anatomy and concepts)
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Endoscopic Surgery Advantages
• The endoscope makes it possible to correlate the patho-physiology of pain of with visualized patho-anatomy. (please refer to DISC website, and click on the top 10 playlists)
• Operating under local anesthesia allows the patient to communicate with the surgeon during surgery
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• All discs undergo degradation in a well-described cascade, matched by imaging and patho-anatomy
• Why some patients have intolerable Pain, and others is NOT completely understood by imaging alone
• Facilitated by Diagnostic and therapeutic injections
• Pfirrmann C et al, Spine, Sept 2001.
Degenerative Conditions
of an Aging Disc
SURGICALLY TREAT THE PAIN SOURCEGUIDED BY IMAGING
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PAIN GENERATORS IN DDD affect the DRG
DRG
Courtesy of Wolfgang Rauschning
Granulation tissue in the annulus
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The Future of Endoscopic Surgery
• Utilized by qualified, adequately trained surgeons and nonsurgeons ( both need training )
• Acceptance will depend on the politics, physician acceptance, and the business of spine in various parts of the world
• Outcome of medical and political turf battles
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The Future of Endoscopic Surgery
“Surgery” will not be just for a neurologic deficit, an “abnormal“ imaging study, or last resort” for surgical intervention.
Transforaminal Decompression will be for Surgical
Pain CARE, not just “Management” under local
anesthesia
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Video demonstrations of Endoscopic Procedures providing video evidence based
validation appropriate for adequately trained surgeons and non surgeons to be showcased
(www.sciatica.com)
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Steady stream of surgeon KOL visitors to my Phoenix surgical facility ( SPSF )
Saiyro
KIM
Yuki
Pt from HK with 5 FBSS surgeries
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Experienced KOL’s taking noticeRecent visit by well known experienced Asian spine
Leaders Learning to ”kill” the pain source
Luke KimDr Sairyo
Japanese spine
surgeon
Chinese
surgeon
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Endoscopic SED™ for toxic annular tears 1.39
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Endoscopic visualization serves as “endoscopic based evidenced”
When correlated with clinical results:ADDING AUDIO FEEDBACK by patient USING LOCAL
ANESTHESIA RE-INFORCES EVIDENCE
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• As a surgical tool:
– Discectomy, Nuclectomy
• Decompression
– Intradiscal Therapy
• Decompression
• Thermal annuloplasty
• Disc irrigation
Y.E.S.S™. Multi-Channel flow integrated Spine Scope
How the Endoscope Should be Utilized
For Diagnosis and Treatment:
Identify Painful Patho-anatomy
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The YESS scope• Endoscopes have integrated channels that is flow and pressure controlled to provide maximal visualization
• It has irrigation channels that a laser fiber can be inserted down one channel for laser ablation
• 2 mm- 4.2 mm working channel for surgical instruments
Oval (4.5mm) shape for narrow discs
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Multiple Endoscope Systems are being marketed
• Other systems are readily Available, with less focus on visualizing intradiscal pathology
• The advantages of the Original YESS oval design still under appreciated as noted by round OEM endoscopes being promoted and marketed that may be simpler to manufacture and use
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There are different systems and Techniques by other Masters and KOL’s
• Results may differ with each individual surgeon and their experience.
• Pick the procedures and technique that works best
in your own hands and your surgical ability: “The
Surgeon Factor”
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The YESS (RIWO) System
Flexible Riwo Carbide Burr
Specialized cannulas
Trephines and Kerrisons
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87Copyright @ HJY-YESS Forward Medical Group
镜子规格:20°工作通道:2.7mm总长度:205mm
The only endoscope with a
Multichannel “flow integrated”
system. With a laser channel
Pressure and flow control fluid
pump facilitates visualization.
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2 Different Techniques (courtesy Luke Kim
Inside Out TechniqueSAFEST Due to
Outside In TechniqueSERIAL DILATION
Hoogland design changeDIRECT VISUALIZATION
MaxMoreJoimax
The Best Designed Endoscope= YESS Scope
INTRADISCAL THERAPY
YESS
“Gospel according to Yoda”
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80 watt LaserDouble Pulse
Laser is a valuable surgical
Tool that facilitates
endoscopic surgery
Accur-e-techValuable Essential Tools
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Side firing laser VaporMAX100dpl
• 4mm Working Channel Foraminal scope can accommodate for more aggressive bone removal
• Standard 350 micron fiber
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Side firing tips discectomy annulus in Spine Surgery
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Laser can dissect scar from nerve
• 550 laser tip dissecting scar from nerve
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Side firing tips ablating bone
• 350 micron Side firing laser
• Ablates facet capsule to expose bone for mechanical decompression
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Laser foraminoplasty
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Mechanical Foraminoplasty for endoscopic fusion
Bonovo’s OLLIF, Flare hawk expandable cage
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Elliquence Bipolar Radiofrequency
Disc Fx System for Surgical Pain Management
Disc FX SystemSurgimax Console
Wolf now has their own system
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YESS Rhizotomy Set by Wolf
for axial back pain
Beveled cannula provides
surgical portal to facet joint
Beveled Distal End Cannula
Provides Surgical window
Rhizotomy Scope
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RhizotomyTechnique
Ablate MB at transverse process
LB/DR
Needle Placement Wiltse Plane
Isovue 300 + 10% indigocarmineLook for lateral branch
MB
TP
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Cadaver Dissection: Branches of the Dorsal Ramus may vary in
location
L2 L3 L4
TP
TP TP
MB
MB protected by osseous tunnel
(Dissection Yinggang Zheng, M.D.)
An endoscope is needed
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The Endoscope is designed to Identify painful patho-
anatomy intradiscally and trans- foraminally in vivo
for Endoscopic Treatment in the Lumbar Spine
Yeung, AT., Gore S., “In-vivo visualization of patho-anatomy in painful
degenerative conditions of the lumbar spine II”
Surgical Technology International XXI, 2012)
Validated by surgery with the patient under local anesthesia
With or Without sedation
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Meticulous Cadaver Dissections have aided the understanding and development of Endoscopic
surgery
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>35 Publications Since 2015
• Moving Away from Fusion by Treating the Pain
Generator: The Secrets of an Endoscopic Master
Anthony T. Yeung
Journal of Spine Dec 2015
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Concept Papers in Open Access Journals 2016On my website www.sciatica.com
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My Technique Publications 2016:
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Multiple Publications In 2017-2018
• Robotics for endoscopic Spine
• SED™ in Athletes
• Treating the Pain Generator
• 25 year experience in endoscopic surgery
• State of the Art in Endoscopic surgery
• Failed back Surgery
• PELD in China
A rapidly growing number of U.S. Asian Korean, Japanese Chinese, Taiwanese, and Indian Spine Surgeons are adding to the published literature
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• My 25 years experience with Endoscopic Transforaminal Spine Surgery: It’s Evolution, The Painful Conditions Treated, Results, Personal Thoughts, and a Review of the Evolving Literature
Editor –in –Chief : and Editorial Boards
Journal of Spine & NeurosurgeryJournal of Neuropathology
ConTROL Journal
Yeung”s contribution
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Transforaminal and Translaminar Endoscopic MIS vs Pain Management
• Formal training rare / mentorship desired
• Not universally taught in Spine or Pain Programs
• Pain specialists are trained and think differently
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The future will not be for everyone !
• Go slow and Decide to specialize in Endoscopic spine surgery
• Learning curve is long and steep
• The future will require competency and specialization for endoscopic surgery to prosper
French Montparnasse station(courtesy Boyle Cheng)
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Current and Future Developments:Payers should accept and re-imburse validated endoscopic procedures performed as a hybrid
procedure as cost effective
If not, some patients may be willing to pay CASH for “warranteed” results
Neuromodulation for salvage options in unrelenting debilitating (NANS)
(ie Stimwave)
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*Yeung’s Method Patent vs SCSneuromodulation of the DRG
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HJY/YESS Centers in China with with new Innovations
• New automated tools (surgifile) (automated burrs)
– Flexible shaver under development by Bonovo for rapid and through discectomy
• Other YESS tools being developed for Chinese domestic use
• YESS Artificial Intelligence incorporated in Robotic Systems
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ORION Surgical Suite Intra-operative CT Scan Cardan Robot*
Navigation system
Surgical robot
Robotic A.I. for endoscopic spine under development
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Treatment OptionsBridging the Gap
Threshold
Conservative
Fusion
Prosthetic Surgery
Interventional Pain Management, Disc
Fx, SCS, Drg neuromodulation
Endoscopic spine surgery:
Surgical Pain Care
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Can Interventional Pain Doctors Learn Minimally Invasive Spine
Surgery?
23nd Annual Gabor Racz Advanced Interventional Pain Conference
Budapest, Hungry
August 27, 2018
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Answer, YES!.....But Training and certification should be required
• Andrew Roberts, first anesthesia trained endoscopic certified endoscopic traisurgeon at UNM
• Roberts was trained by Gabor Racz, but wanted additional training following a “YESS” workshop
• Deformity and degenerative spine surgeons, D.I.S.C., Phoenix and Sohrab Gollagy are also adopting endoscopic spine techniques to augment their procedures
Andrew Roberts, M.D. Fellowship trained endoscopicspine fellow
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• Journal of Spine
Endoscopic Surgery of the Spine as a Multi-
Disciplinary Subspecialty for Appropriately
Trained, and Experienced Providers
Anthony T Yeung1,2*, Christopher A Yeung1, Nima Salari1 and Justin
Field1
Yeung et al., J Spine 2017, 6:5
DOI: 10.4172/2165-7939.1000388
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I support Rational Open Techniques Endoscopic Techniques requires training
YESS fellowships and workshops in Phoenix
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Thank you
MSGA
Hat courtesy of Morgan Lorio, ISASS coding chair
“Make Spine Great Again”