Percutaneous Discectomies

[analgesic]

Hi everyone,

Has anyone had any success with percutaneous discectomies and if so which pain fellowhsips do you recommend to gain exposure to this type of intervention?

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[lobelsteve]

Hi everyone,

Has anyone had any success with percutaneous discectomies and if so which pain fellowhsips do you recommend to gain exposure to this type of intervention?

I've got a few Stryker percuataneous disc decompressors under my belt. I'd say 50/50 at relieving pain. Fun to do as you get some snotty looking stuff out of the disc and get to send it off to pathology.

If you are talking about using a scope or minimally invasive microdiskectomy then I don't think anybody is doing this outside of the spine surgeons.

 

[Aether2000]

I have performed over 100 endoscopic discectomies, foraminoplasties, and annuloplasties. There are no pain fellowships teaching these techniques.
I also have performed many disc dekompressor techniques including thoracic. The technique is not a "home run" technique since it is simply creating a very small cavity in order to reduce the compression of the nerve root. It does nothing to reduce endoneural scarring, the caustic effect of the phospholipase A2 on the myelin, nor the inflammatory effect of the TNF and interleukin.

 

[Doctodd]

Basically getting into the disk is learned by the same technique as a discogram. The perc disk is just a few more steps with fancy equipment, which will vary depending on the company and the equipment they use. They usually offer courses for free, which is to their benefit cuz they will make money off you using their equipment.

T

 

[C Fiber]

Wow Algosdoc,
That is very impressive....how awesome! I bet you were able to help a lot of those patients and save them from the knife. Cool.

We have had a lot of problems getting preapproval and reimbursement for this procedure with the private insurances, because there is still limited data to back it up.

Just out of curiosity, how are you selecting your patients for this procedure? Anyone care to comment?

 

[Aether2000]

The endoscopic approach to the disc is posterior-lateral and uses dilators to provide a conduit for the working channel that is 7mm outside diameter. The scope is 5.5mm diameter and has a working channel for grasping forceps, pituitary forceps, nerve hooks, annulotomes, laser, bipolar RF, etc. The code is 63056 for such a procedure, not 62287 that is the code for other perc discectomies, so payment has not been as much of a problem, but the learning curve is steep. I take the patients the surgeons do not want due to other medical conditions or those with multiple level disease unamenable to surgery.

 

[analgesic]

The endoscopic approach to the disc is posterior-lateral and uses dilators to provide a conduit for the working channel that is 7mm outside diameter. The scope is 5.5mm diameter and has a working channel for grasping forceps, pituitary forceps, nerve hooks, annulotomes, laser, bipolar RF, etc. The code is 63056 for such a procedure, not 62287 that is the code for other perc discectomies, so payment has not been as much of a problem, but the learning curve is steep. I take the patients the surgeons do not want due to other medical conditions or those with multiple level disease unamenable to surgery.

Algos,

Where did you receiive your training for the endoscopic discectomy? As much as I would love to go to Switzerland, I do not have the time nor the financial resources. Is there any place in the States that offers the same kind of training? If not, have you considered developing a course/seminar for other aspiring interventionalists like myself who would love to see this procedure become more integrated in interventional spine practice? I am sure the compensation is generous but I believe it is encumbent upon our field to begin preventing more unnecessary failed back surgery. I hope most of you would agree.

 

[Spine Specialist]

Algos,

Where did you receiive your training for the endoscopic discectomy? As much as I would love to go to Switzerland, I do not have the time nor the financial resources. Is there any place in the States that offers the same kind of training? If not, have you considered developing a course/seminar for other aspiring interventionalists like myself who would love to see this procedure become more integrated in interventional spine practice? I am sure the compensation is generous but I believe it is encumbent upon our field to begin preventing more unnecessary failed back surgery. I hope most of you would agree.

I am signing in for algos course.

 

[analgesic]

I am signing in for algos course.

Pain Specialist,

I knew I could always count on your participation. What do you say algos? I am sure there are others like myself and PS who would love to attend such a course (No pressure)

 

[C Fiber]

Are these procedures done in the OR/ASC? Do hospitals, insurers frawn upon this, since most of us are not trained as surgeons? And yes, where do I sign up for Algodoc's course?

 

[Aether2000]

I have taught this course twice over the past 4 years, but am very concerned with teaching these very advanced techniques to pain management. I have taught orthopedists the technique, but have in general, found the global pain management knowledge and skill does not yet approximate that which would be necessary to achieve even basal skills with the endoscopic discectomy technique. One course was taught at ASIPP, and after I gave an intricate discussion of the access to the disc, differences between lasers, mechanical decompression techniques, etc, one participant that was supposed to be advanced held up her hand and asked if I could show her the scotty dog on the fluoroscopy screen. I nearly fainted on the spot. After that, I met many who wanted to learn the technique but did not have skills in discography, percutaneous disc decompression or disc access, etc. So an indefinite hold has been placed on further teaching of the procedure....
Perhaps later....

 

[Doctodd]

One course was taught at ASIPP, and after I gave an intricate discussion of the access to the disc, differences between lasers, mechanical decompression techniques, etc, one participant that was supposed to be advanced held up her hand and asked if I could show her the scotty dog on the fluoroscopy screen. I nearly fainted on the spot. After that, I met many who wanted to learn the technique but did not have skills in discography, percutaneous disc decompression or disc access, etc. So an indefinite hold has been placed on further teaching of the procedure....
Perhaps later....

That is too funny....but scary at the same time.

T

 

[doctorlarry]

That was 2006. Its now 2012...anyone have an update on this treatment and training opportunities?

 

[epidural man]

I have taught this course twice over the past 4 years, but am very concerned with teaching these very advanced techniques to pain management. I have taught orthopedists the technique, but have in general, found the global pain management knowledge and skill does not yet approximate that which would be necessary to achieve even basal skills with the endoscopic discectomy technique. One course was taught at ASIPP, and after I gave an intricate discussion of the access to the disc, differences between lasers, mechanical decompression techniques, etc, one participant that was supposed to be advanced held up her hand and asked if I could show her the scotty dog on the fluoroscopy screen. I nearly fainted on the spot. After that, I met many who wanted to learn the technique but did not have skills in discography, percutaneous disc decompression or disc access, etc. So an indefinite hold has been placed on further teaching of the procedure....
Perhaps later....

I'm not sure, but did algosdoc just insult me (well, not 'just')?

 

[clubdeac]

Yeah algos , why dont you offer a course just to us Painrounds groupies. We're obviously the best of the best I want to learn these crazy techniques.... And as far as the original post about perc diskectomies. I've done 10-15 perc disks and I am very unimpressed. Anyone else get better results?

 

[epidural man]

Yeah algos , why dont you offer a course just to us Painrounds groupies. We're obviously the best of the best I want to learn these crazy techniques.... And as far as the original post about perc diskectomies. I've done 10-15 perc disks and I am very unimpressed. Anyone else get better results?

Well percentage wise, probably. N=2. Both had good results (with poor f/u so I am assuming I fixed them, like I assume every time when a patient doesn't come back. )

 

[Jcm800]

Well percentage wise, probably. N=2. Both had good results (with poor f/u so I am assuming I fixed them, like I assume every time when a patient doesn't come back. )

i just mentioned this in another post....

i have done only like 15-20, and the vast majority did well... now it is something that we cant get approved, so it doesnt happen. I should pull my actual numbers it might be closer to 15, it was 4-5 year for like 3-4 years, including fellowship...

 

[ParaVert]

As I understand it, the coding for endoscopic discectomy has changed for 2012 - now it is 62287. This reimbursement is only 40% of what 63056 pays. Sadly, I think this is a nail in the coffin for endoscopic discectomy.

62287 - from the AMA CPT Lookup website.
Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar

 

[caligas]

Bumping. 5 years on...anybody having success with these?

 

[Stim4me]

Bumping. 5 years on...anybody having success with these?

Only Stryker decompressor equipment available on the market that I know of. Neurotherm had pulled the plug on acutherm and idet wands. Arthrocare long gone. Results are mixed like anything else. Surprisingly I have one scheduled after 3 year hiatus, typically WC/PI or vip insurances...

 

[myrandom2003]

Any updates on this? how have your outcomes been?
I am seeing more and more patients with epidural fibrosis after a L4/5 or L5/S1 discectomy not sure why.

Anyone using hydrocision
https://www.hydrocision.com/products/discectomy/percresector/

Disc-FX
https://www.elliquence.com/products/disc-fx-system/

 

[lobelsteve]

https://www.elliquence.com/wp-content/uploads/2017/01/SM-009-Disc-FX-Course-Brochure-2017-Rev-G.pdf

Looks cool. Unsure how to get surgery privileges for this, but I'm sure if I started doing this my consults from the surgeons would really tail off.

 

[pmrmd]

I did a workshop for DiscFX. Super neat. Eager for the first case, but I agree surgeons would be ticked if the patient would need to go to OR later.

 

[BobBarker]

I would like to learn that. I could get privileges at my little hospital.

 

[jsaul]

Any updates on this? how have your outcomes been?
I am seeing more and more patients with epidural fibrosis after a L4/5 or L5/S1 discectomy not sure why.

Anyone using hydrocision
https://www.hydrocision.com/products/discectomy/percresector/

Disc-FX
https://www.elliquence.com/products/disc-fx-system/

I have done perhaps 10 disc FX in the last 2 years. There is certain skill required to doing it. I have had 6/10 patients do great with it. The problem is getting insurance to pay for it. the percutaneous discectomy code does to cover the costs of the procedure. It is a nice procedure but as I said it is diffucult to get it approved and CPT code does not cove rthe costs. The company tries to sell you to get the patients to pay cash for it and they have a financing program for the patients.

 

[drpainfree]

what's the CPT code and what does medicare reimburse?

and what kind of cost are we talking about? Is this done in office vs. ASC setting?

I've done stryker decompressor procedure long time ago in my training. heard it was not worthwhile to do.

 

[SeniorWrangler]

Every couple years they come up with something new to do with discs, and if you wait two more years, nobody is talking about it any more and there's something new on the horizon.

 

[ParaVert]

ASIPP course in Arizona this spring.

It’s time we get some academics and well-respected private guys doing this.

Kypho (still works, still pays), MILD (kind of works, kind of pays), Superion (ditto). Treating a real problem is way more rewarding than chasing the moving goal post of symptom management in personality disorder patients (ie: chronic pain mgmt).

Cardiology, GI, IR. Three fields that took business away from surgeons. Is it not our turn?

If not, what will happen to us?

 

[Ducttape]

by that, you mean financially.

I thought $$$ is what got chronic pain management in to the mess it is in today.

 

[ParaVert]

No, I mean the future of the specialty - scientifically, intellectually, and more.

It's a job, man. We're ALL in it for the money. But let's forego the financial side for a bit.

Who here isn't hungry to be challenged with a new skill set? A whole new modality? One that has good evidence and good efficacy? One that sets you apart from nearly all of your needle jockey peers? One that pulls your focus AWAY from chronic pain management and your dependency away from the spine surgeon?

Do you want to actually fix something?

Yes, it's getting harder and harder to do what we do. Opiophobia is rampant, injections are getting harder and harder to get approved through private insurance, and the patients aren't getting any less crazy. Oh, and reimbursement is on the decline. There's your financial argument.

30 years ago, cardiology was a medical specialty. Today they replace heart valves (better and safer than open).

If we don't push our skillset and domain, the field will evaporate. There is no other field of medicine dedicated to treating a symptom. Now that pain is WAY out of vogue, what will happen to us? We don't fix people. We prescribe opioids that kill people. We cost too much.

Endoscopic spinal procedures are the most interesting thing to orbit near our specialty in decades.

 

[Timeoutofmind]

How can you offer this?

I feel like I would get zero spine surgery referrals if they got wind I did one...

And I am pretty sure they would be unwilling to deal with any complications resulting from the procedure unless they were forced to in an emergency type setting.

 

[Ducttape]

I think what you are wishing for is extraordinarily hard (and unlikely) to find.

with those fields you mention, there were treatments that were found that, at the time, were thought to be beneficial. and yes, drcomm, later studies may refute some of the initial findings. we don't have that.

in our case, I agree that the primary problem is treating a symptom rather than a specific condition. that's a big problem. unlike cardiac cath - ie find the 70% blockage and open it up, endoscopy - find the nonhealing ulcer/colonic polyp, pain is too subjective to pinpoint down to something numerical and specific.

we would have to change the primary problem of a wholly subjective phenomenon to one that can be specifically defined to get the benefit and skill set you are looking for. we have to change the paradigm to one of making someone better. imo, rather than finding that 1 procedure, we should be changing how we present ourselves.

 

[ParaVert]

How does one make a patient better? By treating problems that can be improved or cured. Chronic pain isn't one of those, unless you're one hell of a psychiatrist (which I am not). I'm a needle monkey like the rest of us.

How about a microdiscectomy in an awake patient (local + IV sed) through a scope not much larger than a kyphoplasty needle? A foraminotomy on a little old lady "too sick" for general anesthesia? Endoscopic assisted lumbar decompression for stenosis? This is what we could be doing as a specialty in 5-10 years if we get a critical mass of physicians performing and teaching.

 

[SSdoc33]

How does one make a patient better? By treating problems that can be improved or cured. Chronic pain isn't one of those, unless you're one hell of a psychiatrist (which I am not). I'm a needle monkey like the rest of us.

How about a microdiscectomy in an awake patient (local + IV sed) through a scope not much larger than a kyphoplasty needle? A foraminotomy on a little old lady "too sick" for general anesthesia? Endoscopic assisted lumbar decompression for stenosis? This is what we could be doing as a specialty in 5-10 years if we get a critical mass of physicians performing and teaching.

i agree with your general premise, but what happens when you happen to chew up a nerve root during your foraminotomy? Or you get an infection?

you better have a great relationship with some surgeons, or you will be locked out of any of their patients.

if these procedures were effective and readily available, the surgeons themselves would be doing them.

there may be some space in the middle -- more invasive than injections, less invasive then surgery -- but that space is really REALLY small.

until they come up with something i can inject into a disc that actually works, i think we are going to stay where we are.

 

[244913]

How does one make a patient better? By treating problems that can be improved or cured. Chronic pain isn't one of those, unless you're one hell of a psychiatrist (which I am not). I'm a needle monkey like the rest of us.

How about a microdiscectomy in an awake patient (local + IV sed) through a scope not much larger than a kyphoplasty needle? A foraminotomy on a little old lady "too sick" for general anesthesia? Endoscopic assisted lumbar decompression for stenosis? This is what we could be doing as a specialty in 5-10 years if we get a critical mass of physicians performing and teaching.

How are these procedures curative? I see people in my office all the time after microdisks with even worse pain. Same for lumbar decompressions.

The most ethical spine surgeon I know declines to operate about 90% of the time because he realizes the ultimate futility of the vast majority of these procedures. They may “fix” foot drop but they don’t fix pain, with few exceptions.

Any pain physician who wants to leave a lasting mark on his community and society as a whole should focus on deprescribing, assisted with procedural interventions when appropriate.

- ex 61N

 

[newbie04]

Wait until you have a major complication and you wind up in a courtroom with Neurosurgeons asking why you are doing these surgeries with weekend courses and not 7+ years of training?

 

[PapaDosh]

Went to the DiscFx course. They made a big deal about how Medicare would cover it and reimbursement for it would be worth it, but I haven't heard a peep since then (end of 2016) about improved reimbursement. Only patients I see get it done (via another physician in my group) are a handful of auto and WC of which I would say 60-70% improve from it. For surgical privileges, we do it at our own ASC under minimal sedation (pretty much iv versed and tons of subq lidocaine). I think it would be near impossible to get privileges for this procedure without this setup.

 

[Ducttape]

so we have to change the paradigm of "curing" chronic pain to curing something else...

or, IPM will have to become very limited to a select few, not every ACGME boarded pain physician and weekend class docs and NPs and PAs etc. because there wont be enough little old ladies to go around for all the "providers" doing procedures right now.



maybe medical advances will be such that people can be prescreened for possible back pain in the future, turn to focus on prevention of chronic back pain due to work injuries. or prevention of addiction by some medical advance that allows one to determine patients at risk for opioid dependence or frank abuse. maybe...

 

[SSdoc33]

They may “fix” foot drop but they don’t fix pain, with few exceptions.

ummm. what?

patient has foot drop. they get a surgery. they still have foot drop.

 

[244913]

ummm. what?

patient has foot drop. they get a surgery. they still have foot drop.

Meant weakness, not the whole enchilada

 

[ParaVert]

The reasons against incorporating endoscopy into the interventional spine and pain physician skillset thus far:

1. You might get a complication (what about a ruptured coronary artery or perforated bowel?)
2. You might lose referrals from surgeons
3. The procedure must be crap because surgeons aren't doing it (they are. laparoscopy took a generation to catch on)
4. They should come up with something that works with the skillset I already have
5. Spine surgery doesn't work, and we should all become addiction specialists. To wean is to heal.

 

[ParaVert]

Wait until you have a major complication and you wind up in a courtroom with Neurosurgeons asking why you are doing these surgeries with weekend courses and not 7+ years of training?

The same could be said about a paralyzed or dead patient after any procedure we do. An expert witness can always claim that you are an incompetent buffoon.

Find 10 academic pain specialists across the country willing to train, do, teach, and publish research on the procedure. Within 5 years, have 100 private practice physicians who are highly respected in the field doing and teaching the procedure. Develop a pool of experience within the specialty over 5-10 years.

I'm calling a paradigm shift of the specialty. Anybody got a better idea?

 

[newbie04]

That’s great. What about a hospital credentialing / giving you privileges to perform spine surgery?

I would like to expand IPM, but we have no place doing spine surgery.


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[Aether2000]

The history of minimally invasive spine surgeons includes endoscopic surgeons that were pain physicians. As far back as 20 years ago, endoscopic laser discectomies were being performed by pain physicians and 25 years ago some were performing APLD procedures- invented by a radiologist. Selective endoscopic discectomy was used by pain physicians as far back as 2001. I certainly do not believe they are completely beyond the scope of practice for pain physicians, but are beyond the scope of payment. Insurers have eliminated payment for these procedures. Hospitals are not a place these will be performed- the surgery center owned by a group of pain physicians is the ideal location. Risks? Yes, of course, but anatomically the exiting nerve is in the superior anterior portion of the neuroforamen (most of the time) making it relatively easy to avoid. Of course at L5S1 the interlaminar endoscopic approach works well. In any case, hopefully the current generation will be able to do what my generation did not- move the bar.

 

[newbie04]

The history of minimally invasive spine surgeons includes endoscopic surgeons that were pain physicians. As far back as 20 years ago, endoscopic laser discectomies were being performed by pain physicians and 25 years ago some were performing APLD procedures- invented by a radiologist. Selective endoscopic discectomy was used by pain physicians as far back as 2001. I certainly do not believe they are completely beyond the scope of practice for pain physicians, but are beyond the scope of payment. Insurers have eliminated payment for these procedures. Hospitals are not a place these will be performed- the surgery center owned by a group of pain physicians is the ideal location. Risks? Yes, of course, but anatomically the exiting nerve is in the superior anterior portion of the neuroforamen (most of the time) making it relatively easy to avoid. Of course at L5S1 the interlaminar endoscopic approach works well. In any case, hopefully the current generation will be able to do what my generation did not- move the bar.

I guess tell that to the Neurosurgeons.

This reeks of CRNAs being equal to anesthesia-trained docs.

I guess I’ll go sign up for that weekend ASIPP course and call myself good.


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[244913]

The same could be said about a paralyzed or dead patient after any procedure we do. An expert witness can always claim that you are an incompetent buffoon.

Find 10 academic pain specialists across the country willing to train, do, teach, and publish research on the procedure. Within 5 years, have 100 private practice physicians who are highly respected in the field doing and teaching the procedure. Develop a pool of experience within the specialty over 5-10 years.

I'm calling a paradigm shift of the specialty. Anybody got a better idea?

Let’s clean up the mess this specialty made over the last 30 years before we go chasing after reimbursement for the disc procedure du jour.

We as IPM physicians should be in the vanguard of responsible opioid prescribing, not carrying water for the latest procedural fad.

As Algos pointed out, certainly pain physicians can do these procedures. After all, it wasn’t long ago that we had to fight to implant our own devices. This is a turf battle we could probably win- but is this really where our specialty should be expending our focus and resources?

It’s easy to make light of addiction but addiction and chronic pain in the US are very close on the same disordered spectrum- whatever the latest version of the DSM might say.

I trained at one of the most interventional places in the country. We pooh pooh’d addiction too- we much preferred being in the OR or learning the latest injection.

Now- as an attending- I wish I had spent three months doing addiction. This is a battle we can’t shrink from any longer.

- ex 61N

 

[Aether2000]

Good question about where our resources should be allocated and our energies spent. But advances in technology have changed the face of medicine, the the benefit of one specialty and at the expense of another. Examples: cardiac stents/cardiology/cardiac surgery; TAVR/cardiology/cardiac surgery; intravascular coils/radiology/neurosurgery and several others. So I am not so keen to write the obituary for pain management yet, being relegated to doing simple injections or spinal cord stim implants forever. But I agree we are not there yet and should tread carefully.

 

[244913]

Good question about where our resources should be allocated and our energies spent. But advances in technology have changed the face of medicine, the the benefit of one specialty and at the expense of another. Examples: cardiac stents/cardiology/cardiac surgery; TAVR/cardiology/cardiac surgery; intravascular coils/radiology/neurosurgery and several others. So I am not so keen to write the obituary for pain management yet, being relegated to doing simple injections or spinal cord stim implants forever. But I agree we are not there yet and should tread carefully.

Algos- why were reimbursements for these procedures cut?

Why have reimbursements been cut for many such procedures over the years championed by IPM?

 

[Blitz2006]

Let’s clean up the mess this specialty made over the last 30 years before we go chasing after reimbursement for the disc procedure du jour.

We as IPM physicians should be in the vanguard of responsible opioid prescribing, not carrying water for the latest procedural fad.

As Algos pointed out, certainly pain physicians can do these procedures. After all, it wasn’t long ago that we had to fight to implant our own devices. This is a turf battle we could probably win- but is this really where our specialty should be expending our focus and resources?

It’s easy to make light of addiction but addiction and chronic pain in the US are very close on the same disordered spectrum- whatever the latest version of the DSM might say.

I trained at one of the most interventional places in the country. We pooh pooh’d addiction too- we much preferred being in the OR or learning the latest injection.

Now- as an attending- I wish I had spent three months doing addiction. This is a battle we can’t shrink from any longer.

- ex 61N

I agree with you 100%.

But I think this issue needs to be viewed at from a much grander scale...reimbursements in the medical field.

Why do you think most pain docs (Im obviously generalizing, but..) rather spend time in the OR than addiction? $$$

I'm pretty sure if CBT for Pain paid $3000-$4000 per 45 minute session, a lot more pain docs will be attending CBT weekend courses vs. learning how to do MILD/Kyphos/SCS, etc.

 

[Blitz2006]

ASIPP course in Arizona this spring.

It’s time we get some academics and well-respected private guys doing this.

Kypho (still works, still pays), MILD (kind of works, kind of pays), Superion (ditto). Treating a real problem is way more rewarding than chasing the moving goal post of symptom management in personality disorder patients (ie: chronic pain mgmt).

Cardiology, GI, IR. Three fields that took business away from surgeons. Is it not our turn?

If not, what will happen to us?

Not to de-rail this thread, and I know I'm late to the party, but I guess if you think it works, I shouldn't really base my clinical decisions on this paper for kyphos?

http://www.nejm.org/doi/full/10.1056/NEJMoa0900429

Thx,