So don't you think with the opioid crisis and a resonable number of patients that don't respond to epidurals, the future of IPM is moving more surgical (MILD, Percutaneous Discetomies, etc.)?
Percutaneous Discectomies
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So don't you think with the opioid crisis and a resonable number of patients that don't respond to epidurals, the future of IPM is moving more surgical (MILD, Percutaneous Discetomies, etc.)?
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Certainly reimbursement drives care. That is why many pain clinics have only a few diagnostic boxes that fit the more highly reimbursed therapies they offer. The insurance industry took the unprecedented step of blocking all percutaneous discectomy reimbursement by blocking an entire code. They relatively quickly blocked IDET, and have moved pro-actively to block reimbursement for other procedures before they were ever widely performed. It all comes down to IOM estimates of nearly 1/3 the population of the US having chronic pain- this terrifies insurers more than any disease since it may mean perpetual interventional treatments (expensive) for chronic pain. Of course perc discectomies should be a single treatment for a very specific problem (disc displacement with a contained disc herniation accompanied by an anatomically corresponding radiculopathy), but it was not being used with such stringent criteria by pain physicians. Unlike open procedures performed by surgeons, there was little immediate downside to performing a perc discectomy since the complication rate was very low, and the numbers of these treatments were expanding exponentially until blocked by insurance. So, we are back to square one with respect to doing these procedures at this point in time. It is not clear to me that even if insurers were presented with Level I evidence percutaneous discectomies were as effective as open surgery, that they would again be approved. But the medical system may be ripe for a change in philosophy away from insurance driven care to a more patient driven care, especially if the individual mandate for expensive Obamacare era insurance is replaced by a discount cash for services model.
oh. well in that case:
patient has weakness, gets a surgery, still has weakness.
i think you are missing something here.......
no. do a search. we discussed this years ago
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Define surgery.
Is a pump or stim implant surgery? Scalpel, bleeding hole, sutures. Sounds like surgery to me
Kyphoplasty. Big trocar, hammer, drill. Sounds like surgery to me
Superion. Incision, foreign body implant. Sounds like surgery to me
DiscFX. Needle, dilator, mechanical disc tissue removal with forceps. Sounds like surgery to me
I don’t want to be the “guy taking out discs (parts of discs)”.
I’m not a spine surgeon.
PM&R/ Anesthesia / Neuro etc shouldn’t be doing these.
If you wanted to surgery, should have done a *formal* surgical fellowship.
Not a weekend course. Not learning on the job.
@ParaVert, do you consider yourself a spine surgeon? What’s your primary speciality?
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I’m not a spine surgeon.
PM&R/ Anesthesia / Neuro etc shouldn’t be doing these.
If you wanted to surgery, should have done a *formal* surgical fellowship.
Not a weekend course. Not learning on the job.
@ParaVert, do you consider yourself a spine surgeon? What’s your primary speciality?
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Only rarely do surgeons employ true minimally invasive spine procedures for discectomy. If they eschew this approach then it is wide open for pain medicine to do them. The trepid will claim they need a surgeon to approve and serve as a backup in case disaster strikes. So look at the possible disasters and tgen ask what surgeons could do emergently to alter the outcomes. Frankly there are very few things a surgeon can do in these instances. So the argument we should avoid them because of lack of backup is specious. The insinuation our specialty lacks the skills for these procedures is insulting considering surgeons are not trained in performance of interventional pain procedures but do them anyway.
I never insinuated “lack skills.”
Hell, I’m gonna do this and then train my PAs and NPs to do this. Maybe the Chiro down the street. Dude has skills
#cashcow
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I highly doubt anyone going to a weekend training course on endoscopic discectomy is going to be doing this following that. How do I know? I trained at a fellowship where endoscopic discectomies were commonly done. PD traveled all over USA and Europe to teach others, including some surgeons. So you would figure I got a decent amount of exposure and left fellowship able to do this correct? That would be wrong, as I never even scrubbed one case even though these were done on pretty much a weekly basis when I was a fellow. The companies that make this equipment do not want a lot of complications, otherwise they realize that the procedure will likely either A) No longer be covered or B) Have an even larger limitation on whom can do them (ie surgeon only). The company that we worked with required anyone (from Pain at least) using their equipment to have at minimum 2 years of experience as an attending and undergo extensive training prior to even allowing them to set up proctured cases on actual patients. The weekend courses are more to give people an opportunity to learn about the procedure and see if this is something that they would actually consider doing in their own practice. They do not leave competent. That being said I am not really sure how much more training they really have to do to set up the proctured cases. Also I am not planning on doing these either because several of the neurosurgeons in my area do them and I would rather let them deal with the complications that may arise. But a well trained pain physician can certainly do them and closing the wound took only about 2-3 superficial stitches at the most.
I highly doubt anyone going to a weekend training course on endoscopic discectomy is going to be doing this following that. How do I know? I trained at a fellowship where endoscopic discectomies were commonly done. PD traveled all over USA and Europe to teach others, including some surgeons. So you would figure I got a decent amount of exposure and left fellowship able to do this correct? That would be wrong, as I never even scrubbed one case even though these were done on pretty much a weekly basis when I was a fellow. The companies that make this equipment do not want a lot of complications, otherwise they realize that the procedure will likely either A) No longer be covered or B) Have an even larger limitation on whom can do them (ie surgeon only). The company that we worked with required anyone (from Pain at least) using their equipment to have at minimum 2 years of experience as an attending and undergo extensive training prior to even allowing them to set up proctured cases on actual patients. The weekend courses are more to give people an opportunity to learn about the procedure and see if this is something that they would actually consider doing in their own practice. They do not leave competent. That being said I am not really sure how much more training they really have to do to set up the proctured cases. Also I am not planning on doing these either because several of the neurosurgeons in my area do them and I would rather let them deal with the complications that may arise. But a well trained pain physician can certainly do them and closing the wound took only about 2-3 superficial stitches at the most.
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There is an entire array of minimally invasive discectomies, and most are not endoscopic. APLD; laser discectomies with a Ho-Yag, Nd-Yag, KTP, or multidiode laser; Disc-Fx; the technique formerly known as coblation nucleoplasty; hydrocision; manual mechanical fluoro-guided portal transforaminal discectomy; DeKompressor, and others. Endoscopic approaches include LASE, rigid spinal endoscopes, and flex spinescopes, either epidural or introduced via portals. Certainly any pain physician that can do discography can do the non-endoscopic approach perc discectomies and some of the endoscopic techniques (LASE) without significant additional training. The advanced endoscopic techniques can be learned outside of the US from several centers, but I agree the learning curve is steep, and there are far more tricks and skills needed to perform endoscopic.
