UF Non-accredited Endoscopic Spine Fellowship

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Fellowship sounds great and all....but which hospital would let you do this or give you privileges for these procedures? Or would it be limited to doing these procedures in a private practice setting?
 
Hope they have a job lined up that knows this is the intention and is ok with it or it’s a waste of time
 
I think its great but I wouldn't take the 14 month pay cut - maybe if I had no student loans and was born with a silver spoon i wouldn't care. I do a lot of endoscopic spine stuff - but self taught and still actively learning. Took a long time to get privelages to do these at certain facilities but now I am privelaged at HCA to do them. I went to labs, shadowed other surgeons doing them and just selected cases carefully picking easy contained herniations first. On a side note I hear the PD of this fellowship is a master and doing cervical and all crazy cases - good for him and the field!
 
swamprat said:
I think its great but I wouldn't take the 14 month pay cut - maybe if I had no student loans and was born with a silver spoon i wouldn't care. I do a lot of endoscopic spine stuff - but self taught and still actively learning. Took a long time to get privelages to do these at certain facilities but now I am privelaged at HCA to do them. I went to labs, shadowed other surgeons doing them and just selected cases carefully picking easy contained herniations first. On a side note I hear the PD of this fellowship is a master and doing cervical and all crazy cases - good for him and the field!
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It is great that someone from our specialty is advancing this field. Our country is still lagging behind the world in adaptation of endoscopic spine techniques and it will benefit our patients in the future if more and more pain docs learn this. Even if you don’t do much in your practice, just having a correlation with Fluoro and intraspinal HD perspective of dura, nerve root, PLL, disc etc. can make simple bread and butter cases much easier.
 
swamprat said:
I think its great but I wouldn't take the 14 month pay cut - maybe if I had no student loans and was born with a silver spoon i wouldn't care. I do a lot of endoscopic spine stuff - but self taught and still actively learning. Took a long time to get privelages to do these at certain facilities but now I am privelaged at HCA to do them. I went to labs, shadowed other surgeons doing them and just selected cases carefully picking easy contained herniations first. On a side note I hear the PD of this fellowship is a master and doing cervical and all crazy cases - good for him and the field!
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Which companies typically have labs to learn these procedures?
 
PainDoc2025 said:
Which companies typically have labs to learn these procedures?
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Elloquence will train you - they have labs in NY and FL. There are also other distributors with other companies and if you reach out they may be able to set up a lab. The labs are the start - one thing it can't teach you is how to manage bleeding since well.. cadavers don't bleed. Heres a pic of an endo disc I did the other day - this is the pic I saved for the chart of me pulling out the herniation - I had to actually fully take the scope out as the fragment was too big to pull through the endoscope
70593442204--C495EEB3-234A-4E29-A43D-FC6602C7E0BF.jpg
 
swamprat said:
Elloquence will train you - they have labs in NY and FL. There are also other distributors with other companies and if you reach out they may be able to set up a lab. The labs are the start - one thing it can't teach you is how to manage bleeding since well.. cadavers don't bleed. Heres a pic of an endo disc I did the other day - this is the pic I saved for the chart of me pulling out the herniation - I had to actually fully take the scope out as the fragment was too big to pull through the endoscope
View attachment 371852
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Nope. Def not getting involved in that. I have no clue what I'm looking at, and there's zero chance you're as good at that as one of my two in-house spine surgeon.
 
MitchLevi said:
Nope. Def not getting involved in that. I have no clue what I'm looking at, and there's zero chance you're as good at that as one of my two in-house spine surgeon.
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You have no clue . I do . And yeah I prob am better at endoscopic as your in house spine surgeon if they don’t do it it’s an acquired skill that is for the most part not in their training either. Get off your high horse - you prob are the LESI and facet everyone and refer everyone else out pain doc who thinks all opioids are bad. I know the type - just retire already
 
swamprat said:
Every insurance - 62380 is the code

** I should say there are a few comercial that still consider it experimental but mostly covered
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Really? So BCBS, Aetna, UHC, Cigna all cover this ?

What is the average payment on that code from commercial insurance?

How difficult is it to authorize?

Patients must have prior conservative care I expect. But do you also have to prove why this is better/necessary compared to a traditional discectomy?
 
bedrock said:
Really? So BCBS, Aetna, UHC, Cigna all cover this ?

What is the average payment on that code from commercial insurance?

How difficult is it to authorize?

Patients must have prior conservative care I expect. But do you also have to prove why this is better/necessary compared to a traditional discectomy?
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Yep I’ve done it on all those insurances . There was a few “sub plans” or what have you of BcBS that called it experimental and denied it but otherwise fully covered. Usually patient has down PT meds epidurals beforehand . Given there is a cpt code I have never had to argue why I would do this vs a micro disc. Authorization I have found easier then SI fusion or Minuteman for the most part. These patients have radic with correlation on MRI and failed conservative therapy.
 
swamprat said:
Yep I’ve done it on all those insurances . There was a few “sub plans” or what have you of BcBS that called it experimental and denied it but otherwise fully covered. Usually patient has down PT meds epidurals beforehand . Given there is a cpt code I have never had to argue why I would do this vs a micro disc. Authorization I have found easier then SI fusion or Minuteman for the most part. These patients have radic with correlation on MRI and failed conservative therapy.
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Average professional fee payment with that code?
 
bedrock said:
Sorry. I should have also asked you how long is a realistic (not ideal) case ?
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Depends on the case, learning curve is steep but once you get the basics down a typical inside out technique with a contained or mild extruded/migraited fragment I can do in 20 minutes from skin to skin. If it’s sequestered or you have to take down bone the time can go way up so it really depends how in-depth you want to get. I try to stay more on the simple side and if it’s more complex I’ll just send out to a surgeon but there are guys that are doing these cases and chasing after these sequestered fragments it just takes long and increases risk of complications so I just stick to the basic stuff.
 
Maybe that’s why a proper fellow ship is needed to teach all aspects of this surgery including how to take care of any complications. Going to cadaver labs may not teach that aspect and if a surgeon is not available to bail out a big hole in the Dura with the roots coming out then it will be a disaster
 
NEA said:
Maybe that’s why a proper fellow ship is needed to teach all aspects of this surgery including how to take care of any complications. Going to cadaver labs may not teach that aspect and if a surgeon is not available to bail out a big hole in the Dura with the roots coming out then it will be a disaster
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lobelsteve said:
If you get a complication pretending to be a surgeon, do the real surgeons bail you out?
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I have surgeons I can call on yes.

A dural tear that has rootlet herniation would be a distaster but extremely unlikely in a transforaminal approach. I'd say that your risk is similar to an epidural hematoma from a LESI. Smaller tears you can usually leave alone and you can endoscopically repair a medium sized tear. Again a dural tear is pretty rare transforaminally. If you pull on a nerve root well - don't do that know your anatomy. @lobelsteve if you had to self manage every complication that could occur with your procedures you would be essentially doing nothing - why dont you just leave everything to the spine surgeon since if they get a complication they can manage it especially if your putting needles and neurostim leads in the spine or injecting cement into a vertebral body - the same can be said for the spine surgeon that speers the kidney in the retroperitoneum going too far lateral on a transforaminal approach at L2/3 or L3/4 or causes a bowel or vascular injury during an ALIF. The fact there is a fellowship for this where the PD is a pain physician brings a lot of credibility to this procedure and its efficacy in our hands.
 
swamprat said:
I have surgeons I can call on yes.

A dural tear that has rootlet herniation would be a distaster but extremely unlikely in a transforaminal approach. I'd say that your risk is similar to an epidural hematoma from a LESI. Smaller tears you can usually leave alone and you can endoscopically repair a medium sized tear. Again a dural tear is pretty rare transforaminally. If you pull on a nerve root well - don't do that know your anatomy. @lobelsteve if you had to self manage every complication that could occur with your procedures you would be essentially doing nothing - why dont you just leave everything to the spine surgeon since if they get a complication they can manage it especially if your putting needles and neurostim leads in the spine or injecting cement into a vertebral body - the same can be said for the spine surgeon that speers the kidney in the retroperitoneum going too far lateral on a transforaminal approach at L2/3 or L3/4 or causes a bowel or vascular injury during an ALIF. The fact there is a fellowship for this where the PD is a pain physician brings a lot of credibility to this procedure and its efficacy in our hands.
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I only do procedures that fall under the purview of interventional spine/Pain. Endoscopic discectomy is an Ortho Spine or Neurosurgical procedure. I could not get credentialed to do this at a hospital and the surgeons who are credentialed there would and should be pissed if they had to clean up my mess. Someone is better trained than we are at doing this procedure and can open them up with a full lami and dural tear repair if necessary. You cannot do that. But if you want to dabble in the canal, I am glad you have backup.

SCS and Kypho is our purview and shared with surgeons and IR. Pain guys not putting in paddle leads of course.
 
swamprat said:
You have no clue . I do . And yeah I prob am better at endoscopic as your in house spine surgeon if they don’t do it it’s an acquired skill that is for the most part not in their training either. Get off your high horse - you prob are the LESI and facet everyone and refer everyone else out pain doc who thinks all opioids are bad. I know the type - just retire already
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Damn Mitch, you gonna take that..
 
swamprat said:
Depends on the case, learning curve is steep but once you get the basics down a typical inside out technique with a contained or mild extruded/migraited fragment I can do in 20 minutes from skin to skin. If it’s sequestered or you have to take down bone the time can go way up so it really depends how in-depth you want to get. I try to stay more on the simple side and if it’s more complex I’ll just send out to a surgeon but there are guys that are doing these cases and chasing after these sequestered fragments it just takes long and increases risk of complications so I just stick to the basic stuff.
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How come it takes on average 3 hours to do each case for the program director of the above mentioned fellowship?
 
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The set up takes longer than the case. Again I don’t pick complicated cases I’m picking slam dunks with contained or mildly extruded fragments and I didn’t take 20 minutes when I started. If you go after sequestered fragments, try to go inter laminar, facet cysts etc forget about it time will go way up - I send those off. Think of if like a percutaneus discectomy with endo visualization. It is very satisfying to pul out the herniation and see the pulsation of the epidural fat (I usually am not medial enough to see the dural sac) return above the PLL. You know you decompressed it and did a good job. But again there are guys doing complex cases I’m just not one of them.
 
lobelsteve said:
I only do procedures that fall under the purview of interventional spine/Pain. Endoscopic discectomy is an Ortho Spine or Neurosurgical procedure. I could not get credentialed to do this at a hospital and the surgeons who are credentialed there would and should be pissed if they had to clean up my mess. Someone is better trained than we are at doing this procedure and can open them up with a full lami and dural tear repair if necessary. You cannot do that. But if you want to dabble in the canal, I am glad you have backup.

SCS and Kypho is our purview and shared with surgeons and IR. Pain guys not putting in paddle leads of course.
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Fair point but again it’s arbitrary - every field moves forward this is just the next thing. I could give examples like SI fusion,minuteman procedure as well that def were not a thing even 5 years ago for us but after seeing your posts over the years I know you are against us doing that as well. It is what it is but endo disc is essentially an image guided procedure - you need to place your needle exactly where the pathology is after reviewing MRI - once that’s in place it’s pretty straight forward. We’ll agree to disagree I suppose
 
swamprat said:
Fair point but again it’s arbitrary - every field moves forward this is just the next thing. I could give examples like SI fusion,minuteman procedure as well that def were not a thing even 5 years ago for us but after seeing your posts over the years I know you are against us doing that as well. It is what it is but endo disc is essentially an image guided procedure - you need to place your needle exactly where the pathology is after reviewing MRI - once that’s in place it’s pretty straight forward. We’ll agree to disagree I suppose
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Until you get a complication. All good until then.
 
not sure how you keep neurosurgical colleagues.

i know of one local neurosurgeon who went ballistic when he learned about Minuteman. he actually walked in to one of the pain docs ORs in the ASC and started berating the pain doc (fortunately, that doc wasnt doing a Minuteman at the time).
 
Ducttape said:
not sure how you keep neurosurgical colleagues.

i know of one local neurosurgeon who went ballistic when he learned about Minuteman. he actually walked in to one of the pain docs ORs in the ASC and started berating the pain doc (fortunately, that doc wasnt doing a Minuteman at the time).
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Cause that's appropriate behavior right? I wouldn't take that or tolerate anyone speaking to me like that

I refer to all of them a lot so maybe thats why.
 
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If a complication happens, the surgeon will do his best job to repair the complication and help the patient. That isn’t debatable.
 
Swamprat, how many mid levels work for you or in your practice?
 
lobelsteve said:
If a complication happens and leads to a lawsuit, the plaintiff will have a Neurosurgeon testify against you and hold you to their standards of care.
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Well with this endo spine fellowship and the more pain MDs doing it as well as many in Europe where it is more commonplace for interventionalist to do tranforaminal techniques i suspect it won’t be hard to find a defense - no one wants to go into a lawsuit or hurt a patient though .Again you may not realize that most spine surgeons don’t do endoscopy and aren’t trained in it during their training . I just don’t think you have enough knowledge on the subject area to continue to argue this - you trained long before I did and I suspect this is part of the reason you are so against interventional pain branching outside of our bread and butter techniques.
 
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swamprat said:
We have 4 for our practice of 4 physicians
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If I did this procedure I would lose all my NSGY and spine surgeon referrals immediately.

Having mid levels churning opioids for your practice gives some top cover and makes you a lot less vulnerable.
 
lobelsteve said:
If a complication happens and leads to a lawsuit, the plaintiff will have a Neurosurgeon testify against you and hold you to their standards of care.
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In many states you have to find an ‘expert’ in the same specialty to testify for or against you so a neurosurgeon won’t likely be able to testify against a Pain Doc even if he/she wanted to. The plaintiff will have to find another interventional pain management doc who performs endoscopic spine to be willing to testify against the defendant
 
Centurion38 said:
If I did this procedure I would lose all my NSGY and spine surgeon referrals immediately.

Having mid levels churning opioids for your practice gives some top cover and makes you a lot less vulnerable.
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He said he sends them a lot of surgeries. That's like me getting pissed off at a surgeon for doing his own kyphos despite sending me bread and butter
 
Is this any riskier than MILD?

I have done one MILD procedure and probably won't do another. If I was comfortable with the anatomy and visualization, I think pulling out a TF disc endoscopically is probably safer than MILD. I bring it up for sake of discussion. I won't be doing any of these any time soon, will leave it to neurosurgery.
 
The treating surgeon would be a fact witness and there really shouldn’t be anything they would add in the deposition other than things that are also in the medical record.
 
You also have to remember these guys take call and see lots of complications from the other surgeons. Leaks that are identified after discharge being the most common one.
 
ragnathor said:
Is this any riskier than MILD?

I have done one MILD procedure and probably won't do another. If I was comfortable with the anatomy and visualization, I think pulling out a TF disc endoscopically is probably safer than MILD. I bring it up for sake of discussion. I won't be doing any of these any time soon, will leave it to neurosurgery.
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Apples and oranges
 
NEA said:
In many states you have to find an ‘expert’ in the same specialty to testify for or against you so a neurosurgeon won’t likely be able to testify against a Pain Doc even if he/she wanted to. The plaintiff will have to find another interventional pain management doc who performs endoscopic spine to be willing to testify against the defendant
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Unless you are practicing to the standard of care of a different specialty. It would be hard to defend. Kind of like when I am testifying against FP, GPs, IM doing pain procedures or prescribing.
 
swamprat said:
Well with this endo spine fellowship and the more pain MDs doing it as well as many in Europe where it is more commonplace for interventionalist to do tranforaminal techniques i suspect it won’t be hard to find a defense - no one wants to go into a lawsuit or hurt a patient though .Again you may not realize that most spine surgeons don’t do endoscopy and aren’t trained in it during their training . I just don’t think you have enough knowledge on the subject area to continue to argue this - you trained long before I did and I suspect this is part of the reason you are so against interventional pain branching outside of our bread and butter techniques.
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I'm 52. My training is not that old. The scope guys have been at meetings since I was a fellow. I went to a course with Algos in 2005 on this in SC. Option to be pioneers in the field. Played with the toys. Meh. I think you are equating my hesitance for new procedures based on my EBM base and position with reluctance based on my age. Just be careful out there.
 
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