UF Non-accredited Endoscopic Spine Fellowship

[Ducttape]

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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.

technically, yes it is. with MILD, you essentially never enter epidural space (besides with the touhy to start). the needle always stays posterior, unless you really really screw up.

 

[Agast]

I suspect most pain physicians make it quite well without neurosurgery colleagues. In residency and fellowship I don’t recall a single solid referral from the spine surgeons. Mostly post-fusion axial back pain and opioid requests. So I don’t think limiting yourself to keep someone else happy makes sense in this case.

 

[Taus]

I suspect most pain physicians make it quite well without neurosurgery colleagues. In residency and fellowship I don’t recall a single solid referral from the spine surgeons. Mostly post-fusion axial back pain and opioid requests. So I don’t think limiting yourself to keep someone else happy makes sense in this case.

it does work both ways. There are some local practices who don't send them to a surgeon until they've got wires, a battery and spacer implanted. middle-age, healthy people, single level, severe structural pathology. Patients stay because they get the candy.

 

[callmeanesthesia]

it does work both ways. There are some local practices who don't send them to a surgeon until they've got wires, a battery and spacer implanted. middle-age, healthy people, single level, severe structural pathology. Patients stay because they get the candy.

I think if my local surgeons put a 2 level fusion into everybody with back pain and a 2mm disc bulge or disc herniation, I’d do everything to keep patients away from them as well.

In my area, they’re very reasonable, and do good work. That’s a big part of why I don’t bother with things like spacers or MILD (or endoscopic discectomy), and why I very rarely trial someone without FBSS (or CRPS). If they’ve got a disc herniation and fail an epidural or have progressive weakness, I send them off and the surgeon does a microdiscectomy.

 

[Ducttape]

yeah....

the MILD isnt for disc. it is for spinal stenosis that the surgeons dont want to touch...

 

[MitchLevi]

yeah....

the MILD isnt for disc. it is for spinal stenosis that the surgeons dont want to touch...

I think this is a salient point.

I'm not sure most pain docs should manipulate the IVD.

Maybe swamprat is great at this procedure and he's safe. Maybe so, but most pain docs probably wouldn't be.

 

[Taus]

yeah....

the MILD isnt for disc. it is for spinal stenosis that the surgeons dont want to touch...

agreed, but this is most definitely not what I see in my community. Anybody with stenosis of any degree who failed PT and ESI, any age, health, etc.... they all get a mild (and/or spacer). I have no problem with the procedure myself, pain docs doing it for the right indications and actually send out for a few per year...but sometimes patients really do just need surgery.

 

[deleted131481]

technically, yes it is. with MILD, you essentially never enter epidural space (besides with the touhy to start). the needle always stays posterior, unless you really really screw up.

I am making the comparison of being 2 millimeters away from the epidural space on fluoroscopy only with your instrument vs this endoscopic procedure where there is actual visualization of the disc. Unless one is getting somewhat close to the epidural space in MILD, I'm not sure how much is being accomplished. I am not convinced the former is a whole lot safer or more appropriate for our scope of practice assuming both are experienced.

I am not against either procedure if the operator is experienced.

 

[Ducttape]

every epidural, you go in to the epidural space.


the main study showed that CSF leaks were significantly less likely with MILD than with open laminectomy.

agreed, but this is most definitely not what I see in my community. Anybody with stenosis of any degree who failed PT and ESI, any age, health, etc.... they all get a mild (and/or spacer). I have no problem with the procedure myself, pain docs doing it for the right indications and actually send out for a few per year...but sometimes patients really do just need surgery.

isnt this the case with every procedure? one could say the same thing about Minuteman or Veriflex or SI fusion or Intracept.

 

[NEA]

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.

FP,GP, IM putting needles in the spine and doing other pain procedures or prescribing is doing or trying to do the exact same thing as you so same standard of care. A surgeon performing open or microscopic surgery even though it is for the same indication is not the same technique and standard of care as someone performing a full endoscopic surgery. During deposition the surgeon wouldn’t be able to answer the first question: how many endoscopic surgeries he has done and does he know how to put an endoscope in the spine and visualize the structures.

Unless the plaintiff finds a surgeon who is doing Endoscopic surgery only then, the standard would be the same.

 

[lobelsteve]

FP,GP, IM putting needles in the spine and doing other pain procedures or prescribing is doing or trying to do the exact same thing as you so same standard of care. A surgeon performing open or microscopic surgery even though it is for the same indication is not the same technique and standard of care as someone performing a full endoscopic surgery. During deposition the surgeon wouldn’t be able to answer the first question: how many endoscopic surgeries he has done and does he know how to put an endoscope in the spine and visualize the structures.

Unless the plaintiff finds a surgeon who is doing Endoscopic surgery only then, the standard would be the same.

That's what you say. Unless you go to court as I often as I do, I'll stick with my interpretation. Maybe there is not an indication for endoscopic spine surgery. Especially from a non-surgeon

 

[NJPAIN]

yeah....

the MILD isnt for disc. it is for spinal stenosis that the surgeons dont want to touch...

It’s fine for mild to moderate central stenosis in patients who spine surgeons won’t touch. In my experience, it does not work well in severe stenosis in that patient population. Unfortunately, the majority of surgeons in my community won’t operate on these patients based on multiple reasons that boil down to age. Those patients need a real minimally invasive surgical decompression not the Fisher-Price version.

 

[Ducttape]

i dont use it for mild to moderate stenosis. those patients dont need surgery. they get nonsurgical treatment.

i guess i need to be very specific. in my practice and in my opinion, MILD is for the LOL and LOM who have severe spinal stenosis with significant neurogenic claudication and have too many health issues or are not expected to live long enough to reap the benefits of a procedure with a 6 month recovery period.

 

[lobelsteve]

Earlier this week I posted a case of a fit and healthy 63 year old man with a grade 1 L4-5 spondylolisthesis with severe canal stenosis and a left sided synovial cyst with radiculopathy. | Meng Huang

Earlier this week I posted a case of a fit and healthy 63 year old man with a grade 1 L4-5 spondylolisthesis with severe canal stenosis and a left sided synovial cyst with radiculopathy. I appreciate all the expert opinions! Saeed S. Sadrameli Christoph Hofstetter John Ogunlade, DO Raymond...

www.linkedin.com

 

[drusso]

If you get a complication pretending to be a surgeon, do the real surgeons bail you out?

It depends if their shareholders. It's just like when Interventional Cards used to need to have CV Surgery in-house for stents.

 

[Ducttape]

Earlier this week I posted a case of a fit and healthy 63 year old man with a grade 1 L4-5 spondylolisthesis with severe canal stenosis and a left sided synovial cyst with radiculopathy. | Meng Huang

Earlier this week I posted a case of a fit and healthy 63 year old man with a grade 1 L4-5 spondylolisthesis with severe canal stenosis and a left sided synovial cyst with radiculopathy. I appreciate all the expert opinions! Saeed S. Sadrameli Christoph Hofstetter John Ogunlade, DO Raymond...

www.linkedin.com

um... are those the post surgical images in that post? because i dont see any stenosis of note. somehow i am wondering how much change there was between these images and the pre surgical ones.

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i particularly find this comment interesting:

The joints look very arthropathic, would be good excercise to get yearly mris and follow up.

so should we be getting yearly MRIs on the facets that we RFA? cause those facets look really good compared to my patient population.

 

[swamprat]

Earlier this week I posted a case of a fit and healthy 63 year old man with a grade 1 L4-5 spondylolisthesis with severe canal stenosis and a left sided synovial cyst with radiculopathy. | Meng Huang

Earlier this week I posted a case of a fit and healthy 63 year old man with a grade 1 L4-5 spondylolisthesis with severe canal stenosis and a left sided synovial cyst with radiculopathy. I appreciate all the expert opinions! Saeed S. Sadrameli Christoph Hofstetter John Ogunlade, DO Raymond...

www.linkedin.com

So as an interventionalist I wouldn't go interlaminar ( I have but yeah I don't recommend it - more difficult for us and also way more risk of complication as we are going directly down onto the dura once you cut through LF). Also I wouldn't mess with a synovial cyst a lot of times they are adherent to the dura and when you try to remove it can tear it as well. IDK what pre-op MRI looked like but this is def one I would refer out

 

[hyperalgesia]

um... are those the post surgical images in that post? because i dont see any stenosis of note. somehow i am wondering how much change there was between these images and the pre surgical ones.

It's like he's saying he went from something to 100 mph in only 5 seconds. And all the commenters are saying, "wow, impressive!" lol

 

[cowboydoc]

um... are those the post surgical images in that post? because i dont see any stenosis of note. somehow i am wondering how much change there was between these images and the pre surgical ones.

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i particularly find this comment interesting:

so should we be getting yearly MRIs on the facets that we RFA? cause those facets look really good compared to my patient population.

You’re asking questions like you don’t have ownership in the “in house” MRI.