What is Endoscopic Spine Surgery?
After spending 38 years performing surgeries and 18 years spent specifically on endoscopic surgeries, Dr. Mork has compiled a list of three distinctions to connect problems with their commonly asked questions and Eight Things You Should Know Before Having Endoscopic Spinal Surgery (or any type of spinal surgery).
I have identified several broad guidelines that can be used to separate problems and their respective treatments.
First Distinction: Do you have a soft tissue or bone problem?
Is your problem just a soft tissue issue, like a disc herniation at a single level? Or is it a bone problem that results in stenosis or arthritis? Age is typically a factor in distinguishing between the two problems. A simple disc herniation is common in people who are under the age of 55, whereas stenosis and arthritis are more common causes of pain in the neck or low back when getting above the age of 60-65. The treatment can vary somewhat for each problem.
Second Distinction: Is your age a factor?
The age distinction is not as significant as one might imagine, although multi-level issues are more common as we age. The great thing about outpatient endoscopic spine surgery, regardless of age, is that almost everyone can drive a car the day after surgery (at least for short distances) and there is very little time spent lying around, since the pain is usually quite tolerable.
Third Distinction: Is your overall fitness and health level a factor?
A third broad distinction is that of general health and conditioning, which should make total sense. Obviously if you are in great shape, this type of surgery will allow you the fastest recovery possible. However, people not in the best shape can also benefit from this minimally invasive endoscopic surgery because there is simply less pain to deal with and therefore less to keep the deconditioned person down; walking can begin the day after surgery and most people can drive a car the next day as well! This early return to activity can be life saving for people with a more precarious medical history that need to avoid any prolonged bed rest.
Eight questions you should ask before selecting a surgeon and scheduling surgery:
1. Isn't all back surgery the same?
Not at all. In spite of all the confusing medical language, spine surgery usually comes down to one of two things to be accomplished. The goal of spine surgery is either to decompress or fuse. The goals could not be more opposite; one is meant to preserve motion and the other is meant to eliminate it. In many ways, it is a philosophical divide. Dr's. who like fusions believe that “when there is no motion, there is no pain”. If this were really true then fusions would be universally successful, which they are not.
Once you understand the two opposing goals of spine surgery (decompression or fusion), then you can start to compare techniques, risks, as well as short and long term complications.
The most obvious difference between decompression and fusion surgery in the short term is that a fusion is irreversible, if you don’t like it, there is no way to go back. On the other hand, if you do a decompression and don’t get enough relief, then a fusion can be performed. The most obvious difference between decompression and fusion surgery in the long term is the occurrence of ADD or adjacent disc disease after a fusion. This occurs because of the additional wear and tear of the discs that weren’t fused. The motion that was lost to the fusion will be picked up by the remaining discs.
We only perform endoscopic surgery to decompress disc herniation's and stenosis. The term minimally invasive is not meaningful since there is no definition of how big the incision is and now people use the term when talking about doing a fusion.
To date, I have performed over 8000 procedures.
2. How large is the incision?
The size of the incision is determined by the size of the instruments being used to perform the surgery. This is the main reason that tubular retractors are used these days instead of blade retractors. The amount of post-operative scarring, tissue disruption and pain is directly proportional to the size of the incision, so the smaller the better.
The tubes to perform endoscopic vary from procedure to another, but range from 3 mm to 10 mm. The reason the instruments can be so small is because the light and camera lens are at the tip of the scope and the working instruments are passed through a channel inside the scope. Endoscopic instrumentation is the “ultimate” in minimally invasive with tube diameters to prove it.
3. What are the potential complications?
Potential complications should be thought of as short term or long term. Short term surgical complications are related to the surgery, such as bleeding, nerve injury, dural leaks and infection. The occurrence of these depends on the type of surgery performed and skill level of the surgeon.
The other type of short term complication is of a medical nature. Examples of this would be vein clots resulting in deep venous thrombosis, or pulmonary embolus. Pneumonia is rarely seen after endoscopic spine surgery because activity levels are pretty normal, but can be a problem with too much bed rest after a larger procedure.
The main long term complication rate seems more related to fusion surgery is adjacent disc disease. The main long term problem that gets worse with time is adjacent disc disease that can occur after a fusion, since a fusion removes the motion of a disc space. The loss of motion increases the workload of the discs on each side of the fusion where motion is still possible, and they seem to wear out faster. This advanced wear seems to occur about 25% over normal in the neck and about 50% over normal in the lumbar spine after 10 years.
The likelihood of this long term problem increases with time as the discs at the ends of the fusion break down prematurely. They break down prematurely because they have to do extra work to compensate for the motion lost by the fusion. The loss of motion increases the workload of the discs on each side of the fusion where motion is still possible, and they wear out faster. This advanced wear occurs at a rate of about 2.5% per year in the neck and about 5.0% over normal in the lumbar spine.
- Blood Loss - In my endoscopic spinal surgery practice, blood loss averages less than 10cc (3 ounces) and I have never (0%) had to transfuse anyone or use a cell saver device.
- Nerve injury - This can cover a wide spectrum of complaints, from sensory changes of numbness to actual muscle weakness or paralysis that can vary with procedure. I have noted a very low nerve injury rate regardless. Most nerve “injuries” are described as numbness that resolves in a few weeks.
“awake” patient is the “most sensitive spinal cord monitor there is.” I would prefer not to have a general anesthetic if there was another reasonable choice.
- Incidence of dural leaks is very low (< 1%) - This is incredibly low given the fact that many of my patients have had previous open surgery. The incidence of leaks just get lower with time and experience of 20 years.
- Anesthesia - I currently recommend IV sedation in almost all cases for maximum comfort, minimal post op discomfort and nausea.
- Infection Rate - Endoscopic spine surgery is performed in a hermetically sealed water environment. There is no exposure to air. The use of continuous, cleansing irrigation during the procedure and relatively short operating times give rise to very low infection rates (< 1%). Implanted devices, which I don’t use, give rise to higher infection rates.
4. What is the success rate?
This is the big question and it’s easy to get misled for a couple of reasons. First of all, the results will vary for each problem and procedure performed. Then consider this, most surgery performed on the neck will generally have a better outcome than that performed on the lumbar spine because there is less weight transmitted across the cervical spine.
When we talk about success, we want to know how well things will be working out in the next few years, not the next few hours. I have seen ridiculous claims on the Internet of “98% Success” while people are asked that question in the recovery room and still sedated ! While I’m on the subject of percentages, I’m always a little skeptical when I hear 90% success stories for any spine surgery. I have read hundreds of well written scientific papers and don’t recall seeing a 90% success rate in any of them.
What is “success” anyway? Does this mean 100% resolution of the problem, or would you be happy with 50% improvement? This is why most scientific papers divide “success” into a few categories like excellent, good, fair and poor. Maybe if you added the excellent, good and fair results together, we could come to 90% successful, but most people don’t consider “fair” results a great success.
Is there a published paper to prove the results? A published paper usually means that the doctor has taken much more time and effort to evaluate his long term results as well as any problems that occurred. Most journals require at least 2 years post-surgery to be considered permanent.I have authored or coauthored more than 10 papers on the topic of Endoscopic Spinal Surgery.
5. What is Pain Mapping of the Spine and do I need it?
Pre-surgical pain mapping is used to identify the nerve or structure causing the pain you have if there is any confusion about where the pain originates. This can be helpful to determine what is causing the main pain you have, when there is more than one contributor. Spinal pain Mapping may not be necessary if the problem is obvious and single level (large disc or single level stenosis).
The big problem is that beck and neck pain often is radiating from somewhere; it is not felt directly over the structure causing the problem. An example is when people feel groin pain when they have an annular tear of a lumbar 4-5 disc. Another problem is when two structures radiate pain to the same area.
Spinal pain mapping can be very helpful to identify that part of the anatomy (disc, facet or nerve) that is causing pain when there is more than one problem that could be causing the problem. Why operate on something unless it can be proven to hurt? Just because 3 discs“look bad” on the MRI, it doesn’t mean they are all painful. I certainly wouldn’t want surgery on my discs if the facets were causing my back pain, and Pain Mapping can really help figure this out.
The less surgery the better,fix what needs to be fixed and nothing more. There are a lot of moving parts in the spine and more than one may be contributing to your pain. Pain mapping can help determine which area should be addressed first.
6. How long will my recovery take?
- What activity level are you striving to regain?
Returning to a sedentary activity at work is a lot different than wanting to return to walk an 18 holes of golf or go horseback riding. You can often return to a sedentary activity on a limited basis can often occur after 7-14 days. It can take 5-6 weeks to return to more vigorous activities. The more vigorous the activity is that you want to resume, the longer it will take to get back to it.
The key is a progressive re-entry using stopwatch. You can use a stopwatch to “ratchet” your way back into an activity in small increments of time. The idea is to increase your endurance, but stop before any pain begins. Using a stopwatch requires discipline, but will get you the fastest results since you will know your limits within a few minutes and can make steady progress to your goal.
- What does conditioning refer to?
Conditioning refers to the strength and condition of your back and abdominal (core) muscles which are probably weak as a result of your back problem. These must be brought back to life before increasing your activity significantly, particularly in the younger and more active patient anxious to return to an active lifestyle. Be patient in the early postoperative period and don’t overdo it. Progress slowly, you don’t want a recurrence of your problem.
- Is The exercise regimen after surgery is the same for everybody?
One myth is that the physical exercise regimen is the same for everyone after surgery, regardless of age. This is simply not the case! A younger person, with a single level herniated disc, will resume a higher level of activity more quickly and usually find physical therapy very helpful. This scenario contrasts dramatically with an older person who is deconditioned and has surgery to treat stenosis.
The recovery in the stenosis situation is highlighted by walking as the main exercise. I rarely suggest that someone over the age of 65-70, who has never been too active or involved with an exercise program, start a vigorous spine exercise program after surgery. I have seen too many problems caused by this approach, some of which were generated by the exercise program.
- Once your pain is gone after surgery, you can do what you want.
This is another myth. Just because your pain is relieved, doesn't mean your muscle strength is back to normal or that the early scar tissue is strong enough to support unlimited activity. This is my biggest problem after endoscopic spine surgery! People then assume that once the pain is gone, that everything is back to normal, and they can do what comes to mind, like lift a suitcase or child. I know that people don’t do these things on purpose, but these activities can cause a recurrence of the problem.
The relief of neck or back pain after surgery will only allow you to begin the exercises to strengthen the de-conditioned muscles, or start the walking process. It really takes about 6 weeks for the scar tissue to begin to stabilize the surgical site.
- A back brace is all that is needed to resume my activities after surgery.
Another myth is that a back brace will take the place of exercise and time to heal to allow you to get going faster. This is simply not true. A brace may make you feel better by supporting you and reducing your pain, but remember that just being pain free doesn’t mean that your strength is where it needs to be. You don’t want a brace to give you a false sense of security to perform activities that might injure you after surgery. Braces are most helpful as a reminder that you have had a surgical procedure and need time and some restricted activity to heal.
7. Is this a fusion procedure?
A spine fusion is a fusion is a fusion.
The answer is no. I have designed my practice to cure back and neck pain without a fusion. My tagline is “refuse to fuse” when possible. There are some procedures out there being marketed as "minimally invasive", but fusions in reality. Fusions are accomplished with implanted devices that can be difficult to remove, if at all. Even if the hardware is removed, the spine motion will not return.
Fusions are irreversible and use an implant to remove any motion. Good to excellent results vary for a fusion depending on what problem is treated; the results vary considerably but probably average around 70% in most large series.
There are lots more complications when performing a fusion than an endoscopic spine surgery, in both long and short term. Although a fusion is necessary in some situations, I would save it for last if something much less invasive, like endoscopic spine surgery, could be done first. Remember, if the endoscopic spine procedure doesn’t help you enough, you can always have a fusion. The question is, “what options are available if the fusion doesn’t work? Unfortunately, the answer is, not many.
8. Can I come alone and have this surgery? How long do I have to stay in the area?
This surgery can be performed in a hospital or surgery center setting as an outpatient, or with an overnight stay (sometimes called a 23 hour hold). If you stay at a local hotel, I can visit you in your room the day after surgery and see how things are going and change your dressing. I think it's silly for a postoperative patient to make the effort to get up to see me in the office when you are the one in pain.
There are many luxury hotels in the area and any amenity you can imagine, as well as transportation. I recommend staying a total of 4-5 days to make things feel unhurried and comfortable. If you come alone, transportation arrangements can be made to get you from the hospital to your hotel after your surgery.
If you would like a one-on-one review of your MRI or have additional questions please contact us now!
I look forward to helping you get your life back.
Anthony Mork M.D.