What about Laser Spine Institute?

Sometimes during my patient consultations, I receive the question “What about Laser Spine?” Having practiced in Phoenix and currently living in New Mexico, I have encountered many patients before and after their experience with the Laser Spine Institute (LSI). My impression of LSI has more to do with a focus on promoting Minimally Invasive Surgery (MIS) than with a focus on using a laser.

Starting approximately 10 years ago, outpatient (MIS) surgery has grown extensively. Some authorities estimate that by 2025, fifty percent of spine surgeries will be performed in an outpatient setting. Currently, in my practice, cases that are performed at the Las Cruces Surgical Center (LCSC) include healthy patients in need of Posterior Lumbar Disc Surgery, Sacroiliac fusion or single level Anterior Cervical Fusions (ACD&F).

The key with successful outpatient surgery is patient selection. One size does not fit all. Healthy patients with minimal medical issues fit the profile better for successful outpatient surgery than older patients with medical issues such as obesity, heart or lung issues, and chronic pain. Minimizing risk is important because Ambulatory Surgical Centers (ASC’s) do not have access to all of the specialties (Cardiologist, Urologist, Internal Medicine) that a hospital may have to offer. Patient selection and surgical procedures have to be chosen carefully.

Oftentimes, patients ask whether I can perform the surgery we are discussing using “one 1 inch incision” (per the Laser Spine Institute commercial). I routinely chuckle because the size of the incision is the least of my pre surgical concerns. I only know of three spine surgeries that could realistically be done with one 1 inch incision: MIS Lumbar Microdiscectomy, Posterior Cervical Foraminotomy, and perhaps a one level ACD&F. In my practice, this accounts for < 10% of the surgical cases. Interestingly, the patients asking for the smaller incisions have the most extensive findings (multi-level arthritic changes with Scoliosis or stenosis). Can you perform theses surgeries with “one 1 inch incision”; the answer is NO.

Ultimately, surgery should be tailored to the disease of the spine. If the goal of surgery is to decrease leg or back pain, then the incision size should match the spine disease…not vice versa. A mentor of mine taught me “Do what you do best”. If a specific surgery requires a larger incision, then a larger incision is needed. Patients want to feel better, the incision size is secondary. What good is a small incision if the patient still has symptoms?

To conclude, MIS/ Laser Surgery/ Outpatient spine surgery is here to stay. Additional precautions have to be taken in performing these surgeries from patient selection, ability to achieve a surgical goal with a smaller incision, emergency and pain management protocols, as well as investment in expensive equipment. Every patient is different and safety has to be a priority. Las Cruces Surgical Center has been performing outpatient spine surgery since 2008. The important point is not whether I am using a Laser, Endoscope or a Tube system (MIS); what matters is whether the goal of surgery is attained. A successful outcome with a larger incision is always better than a small incision with continued pain.images (4)

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Spineline article recently published

Spineline_edited-1

Paul Saiz, MD recently had an article published in the May-June issue of SpineLine 2015. He co-authored an article with Chris Kauffman, MD entitled “Timing of CCI edits for Interbody Fusion and Laminectomy at the same level.” This article explains the history behind the linking of two surgical codes: Lumbar fusion with decompression.

SpineLine is a clinical and news publication aimed at Spine Care Professionals, which is published every other month.

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2015 New Mexico Workers Comp Annual Meeting

The 2015 Annual New Mexico Workers Comp meeting took place at the Ysleta resort in Albuquerque on May 13-15th. I was given an opportunity to discuss causation issues re: neck pain on May 14th. My talk titled “Neck pain in the work environment” discussed workers comp issues in regards to chronic and acute pain and addressing causation.

The concepts of temporal relationships, dose response and mechanistic plausibility were discussed. A literature review was also presented.

The Workers Comp talks and conference allows for meaningful interaction between MD’s, Lawyers, Insurance Companies, Physical Therapists and Nurses; regarding Workers Comp injuries. The sharing of information on best practices & methodology allows for better coordinated care of the injured worker.

Paul Saiz, MD

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Smokers may have higher incidence of swallowing issues after Anterior Neck Surgery than non-smokers

Cervical fusions typically involve approaching the neck from the front. This approach includes mobilization of the esophagus and trachea which always involves some amount of dysphagia (problems swallowing). Dysphagia can last anywhere from two weeks to sometimes multiple months or years. A general rule of thumb is that the more levels operated on, the more likely the patient is to have dysphagia. Other risk factors for swallowing issues post op include prior surgery, length of surgical procedure and preoperative swallowing complaints

A recent study presented at the Cervical Spine Research Society Annual Meeting by Erik Olsson, MD et al found that smoking can be a risk factor for dysphagia. “Their (Smokers) symptoms when they experienced dysphagia, were more severe when compared to non-smokers or former smokers.” The authors identified prior surgery and smoking as risk factors for long term swallowing problems.

Smoking has always been associated with higher rates of nonunion (inability to grow new bone) in spine surgery. This study by Olsson and associates, sheds light on the increased risk of long term dysphagia in smokers.

Prior to any spine surgery it is important to counsel the patient as to the increased risks associated with smoking and how smoking can affect surgical outcomes. Ultimately, it must be the patient who decides not to smoke.

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Neck surgery can be more cost effective and just as safe at Ambulatory Surgical Center (ASC) vs Hospital

A recent study presented at the Congress of Neurological Surgeons (CNS) in Boston showed that 1 & 2 level neck fusions can be performed as safely and cheaper than the same surgery performed at a hospital. Matthew J McGirt, MD presented the findings at the annual CNS meeting and along with his co-investigator also received The Samuel Hassenbusch Young Neurosurgeon Award at the meeting for the research.

The study compared two groups of patients who underwent 1 and 2 level anterior neck surgeries (ACD&F) at an ASC vs a hospital. They found the complication rates, return to work rates and outcomes at 3 months were equal. More importantly, the surgeries performed at an ASC were on average $7,000 cheaper. “This is a cost saving advancement in ACD&F surgery. From a patient, payer, purchaser, and societal perspective, the ASC setting offers superior value and can lead to cost savings of over $7,000 per patient.” adds Dr McGirt.

Las Cruces Orthopedic Associates (LCOA) and Las Cruces Surgical Center (LCSC) have been performing outpatient anterior neck surgery since 2009. Our goal has always been to provide the most efficient and cost effective care possible. This important paper adds more evidence to the effectiveness of outpatient, ASC based surgical care.

Paul Saiz, MDACD&F C5-6

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Did you know?

Las Cruces Orthopedic Associates would like to congratulate Dr Paul Saiz, for being the first physician in Southern New Mexico and the El Paso area to implant the new Medtronic low profile (LP) Prestige Cervical Disc Replacement.

Disc replacement, in certain patients, can replace neck fusion for neck and arm pain while preserving motion above and below the area of surgery. Single level disc replacements can be performed as outpatient surgery and is one of the many spine surgeries performed by Paul Saiz, MD in an outpatient setting.

Las Cruces Orthopedic Associates (LCOA)

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Why do complications happen?

Once a back or neck surgery decision is made; a consent form is signed detailing risks and benefits of surgery. Typical benefits from surgery include a decrease in back-neck &/ or leg-arm pain, more motion, less reliance on medications and improved function.

The downside of surgery involves complications. This typically involves unexpected negative results such as infection, nerve injury, failure of screws and continued pain. A common question I am asked is “Why did this happen?” The answer is as varied as the complications. The simplest answer is that unexpected results always occur, a certain percentage of the time. For example, if infection happens 2-4% of the time and you perform 100 surgeries; that is 2-4 infections.

We also know that certain risk factors increase complication rates. Obesity has been shown to increase the risk of infection, failure of hardware, blood clots and non-union. Smoking has been shown to increase chances of non-union, wound breakdown, infection and lung issues with anesthesia. Interestingly, people who smoke or are obese are more likely to have back and leg problems. For instance, smokers are 2X more likely to have low back surgery and 2.5X more likely to have neck surgery.

Other risk factors for complications include prior back &/ or neck surgery, workers comp injury, failure to follow post op directions and narcotic abuse among others. We have not even brought up the risks associated with anesthesia & pain control which are separate from the surgery. This includes heart issues, constipation, lung problems, uncontrolled diabetes and blood clots. A general rule of thumb is that the sicker you are, the more likely you are to have a complication.

The effect of prior surgery is often underestimated. Having had anatomy disturbed which includes nerves uncovered or spine levels fused; increases the complexity of the surgery and alters surgeon decision making. Risks of unexpected injury to nerves or blood vessels, infection, failure of screws or cages, lack of pain improvement, and longer recovery times are all more frequent after repeat surgery. Many surgeons will not operate on patients with prior surgery because of the above reasons.

Overall, back and neck surgery has become more effective over time. However, complications still happen. As a surgeon, my job is to treat the individual patient and make decisions based on my training and twelve years experience. If an unexpected event does happen, I will do everything I can to fix the problem. Some complications cannot be avoided and fault belongs to no one. More importantly, a motivated and positive patient helps enormously in overcoming obstacles and achieving a successful outcome.

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