Becker's Spine Review

12 SPINE SURGEONS Why endoscopic spine surgery in the US lags behind Europe, Asia By Alan Condon E ndoscopic spine surgery is growing in popularity among surgeons in the U.S., but lags growth in Asia and Europe. Reimbursement shackles and a lack of train- ing are two big hurdles affecting its adoption. ree spine surgeons discuss how endoscopy has benefited their practice and expand on the challenges affecting its widespread adop- tion in the U.S. Note: Responses are lightly edited for style and clarity. Saqib Hasan, MD. Webster Orthopedics (Oakland, Calif.): Endoscopic spine surgery is already very popular in Asia and Europe, and more U.S. surgeons continue to adopt these techniques. Training always lags behind new technology. Only aer a critical mass of spine surgeons begin utilizing endoscopic techniques will you start to see it as part of a normal spine surgical curriculum in the U.S. Many of my attendings in residency learned arthroscopic techniques aer they had com- pleted their training. Arthroscopic surgery re- ally revolutionized orthopedic surgery because of the paradigm shi from open surgery. Unfortunately, I believe early iterations of endoscopic spine surgery were not ready for prime time. e technology and techniques were not there, hence, the clinical data didn't stack well against what was tried and true. With the current picture quality and instru- ment improvements, endoscopic spine sur- gery today allows for an elegant and versatile method of treating both simple and complex spinal pathology. Tony Mork, MD. Endoscopic Spine Academy (Newport Beach, Calif.): ere's little to no comprehensive training readily available. e endoscopic approach uses a totally different skill set than open surgery and requires a relearning of the anatomy. When you start to look at the spine through a scope, it's very different at first. Any problems encountered, for example a dural tear or bleeding, must be taken care of through the scope. is takes a little patience and a lot of practice to feel comfortable. e second reason is that the reimbursement is not very good. e equipment is expensive: A diamond burr, used for bone work, can cost up to $1,900 per burr. So, if the facility isn't being reimbursed adequately, then it becomes a financial issue. Endoscopic spine surgeries are mostly outpatient procedures, so hospitals are concerned because they're not getting ad- equately reimbursed. Also, it's the physicians that decide between an endoscopic procedure and a fusion for a given condition. So, if the outcomes may be similar, some physicians might do a fusion because the reimburse- ments are so much better. Raymond Gardocki, MD. Vanderbilt Health (Nashville, Tenn.): Endoscopy has been around for a while, but in the early days the optics were poor. I think there were some people pushing endoscopic spine sur- gery who promised it could do more than it actually can. at le a bad taste in peoples' mouths, especially in the spine community. ere's a greater risk of liability in the U.S. than other countries, so people don't want to be the first person to do something. I start- ed doing outpatient lumbar fusions in 2008, and it weighed heavily on my mind because I was basically outside the standard of care. If I had any complications, it would have been very hard to defend. But it's slowly becoming accepted now. Having had that experience, I felt I could tackle the endoscopic aspect. Fundamentally, I think it's better. It's less invasive, not only intuitively, but there are studies that show inflammatory mediators are lower aer an endoscopic approach than even a tubular ap- proach. It's objectively less invasive; it allows us to do surgery on patients that are awake so you can avoid the risk of general anesthesia, which can be significant in the elderly pop- ulation. You also get instant feedback — you can sometimes tell while the patient is on the table if they're better because you can ask them how their leg feels. n Spine surgeon gets 10-year prison sentence for healthcare fraud By Alan Condon T he owner of Texas Center for Orthopedic and Spinal Disorders in Fort Worth was sentenced Feb. 25 to 10 years in prison for his role in a $10 million healthcare fraud scheme. Mark Kuper, MD, admitted to conspiring with his wife and a physical therapist at his practice to defraud Medicare, Medicaid and Tricare, according to the Department of Justice. The DOJ said Dr. Kuper billed insurers for services the clinic never performed, including physical therapy and psychotherapy, and required patients to attend sham appointments to get prescriptions for controlled substances. Many times, Dr. Kuper billed for more than 100 hours' work he said he provid- ed in a single day, said the DOJ. Furthermore, the surgeon and his wife accidentally burned down their $1.6 million house after burning medical records in an attempt to destroy evidence of the fraudulent claims. His wife also tried to hide evidence by altering treat- ment notes in electronic patient records, according to the DOJ. In September, Dr. Kuper's wife and the physical therapist involved in the scheme pleaded guilty to conspiracy to commit healthcare fraud. They re- ceived 18-month and 36-month prison terms respectively.n

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