Evidence Based Medicine versus Personalized Treatment of Symptomatic Conditions of the Spine Under Local Anesthesia: the Role of Endoscopic versus Spinal Fusion Surgery as a “Disruptive” Technique

Abstract

Runaway cost for surgical spine care has led to increased scrutiny on its medical necessity. Consequently, the beaurocracy involved in determining coverage for these services has grown. The call for high-grade clinical evidence dominates the debate on whether endoscopic surgery has a place in treating painful conditions of the aging spine. The cost-effectiveness and durability of the endoscopic treatment benefit are questioned every time technology advances prompt an expansion of its clinical indications. The authors of this chapter introduce the concept of early-staged management of spine pain and make the case for personalized spine care focused on predominant pain generators rather than image-based necessity criteria for surgery often applied in population-based management strategies. The authors stipulate that future endoscopic spine care will likely bridge the gap between interventional pain management and open spine surgery. This emerging field of interventional endoscopic pain surgery aims to meet the unanswered patient demand for less burdensome treatments under local anesthesia and sedation. The very young and old patients often are ignored because their conditions are either not bad enough or too advanced for a successful outcome with traditional spine care. In this watershed area of spine care, the authors predict endoscopic spine surgery will thrive and carve out accepted surgical indications in direct competition with pain management and traditional open spine fusion protocols.