Anthony T. Yeung, M.D., Clinical Professor

University of New Mexico School Of Medicine

Desert Institute for Spine Care, Phoenix, Arizona

Executive director, (IITS.org)

Beckers 17th Annual future of Spine and Pain Management Conference

June 12-19, 2019

Utilizing “Disruptive” Endoscopic Techniques: The Role and Future of Endoscopic Surgery for the

Treatment of Symptomatic Conditions of the Spine( an evidence based concept talk)

Health Care Cost is in Crisis… No easy answer

• Affected by stakeholders all competing for services or products causing an affordability crisis

• Privilege or Right?

• Free, single payer, or best solved by a Free market?

• What is the Role of health care providers that has to deliver health care , vs government / insurance payers?

Health Care Affordability is the Crisis

• Affordability is a real challenge without the means to pay for “real quality “

• A growing trend is for hospital and physicians to manage cost-sharing and quality metrics

• What about “disruptive” concepts,

– Treating the pain source surgically with a “warrantee”?

– Ie. surgical pain care with visualized surgical treatment of the pain generator as a staged procedure

My opinion:

Consider “disruptive” techniques that preserve patient choice and physician

autonomy= free market concepts

Endoscopic Spine Care, 5G, Robotic A.I.

Single payer w/o insurance choice, USPO without FEDEX,

I am “Conflicted” by 28 years >11,000 Endoscopic Procedures since 1991

• Developed the YESS™ Endoscopic Spine System 1997

– Personal experience with the first Medicare approved Spine ASC

• Over 140 Level IV and V EBM publications

– Now level 3 with like minded surgical collaborators

– All innovations start as level V

Personal observations

The Background for my “Confliction”

• BACKGROUND: I was a General Orthopedic Surgeon for 20 years, before Spine Fellowship Programs spawned the myriad of fusion procedures considered the “State of the Art”.

• I support current concepts in Spine Surgery, including fusion

– I see the success of fusion for the right indications by my fellowship trained associates at Desert Institute for Spine Care

• After adopting endoscopic spine surgery in 1991, I became passionate about endoscopic spine surgery because it offered greater surgical options, but “disruptive” to traditionalists

Take home message

• Endoscopic surgery on the pain generators of spine symptoms and pain can be correlated with patho-physiology supported by endoscopic documentation

• The patho-physiology of pain is better understood than just reliance on current imaging techniques alone

Initial Response by many traditionaliststo “Disruptive” Surgical Platforms

Why is Endoscopic Spine Surgery ”Disruptive?”

• Eliminates the need for fusion, (the current focus) by 30-

85% (stratified)

– The most costly surgical option

• Decrease the need for more costly Spinal cord stimulation

for FBSS from failed decomoression and fusion

– * I share the DRG neuromodulation method for neuropathic pain

• It mitigates dependence and over utilization of

Opiods by “surgically” treating the pain generator

“surgical pain care”

Why is Endoscopic Spine Surgery ”Disruptive?”

• Endoscopic decompression accomplished under

local anesthesia by Surgically Trained

Endoscopists as a “STAGED” procedure can

eliminate 70-90 percent of fusions being utilized as

the first option for decompression and stabilization

• Mitigates the fusion solution driving evidence

based medicine studies and 3rd party payment

Scott Becker’s Thoughts on Health Care Systems

• Scott Becker Outlined the headwinds facing Current Trends in health care delivery

• Scott Becker concludes that current medical doctrine…IS NOT Likely to Work in the Next 10 years

• Are Scott Becker’s “other” Issues “DISRUPTIVE”?

–*Endoscopic Spine Surgery for symptomatic conditions of the lumbar spine is Becker’s “other” issue for more cost effectiveness in spine care

My Thoughts on Disruptive Health Care Issues under Becker’s “other” platform

• Convert pay for service to pay for “value”

• The provider issues “value warranty” for the requested fee

• Treat surgeons like PROFESSIONAL ATHLETES where only the very best are paid what they command

My Thoughts on Disruptive Health Care Issues under Becker’s “other” platform

• Educate the next generation of physicians to be competitive in the new era of healthcare by:

– Focusing on what is best for their patient

–Adopting endoscopic “surgical spine care “

– Surgeons offering a “warranty”

• Robotics for endoscopic spine surgery will shorten learning curve, improve results

Current political Situation in the USA

• ”FREE” single payer “ one size fits all” concept will

provide less quality, less choice, rationing, and greater cost

• Health care providers “gaming” the system will add cost by protecting their turf without improving care will be the demise of universal “free” health care

• The Best solution is still be debatable and must be rationed

• Oval design as a surgical tool:– Discectomy, Nuclectomy

• Decompression

– Intradiscal Therapy• Decompression

• Thermal annuloplasty

• Disc irrigation

– Nerve Ablation• Intradiscal annuloplasty

• Rhizolysis• Disc and Axial back pain

Facilitate And augment All Surgical Approaches

Wolf Y.E.S.S™. Multi-Channel Spine different systems in the market

Many Endoscope DesignsFor Diagnosis and Treatment:

Identify Painful Patho-anatomy

YESS Endoscope Provides Endoscopic

Documentation of patho-anatomy of pain

generators: A New EBM concept

The YESS Scope Design: Oval endoscope with Multi-channel flow integrated system ( 1997)

Wolf Award 2017 commemorating 20 years of innovation

NEW 3D SCOPE under development

Oval endoscope configuration facilitates intradiscal therapy visualization in a

narrowed aging spine

( other OEM endoscopes are round)

Oval shape Enhances visualization by a fluid pump that controls

irrigation flow and pressure to keep the endoscopic field clear

Surgical pain treatment is a “disruptive” concept

• The endoscope can document patho-anatomy responsible for symptoms and pain from normal aging

• It can correlate the pathophysiology and symptomatology when endoscopic surgery is performed with pt feedback under local anesthesia

Clinical example: Correlation of

epidurography and “evocative”

discograms with the patho-

anatomy of symptom generation

Video of painful anular tear (1.5 min)

Why is endoscopic spine “disruptive”?Too many stake holders in the spinal care platform

• Surgeons and nonsurgeonswho do not perform endoscopic surgery may have a different opinion about endoscopic spine surgery

• Many are opposed or “agnostic” about it

• Accomplished Endoscopists

requires special surgical training to be proficient

for this “new” concept of “evidence based medicine”

Why is Endoscopic Spine Surgery ”Disruptive?”

• It will mitigate dependence and over utilization of opiods

and pain management procedures that are easily abused

• Decrease the need for costly Spinal cord stimulation or

nerve and DRG neuromodulation for “FBSS” Pain

• A Yeung owns the foraminal DRG neuromodulation method,

but almost all utilization is by pain management providers

familiar with concepts of Spinal cord stimulation

This experience provides endoscopic “evidence based medicine” by treating the pain and

symptom generator, with endoscopic documentation of the patho-anatomy.

*Traditional imaging requirements to make clinical decisions is not completely accurate

*Neuromodulation can treat neuropathic pain

When the visualized “pain or symptom” generating patho-anatomy is correlated with the patient’s response and feedback during

surgery, a new type of “evidence based” validation of the surgical effect, considered “disruptive” can be studied and validated

The “E” in Endoscopic Evidence Based

Medicine (a new concept)

• E= Evidenced based

• E=Endoscopic Visually Based

• E= Expedient and Efficient Based

• E= Economically Based

• E= EXPERTISE Based

Treat the pain generator, not just the available imaging

The “disruptive” process provides information on pain generators that is not appreciated by traditional spine surgeons and non surgeons.

A. Yeung’s data base of >11,000 surgical procedures on endoscopic surgery under local anesthesia identifies the best indications for

“surgical pain care”

The “YESS” endoscopic philosophy and technique

• Appropriate for patients deemed “too Young”, “too old”, “ too pain sensitive”, with “psychologic disorders” or having “too many co-morbidities” to be good candidates for the risks of traditional surgical intervention

Morbid Obesity 350 #

Biportal Endoscopic Technique

Video example of biportal endoscopic technique

The surgeon and

assistant can

work together

inside the disc

An endoscope

Visualizes the

surgical process

Extruded

herniations

Are pulled back

into the disc

THE BEST TECHNIQUE, as defined by safety through reduction of complications, efficacy,

and cost effectiveness should be adopted by the best results in each individual surgeon’s

hands

“Best” Minimally Invasive Surgical Technique is Transforaminal Decompression under local

anesthesia

• It is Safer than traditional open surgery!

• 3.5% published complication rate

• NOW *< 1%-2% endoscopic complication rate after overcoming the learning curve

– A Yeung’s overall CUMMULATIVE case series

FEATURES of Transforaminal Decompression:

• Clinically Effective, and Cost Effective– Local anesthetic performed with MAC or no sedation

– Outpatient, one hour recovery in ASC, surgical time dependent on case complexity and surgeon experience

– *Neuromonitoring NOT NEEDED ( at cost savings )

– Earlier Surgical Care bypasses less effective nonsurgical methods and more surgically morbid care

The “Surgeon” factor:

Endoscopic surgeons or nonsurgeon providers must develop critical skills, with appropriate training, and gain competency to perform at a high enough skill level needed to attain the safest and best results

Appropriate training, “turf battles”, “hype”,

unaccepting surgeons, FALSE marketing

CONCERNS

A systematic review of A YEUNG’S endoscopic database 10,000 cases 1991-2018

• Discogenic pain validated by evocative chromo-discography with intra-operative vital staining

• Progression to contained, then protruded and extruded HNP of various types

• Progression to foraminal decompression and

foraminoplasty

• Statification of endoscopic indications in past 15 years to present evolution in 2019

Growth of Endoscopic Spine

• ENDOSCOPIC VISUALIZATION ,EXCISION, DECOMPRESSION AND STABILIZATION of the lumbar thoracic and cervical spine Is CURRENTLY BEING PRACTICED WIDELY in ASIA

• Transforaminal Endoscopic Decompression, providing symptom relief is possible for 80%-90% of the Painful Patho-anatomy of each Degenerating symptomatic Spinal Segment

China 2018

Courtesy of Luke Kim

Endoscopic Spine State of the Art

• A “full endoscopic” approach is first promoted by Sebastian Ruetten and others by combining the Translaminar with a Transforaminal approach

– The future will be by combining all endoscopic approaches possibly staged, aided by Robotic A.I.*

• Endoscopic procedures now BEING UTILIZED for trauma, neoplasm, and instability, including fusion as a surgical option for pain resolution from “FBSS”

* ATY’s A.I. for endoscopic techniques

A.I. in computer technology for health care

• Assimilation in Asian countries will be at a much higher rate than the West because it is culture and Asian political policy dependent

• Asia (China) has a large population with relatively lower costs, that “insulate” Asia from loss of low level and blue collar jobs at risk in Advanced Western Countries currently in political turmoil

• *Physician A.I. needs a reimbursement platform to innovate, but under attack because of payment headwinds

Endoscopic Spine as an Academic Endeavor

• The Yeung Endoscopic Spine Center established in 1993 at the University of New Mexico ( Yeung’s Alma Mater) as the

first academic center to create a multidisciplinary program for Endoscopic Spine Procedures. Certification for endoscopic spine surgery graduated it’s first anesthesia trained spine fellow Andrew Roberts, M.D.

• More fellowship trained spine surgeons adopting endoscopic spine to augment their practice

• (D.I.S.C. Phoenix, Arizona)

Endoscopic surgery augments open “gold standard” surgery by adding intradiscal therapy

• Intradiscal therapy: Endoscopic Selective Decompression, thermal ablation , Irrigation, and neutralization of disc pH

• *Endoscopic visualization of patho-anatomy under local anesthesia with patient feedback during surgery is an important aspect of endoscopic evidence based medicine

The Exit Zone

Hidden Shoulder

Osteophytes

Inflamed Nerve

Superior Foraminal

Lig. Impingement

Superior Foraminal

Osteophytic Impingement

Impacting Facet

Margin

Tender Capsule

Hypertrophied SAP

Hyper-vascular

Scared SWZ

Inflamed Disc

* Superior foraminal ligament Impingement

* Superior notch Osteophytes

* Dorsal & Shoulder Osteophytes

* Facet Joint Impaction

* Facet Joint Cysts

* Pars Intrarticularis tethering

* SWZ & notch Engorgement

* Ligamentum flavum Infolding

* Disc Pad

* PLL Irritation

* Inter Transverse lig & Muscle Entrapment

*Inferior External Pedicular Tethering

*Annular thinning

*Annular Tears

*Shoulder Osteophytes

*Lateral Osteophytes

*Perineural Tethering

*9 common, 17 endoscopically documented painful

conditions and its anatomic locations in the foramen

The list is still growing, with endoscopic solutions for FBSS

Ie. compressed or stretched scar tissue previously asymptomatic

9 Common endoscopically visualized Conditions, aided by endoscopic foraminoplasty

• 1. Inflammed disc

• 2. Inflammed nerve

• 3. Hypervascular scar• 4. Hypertrophied SAP, lig flavum impingement

• 5. Tender capsule

• 6. Impacting facet margin

• 7. Superior foraminal facet osteophyte

• 8. Superior foraminal ligament impingement

• 9. Hidden shoulder osteophyte

Additional endoscopic documented conditions

• Symptomatic scar tissue (from stretching or compression)

• Facet joint soft tissue and bony impingement

• Facet Joint cysts (many unrecognized by imaging

• Pars defect tethering in isthmic spondylolisthesis

• PLL and annular inflammatory irritation

• Annular thinning and tears with chemical inflammation

• Perineural tethering by scar post operative or inflammation

• Foraminal osteophytosis

• Endplate tethering and impingement

( * “YESS” technique)

Yeung’s KEY PUBLISHED ARTICLES

• Endoscopic Identification and Treating the Pain Generators in the Lumbar Spine that Escape Detection by Traditional Imaging Studies J of Spine

– J Spine April 21, 2017 * (intradiscal therapy and foraminoplasty to access the “hidden zone of MacNab”)

• In-vivo endoscopic visualization of patho-anatomy

in symptomatic degenerative conditions of the lumbar spine II: Intradiscal, foraminal, and central canal decompression. Surg Technol Int 1: 299-319.

Journal of Spine Yeung and Yeung, J Spine 2017,

6:2 DOI: 10.4172/2165-7939.1000369

Endoscopic Identification and Treating

the Pain Generators in the Lumbar

Spine that Escape Detection by

Traditional Imaging Studies

Department of Neurosurgery, University of New School of

Medicine, Albuquerque, New Mexico

Desert Institute for Spine Care, Phoenix, Arizona, USA

KEY Article for Endoscopy

2 Basic Endoscopic Techniques

Inside Out Technique

Anthony Yeung

Outside In Technique

Hoogland

Richard WOLFMaxMore

Joimax

Both Target the Patho-Anatomy

Slide Courtesy of Luke Kim

“The gospel according to Luke”

2 Different Targeting Techniques

Inside Out Technique“SAFEST” Due to

Outside In TechniqueSERIAL DILATION

Hoogland design change

DIRECT VISUALIZATION MaxMoreJoimax

The Best Designed Endoscope= YESS Scope ( personal opinion)

not reflected by Wolf’s Marketing plan

INTRADISCAL THERAPY

YESS

“Gospel of Yoda using a Starwars Theme”

YESS Technique = “Easy” TechniqueXifeng Zhang, first YESS Chinese spine fellow

Mobile cannulas, direct visualization, local anesthesia

Mobile cannulas

Similar Approach with “outside in” mobile cannulas

• “Novel” targeted “outside in” approach using Joimaxsystem and mobile retractors loosing appeal due to outside large trephines increasing complication rate

• Hoogland converted his original THessys serial dilation and outside trephines for safer inside reaming (Maxmore)

• Targeted decompression and excision techniques developed for trauma, neoplasms, and stenosis

• Journal of Spine

Endoscopic Surgery of the Spine as a Subspecialty for Trained and Experienced Providers

Anthony T Yeung1,2*, Christopher A Yeung

Nima Salari, and Justin Field

Yeung et al., J Spine 2017, 6:5

DOI: 10.4172/2165-7939.1000388

The future will have Multi-disciplinary contributions,

working together rather than as competitors

Trend: “Moving away from Fusion”

• Fusion is not needed if we can treat the cause of pain early

• Natural healing over time will decrease the need for fusion to treat pain

• Fusion will be for deformity or instability

– Endoscopic MIS Fusion and dynamic stabilization is possible

Moving Away from Fusion by Treating the Pain Generator: The Secrets of

an Endoscopic Master

Anthony T. Yeung* Citation: Yeung AT (2015) Moving Away from Fusion by

Treating the Pain Generator: The Secrets of an Endoscopic

Master. J Spine 4: e121.doi:10.4172/2165- 7939.1000e121

Journal of Spine Spine

> 25 publications since 2015

Appropriate adoption and training will be critical

Key Important Factors

• Appropriate Training

• Adopters must perform the procedures “really well”,

and evolve their own learning curve

• Transparent pricing ( cash vs insurance)

• Practice good EBM ( Evidenced based Medicine )

Disc Degeneration, even in asymptomatic patients has a high Risk of eventually developing low back

pain and sciatica in the normal aging process

Little Known or appreciated Premise?

Common Low Back Pain begins in the disc

• Disc Degeneration in asymptomatic patients increases risk of low back pain

– a prospectively assessment of Southern chinese

– Dino Samartzis, HK University faculty

• New technologies being developed with Yeung involvement*

– Disc shunt

– Imaging ( Nocimed)

– Neuromodulation *( invasive and noninvasive )

– Robotics for endoscopic targeting *

Primary Pain Source:

The Disc• Current research and interest should be with

intradiscal therapy– Validated by level I EBM

Chymopapain

• New technologies for nucleus augmentation, biologics is still in its infancy, but promising

Disc Anatomy

80 Percent support

*The demise of chymopapain is a lesson that even level 1 EBM validated studies can fall

victim to over regulation and risk vs profitability over efficacy. Good training also an issue for poorly trained practioners “ruining”or

discrediting the endoscopic procedure

IS OVER REGULATION AND RECENT PHARMA SHORTAGES and COST THE PROBLEM?

• SHORTAGES OF COMMON INEXPENSIVE ENDOSCOPIC SUPPLIES * SINGLE OR MULTI USE

– SALINE

– WATERSOLUABLE COMPOUNDED STERIODS

• Betamethasone

– VITAL DYES

• indigocarmine

• Methylene blue

– NON-IONIC CONTRAST INJECTIONS

• Iso-vue 300

Evidence: Evocative Chromodiscography™Specificity> 99% False Positive< 1% (Yeung)

Supported by review literature: Disagrees with Caragee

Endoscopic Evidence: Toxic Annular Tears Testimony: Wife of Pain Physician on Disc website you and tube videos

www.sciatica.com

Playlists (U tube) www.sciatica.comDocuments case examples with audio-video illustrations

Clinical Rationale of Endoscopic Treatment

• Intradiscal Therapy ( lumbar spine )

– Validated by Level I studies ( chymopapain)

• Foraminal decompression: Foraminal Decompression vs Foraminoplasty

– ENDOSCOPIC EXCISION and neuromodulation of patho-anatomy

• Dorsal rhizotomy

• Hybrid Procedures incorporating all three Therapies

Endoscopic Surgery is the least invasive Surgical Procedure to treat the patho-anatomy of

chronic back pain and sciatica

New Indications are constantly being developed,

aided by new instrumentation and surgical techniques

• Save Fusion for last, avoiding “ burning bridges” for more invasive procedures as a staged procedure

• Fusion continues to flourish as well, with “new” surgical concepts changing every 10 years

• Many patients want to avoid fusion due to a ”bad” result to or to fear of the paradoxical effects of adjacent level deterioration

FUSION

Clinical Research validates Both Clinical Rationale

• The research design focuses on Evidence Based Medicine: EBM allows us to rate clinical data into :

• Levels of Evidence, I-V

• Grades of Recommendation

• Current focus on SCS and DRG neuromodulation

should be for “ true” FBSS causing neuropathy

The Practice of Evidence Based Medicine is the integration of:

–Clinical Expertise ( starting with level V)

–Patient’s personal Needs and Values

–Best Research Evidence

Evidence Based Medicine

• Almost all physicians feel they are already practicing “Evidence –based Medicine”

–Medical Schools teach and use the scientific method

–Many read medical journals appropriate to their practice

Excerpted from presentation by W. Watters, NASS President

Surgical Concepts on Expertise and Education: ( NASS past president W. Watters)

• “What you think you may know may no longer be valid or become disproven over time with future research”

Patient Values are also Important

• Each patient brings a set of personal beliefs and knowledge base to the patient-physician relationship

• Patients rely heavily upon the recommendations of their physician, family, and friends for personal choices

– Different cultures may have varied beliefs based on their cultural biases that will affect their acceptance of recommended treatment

• Physicians offer guidance to their patients for a joint decision on their choice

The Best Research Evidence

–Reduces bias, which is difficult to overcome, but should be acknowledged

–Promotes ethical clinical decision making and Minimizes outside influences

• Journal of Spine

Endoscopic Surgery of the Spine as a Multi-Disciplinary Subspecialty for Appropriately Trained, and Experienced Providers

Anthony T Yeung1,2*, Christopher A Yeung1,

Nima Salari1 and Justin Field1

Yeung et al., J Spine 2017, 6:5

DOI: 10.4172/2165-7939.1000388

In Endoscopic Surgery: Cooperation is neededCross training, communication, shared responsibilities

• Training is different

• Background is different

• Concepts are different

• Experience is Different

Technical abilities

are different, and

disruptive for

colleagues with a different

surgical background

Decision making and surgical skills are both necessary and go together.

Training, knowledge of indications, and competency is critical.

(My Greatest Worry: Endoscopic Technique discredited by poorly trained non – surgeons with

no training in surgical anatomy and concepts)

Endoscopic Surgery Advantages

• The endoscope makes it possible to correlate the patho-physiology of pain of with visualized patho-anatomy. (please refer to DISC website, and click on the top 10 playlists)

• Operating under local anesthesia allows the patient to communicate with the surgeon during surgery

• All discs undergo degradation in a well-described cascade, matched by imaging and patho-anatomy

• Why some patients have intolerable Pain, and others is NOT completely understood by imaging alone

• Facilitated by Diagnostic and therapeutic injections

• Pfirrmann C et al, Spine, Sept 2001.

Degenerative Conditions

of an Aging Disc

SURGICALLY TREAT THE PAIN SOURCEGUIDED BY IMAGING

PAIN GENERATORS IN DDD affect the DRG

DRG

Courtesy of Wolfgang Rauschning

Granulation tissue in the annulus

The Future of Endoscopic Surgery

• Utilized by qualified, adequately trained surgeons and nonsurgeons ( both need training )

• Acceptance will depend on the politics, physician acceptance, and the business of spine in various parts of the world

• Outcome of medical and political turf battles

The Future of Endoscopic Surgery

“Surgery” will not be just for a neurologic deficit, an “abnormal“ imaging study, or last resort” for surgical intervention.

Transforaminal Decompression will be for Surgical

Pain CARE, not just “Management” under local

anesthesia

Video demonstrations of Endoscopic Procedures providing video evidence based

validation appropriate for adequately trained surgeons and non surgeons to be showcased

(www.sciatica.com)

Steady stream of surgeon KOL visitors to my Phoenix surgical facility ( SPSF )

Saiyro

KIM

Yuki

Pt from HK with 5 FBSS surgeries

Experienced KOL’s taking noticeRecent visit by well known experienced Asian spine

Leaders Learning to ”kill” the pain source

Luke KimDr Sairyo

Japanese spine

surgeon

Chinese

surgeon

Endoscopic SED™ for toxic annular tears 1.39

Endoscopic visualization serves as “endoscopic based evidenced”

When correlated with clinical results:ADDING AUDIO FEEDBACK by patient USING LOCAL

ANESTHESIA RE-INFORCES EVIDENCE

• As a surgical tool:

– Discectomy, Nuclectomy

• Decompression

– Intradiscal Therapy

• Decompression

• Thermal annuloplasty

• Disc irrigation

Y.E.S.S™. Multi-Channel flow integrated Spine Scope

How the Endoscope Should be Utilized

For Diagnosis and Treatment:

Identify Painful Patho-anatomy

The YESS scope• Endoscopes have integrated channels that is flow and pressure controlled to provide maximal visualization

• It has irrigation channels that a laser fiber can be inserted down one channel for laser ablation

• 2 mm- 4.2 mm working channel for surgical instruments

Oval (4.5mm) shape for narrow discs

Multiple Endoscope Systems are being marketed

• Other systems are readily Available, with less focus on visualizing intradiscal pathology

• The advantages of the Original YESS oval design still under appreciated as noted by round OEM endoscopes being promoted and marketed that may be simpler to manufacture and use

There are different systems and Techniques by other Masters and KOL’s

• Results may differ with each individual surgeon and their experience.

• Pick the procedures and technique that works best

in your own hands and your surgical ability: “The

Surgeon Factor”

The YESS (RIWO) System

Flexible Riwo Carbide Burr

Specialized cannulas

Trephines and Kerrisons

87Copyright @ HJY-YESS Forward Medical Group

镜子规格：20°工作通道：2.7mm总长度：205mm

The only endoscope with a

Multichannel “flow integrated”

system. With a laser channel

Pressure and flow control fluid

pump facilitates visualization.

2 Different Techniques (courtesy Luke Kim

Inside Out TechniqueSAFEST Due to

Outside In TechniqueSERIAL DILATION

Hoogland design changeDIRECT VISUALIZATION

MaxMoreJoimax

The Best Designed Endoscope= YESS Scope

INTRADISCAL THERAPY

YESS

“Gospel according to Yoda”

80 watt LaserDouble Pulse

Laser is a valuable surgical

Tool that facilitates

endoscopic surgery

Accur-e-techValuable Essential Tools

Side firing laser VaporMAX100dpl

• 4mm Working Channel Foraminal scope can accommodate for more aggressive bone removal

• Standard 350 micron fiber

Side firing tips discectomy annulus in Spine Surgery

Laser can dissect scar from nerve

• 550 laser tip dissecting scar from nerve

Side firing tips ablating bone

• 350 micron Side firing laser

• Ablates facet capsule to expose bone for mechanical decompression

Laser foraminoplasty

Mechanical Foraminoplasty for endoscopic fusion

Bonovo’s OLLIF, Flare hawk expandable cage

Elliquence Bipolar Radiofrequency

Disc Fx System for Surgical Pain Management

Disc FX SystemSurgimax Console

Wolf now has their own system

YESS Rhizotomy Set by Wolf

for axial back pain

Beveled cannula provides

surgical portal to facet joint

Beveled Distal End Cannula

Provides Surgical window

Rhizotomy Scope

RhizotomyTechnique

Ablate MB at transverse process

LB/DR

Needle Placement Wiltse Plane

Isovue 300 + 10% indigocarmineLook for lateral branch

MB

TP

Cadaver Dissection: Branches of the Dorsal Ramus may vary in

location

L2 L3 L4

TP

TP TP

MB

MB protected by osseous tunnel

(Dissection Yinggang Zheng, M.D.)

An endoscope is needed

The Endoscope is designed to Identify painful patho-

anatomy intradiscally and trans- foraminally in vivo

for Endoscopic Treatment in the Lumbar Spine

Yeung, AT., Gore S., “In-vivo visualization of patho-anatomy in painful

degenerative conditions of the lumbar spine II”

Surgical Technology International XXI, 2012)

Validated by surgery with the patient under local anesthesia

With or Without sedation

Meticulous Cadaver Dissections have aided the understanding and development of Endoscopic

surgery

>35 Publications Since 2015

• Moving Away from Fusion by Treating the Pain

Generator: The Secrets of an Endoscopic Master

Anthony T. Yeung

Journal of Spine Dec 2015

Concept Papers in Open Access Journals 2016On my website www.sciatica.com

My Technique Publications 2016:

Multiple Publications In 2017-2018

• Robotics for endoscopic Spine

• SED™ in Athletes

• Treating the Pain Generator

• 25 year experience in endoscopic surgery

• State of the Art in Endoscopic surgery

• Failed back Surgery

• PELD in China

A rapidly growing number of U.S. Asian Korean, Japanese Chinese, Taiwanese, and Indian Spine Surgeons are adding to the published literature

• My 25 years experience with Endoscopic Transforaminal Spine Surgery: It’s Evolution, The Painful Conditions Treated, Results, Personal Thoughts, and a Review of the Evolving Literature

Editor –in –Chief : and Editorial Boards

Journal of Spine & NeurosurgeryJournal of Neuropathology

ConTROL Journal

Yeung”s contribution

Transforaminal and Translaminar Endoscopic MIS vs Pain Management

• Formal training rare / mentorship desired

• Not universally taught in Spine or Pain Programs

• Pain specialists are trained and think differently

The future will not be for everyone !

• Go slow and Decide to specialize in Endoscopic spine surgery

• Learning curve is long and steep

• The future will require competency and specialization for endoscopic surgery to prosper

French Montparnasse station(courtesy Boyle Cheng)

Current and Future Developments:Payers should accept and re-imburse validated endoscopic procedures performed as a hybrid

procedure as cost effective

If not, some patients may be willing to pay CASH for “warranteed” results

Neuromodulation for salvage options in unrelenting debilitating (NANS)

(ie Stimwave)

*Yeung’s Method Patent vs SCSneuromodulation of the DRG

HJY/YESS Centers in China with with new Innovations

• New automated tools (surgifile) (automated burrs)

– Flexible shaver under development by Bonovo for rapid and through discectomy

• Other YESS tools being developed for Chinese domestic use

• YESS Artificial Intelligence incorporated in Robotic Systems

ORION Surgical Suite Intra-operative CT Scan Cardan Robot*

Navigation system

Surgical robot

Robotic A.I. for endoscopic spine under development

Treatment OptionsBridging the Gap

Threshold

Conservative

Fusion

Prosthetic Surgery

Interventional Pain Management, Disc

Fx, SCS, Drg neuromodulation

Endoscopic spine surgery:

Surgical Pain Care

Can Interventional Pain Doctors Learn Minimally Invasive Spine

Surgery?

23nd Annual Gabor Racz Advanced Interventional Pain Conference

Budapest, Hungry

August 27, 2018

Answer, YES!.....But Training and certification should be required

• Andrew Roberts, first anesthesia trained endoscopic certified endoscopic traisurgeon at UNM

• Roberts was trained by Gabor Racz, but wanted additional training following a “YESS” workshop

• Deformity and degenerative spine surgeons, D.I.S.C., Phoenix and Sohrab Gollagy are also adopting endoscopic spine techniques to augment their procedures

Andrew Roberts, M.D. Fellowship trained endoscopicspine fellow

• Journal of Spine

Endoscopic Surgery of the Spine as a Multi-

Disciplinary Subspecialty for Appropriately

Trained, and Experienced Providers

Anthony T Yeung1,2*, Christopher A Yeung1, Nima Salari1 and Justin

Field1

Yeung et al., J Spine 2017, 6:5

DOI: 10.4172/2165-7939.1000388

I support Rational Open Techniques Endoscopic Techniques requires training

YESS fellowships and workshops in Phoenix

Thank you

MSGA

Hat courtesy of Morgan Lorio, ISASS coding chair

“Make Spine Great Again”