Back In Action
From Med Update reproduced with permission.
Copyright © 2001 by Lionheart Ventures, L.L.C.
When Shauna Scrivner herniated her disc last summer while training for a tennis tournament in Flagstaff, doctors told her she had torn her hamstring but that it was probably nothing serious.
“I was hitting with a guy who lives near me who has a very strong stroke, says Ms. Scrivner, a 38-year old Emergency Room nurse in Phoenix. “He returned a shot to me that was cross-court to my left and traveling very fast. I over-extended my backhand to hit the ball and felt an immediate surge of pain down my left leg,” she says.
Her pain became constant and unbearable. She would fall into bed after work and began isolating herself from friends and family. Eventually, doctors found she had ruptured (herniated) two disks in her lower back-the lumbar and sacral discs — and had also torn the outer area around them. Worse, one of the ruptured discs was pressing against a spinal nerve—the sciatic—causing her unbearable leg pain.
She knew she needed surgery but she was extremely wary of it – and rightly so. As an emergency room nurse for 15 years, Ms. Scrivner says she treats one or two people a week with failed back surgery “who go from ER to ER” with their medical records in hand, requesting shots of morphine and other narcotics for their pain. She didn’t want to be such a casualty.
After consulting with two other orthopedic spine surgeons—who gave her only a 50 percent chance of recovery—Ms. Scrivner was convinced that her only hope of relieving the pain and reclaiming her normal, healthy lifestyle lay in finding an alternative to conventional treatment. Scouring the internet, she found orthopedic spine surgeon Anthony T. Yeung, M.D., who runs the Arizona Institute for Minimally Invasive Spine Surgery in Phoenix. (www.sciatica.com). Coincidentally, Ms. Scrivner’s first surgeon had completed a residency under doctor Yeung and also recommended that she see him.
Bucking conventional doctrine, Dr. Yeung has spent much of the last decade pioneering a new approach to back injury called minimally invasive or endoscopic spinal surgery: It’s aim is rapid recovery with as little trauma as possible. “Traditional spinal surgery may cause so much damage to the muscles and ligaments and the delicate nerves that if it does not make you better it can make you much worse,” Dr. Yeung says.
The surgeon says his quest to perfect spinal surgery was inspired by the lifetime of pain his mother has had to endure. It happened over 30 years ago, when Dr. Yeung, then an orthopedic resident, recommended she have spinal surgery for a herniated disc. “The surgery damaged her nerve and there was also so much bone removed that not only did the disc collapse but the spine slipped 50 percent,” Dr. Yeung says. “Not a day goes by when she doesn’t have some kind of discomfort.”
Although endoscopic spine surgery may be difficult to master, according to Dr. Yeung, it’s been well worth it. Rather than cutting through muscle and bone to get to the disc, endoscopic surgeons simply make tiny incisions in the patients’ back. An illuminated and magnified endoscope— a camera-like instrument— is inserted into the spine and projects the spinal structures onto a T.V. screen. (The camera is designed to capture an image of all the structures in the spine that a traditional surgeon sees with a microscope, including the herniated disc.) After the herniation is removed, the hole it has caused is closed using a laser or radiofrequency probe. Patients leave the surgical facility the same day, with nothing but a Band-Aid on their backs to show for it. In Ms. Scrivner’s case, she says she was amazed at how much better she felt immediately following Dr. Yeung’s surgery. The pain in her leg was gone. Three months later, she was walking, lifting light weights and swimming four to five miles a week.
While Parviz Kambin, M.D., fathered the concept of endoscopic spinal surgery in 1973, Dr. Yeung has been refining the technique since Dr. Kambin taught it to him in 1991. Dr. Yeung explained that before the 1990’s, the technology to view the spinal structures clearly was not yet in place. Dr. Yeung helped solve this problem by designing an endoscope with three portal holes instead of one so the spine is easier to visualize. It was approved by the FDA in 1998.
“The endoscope I designed and the complimentary instruments that do the repairs were the breakthroughs needed to advance the technique,” he says.
While Dr. Yeung is further refining the mechanics of his procedure, he also is forging a new body of literature. For example, in a study involving his first 500 patients—published by the Mount Sinai Journal of Medicine in September 2000—he reported an 85 to 90 percent recovery rate among his patients. What’s more, 91 percent of these patients said in a questionnaire that they were satisfied they had undergone minimally-invasive surgery and would recommend it to family and friends. (Dr. Yeung is now awaiting publication of two newer studies, one in Spine and the second in Spine Journal, a new publication of the North American Spine Society.) He has performed more than 1300 operations to date and says his success rates are climbing as his technique improves. What’s more, he says he is able to alleviate pain for degenerative conditions that other surgeons say are inoperable.
“Traditional back surgery is in the dark ages,” the pioneering surgeon argues. “Compare it to athroscopic – minimally invasive – knee surgery. Every professional and recreational athlete has come to expect minimally invasive knee surgery. When their knee injury does not heal, a sports medicine specialist can put an endoscope into the knee, find the problem, and trim it up or repair it so it doesn’t get worse”
In sharp contrast, conventional spinal surgeons will only consider performing disc surgery after a herniated disc is pressing on a nerve and is causing debilitating pain, Dr. Yeung says. “If they bothered to learn endoscopy, they could scope the damage and repair it before the condition advanced,” Dr. Yeung says, (especially since he says the complications with minimally invasive surgery are a miniscule 1 percent.) Another advantage to endoscopy is that since patients are awake, they can help identify the origin of their back pain, which some doctors still insist is “all in their heads.” (Patients undergoing conventional surgery are put to sleep during the operation.).
Regrettably, Dr. Yeung says, many surgeons today do not diagnose back pain correctly either: Even the most sophisticated equipment used by mainstream surgeons—the MRI-often misses tears in the discs, according to Dr. Yeung, whereas an endoscope can detect them.
Despite some opposition from the “old-guard,” Dr. Yeung’s crusade to cure back pain is catching on. This month, for instance, 50 orthopedic surgeons from around the world will gather in his operating room to learn his technique.
And, due in no small part to Dr. Yeung’s scathing protests when insurance companies label the surgery “experimental”, many insurers are now agreeing to pay for it. A major victory for Dr. Yeung is Blue Cross/Blue Shield of Arizona’s contract with him to perform the surgery at an agreed-upon price. Other insurers aren’t as progressive. In Ms. Scrivner’s case, two insurance-company physician consultants ruled that her sciatica condition did not require surgery. Dr. Yeung would not back down and a third physician finally approved her claim. Ms. Scrivner says she was very grateful when Dr. Yeung told her he would perform the surgery whether insurance paid for it or not.
To further shield his patients from the medical bureaucracy, Dr.Yeung recently built the Squaw Peak Surgical Facility so he can operate on patients for half of what it would cost them at a nearby hospital.
Minimally invasive spinal surgery is the wave of the future, Dr. Yeung says. Demand for it will increase because the population is aging, and aging— as well as injury— causes spinal abnormalities. He compares the spinal discs to a rubber tire. ” When it ages even the perfect tire may start leaking, the rubber may crack and little tears may develop.” Until endoscopy came along, many patients suffering back pain had little recourse but to “pop Motrin and live with it.” Some went from doctor to doctor because their pain is underestimated and undertreated,” he says. “Now, people are refusing to accept pain that is able to be relieved.”
“Take one of my patients who happens to be a physician,” Dr. Yeung says. “He had terrible bone spurs. His discs were collapsed and bulging. This is considered normal at his age. Many people live with these ailments, because they happen so gradually, the body adjusts.”
“But the doctor was not happy with his life. He had to give up tennis and golf and skiing with his children. He wanted a better quality of life but he did not want surgery. He knew that open back surgery has a 70 to 80 percent success rate. But if it’s not successful, it can make you worse. He decided it was not worth it.”
Then he heard about endoscopy and Dr. Yeung’s surgery. Vive la difference. The doctor is playing tennis—again.
Meanwhile, Dr. Yeung continues to innovate. His new project is an artificial disc, made to support a collapsed disc. And naturally, it will be inserted through an endoscope.
Also joining Dr. Yeung’s specialized spine center in the future will be his son, Christopher. Having finished his orthopedic residency, Christopher Yeung, M.D., will start an orthopedic spine fellowship at The University of Southern California’s Center for Spinal Surgery with Dr. Robert Watkins, an internationally known spine surgeon who has operated on many professional athletes. Afterwards, the junior Dr. Yeung plans to do an extended fellowship with his father before joining his practice.
Dr. Yeung’s daughter, Kim Yeung-Yue, M.D., has accepted a dermatology research fellowship at The University of Texas, Galveston. She is planning to return to Phoenix when she completes her residency.