Minimally Invasive and Maximally Destructive
One of the things that I am increasingly uncomfortable with is the new and manifold ways my colleagues are finding to permanently destroy tissue using minimally invasive procedures. What I mean is that there is a trend to take destructive surgeries and turn them into procedures that can be performed by pain management physicians using imaging guidance. Let’s dig in.
My History with Destructive Procedures
Way back when, some 20 years ago, we used to offer radiofrequency ablation of the facet joints. This is when the doctor burns the nerve that takes the pain signals from the joint. This procedure when performed in the neck could be quite effective in reducing pain for 1-2 years. However, as the years wore on and I had more and more patients who would come in every 1-2 years to get their RFA repeated, these patients got increasingly “brittle” What I mean is that they became worse and worse when their RFA wore off. After years of this, it became clear that I was doing more harm than good, so in 2005 when we began using stem cells to treat patients, I slowly began tapering patients off rFA. By 2010 or so, I had performed my last RFA.
The New Trend of Making Maximally Invasive Procedures Minimally Invasive
Minimally invasive in medicine means that a procedure can be performed by disturbing less tissue. This past decade, we’ve seen many maximally destructive surgical procedures get minimally invasive counterparts. An example is SI joint fusion. Two decades ago this was an open surgical procedure where a big incision was used to insert screws across the SI joint. These days this is a procedure that can be performed with a small incision, a tool, and x-ray guidance. However, while applying the screws has become less invasive, the procedure still destroys the joint. So allowing SI fusion to be performed by an interventional pain physician instead of a surgeon still causes the same bad result.
The Growth of Minimally Invasive End of the Road Procedures
My concern with all of these procedures like percutaneous SI joint fusion and others is that by making permanent tissue destruction widely available, we are hurting more and not fewer patients. Meaning that it used to be only spine surgeons that permanently destroyed tissue. Now we have placed that ability into the hands of armies of interventional pain physicians, expanding the public’s exposure to these destructive procedures.
These are all “end of the road” procedures. What I mean by that is that they are once they’re done, there is no going back. In the case of the SI joint fusion, there is no way to back out those screws and go back to what existed before if the fusion doesn’t help or makes the patient worse. Why? The doctor has drilled large holes in the joint and destroyed the internal joint surfaces. Hence, the joint will quickly become severely arthritic and painful if the screws are removed.
Why Are We Doing This?
Physicians who are adopting these minimally invasive and maximally destructive procedures state that they’re doing this because they want to offer more options to patients. However, in reality, often the real motive is fat procedural fees, surgery center payments, and insurance coverage. Hence, we have an entire field of medicine that is now adopting a bad option for the patient just because it’s covered by insurance. I have blogged previously on this concept.
Why Aren’t We Working Harder to Regenerate Rather than Destroy?
While the easiest way to get the maximum reimbursement from insurance companies is to take surgeries and make them minimally invasive, this is not an elegant way to treat musculoskeletal problems. At best, it’s a bull in the proverbial china shop of our patient’s bodies. We all know, as physicians, that an option that could help regenerate or repair or improve tissue will always be better than one where tissue is destroyed, even if that destruction is minimally invasive. That’s why, at Regenexx, we’ve been working hard to get companies to cover regenerative medicine procedures for our patients.
The upshot? At the end of the day, why are interventional pain doctors adopting minimally invasive and maximally destructive procedures? You really can’t have this one both ways. Either you believe that the best option, and not the best-covered option is what should be offered to your patients, or you don’t.