Laser vs. Ultrasonic vs. Endoscopic: What is the difference?

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Few things are more painful than the back and leg pain that comes from a herniated disc. The burning pain, also known as sciatica, results in missed work, doctor visits, and sometimes a trip to the emergency room. What happens when therapy, injections, and medications are no longer effective?

Minimally invasive spinal surgery has come a long way in the past decade.  Suggested alternatives to traditional spine surgery include: laser spine surgery, ultrasonic spine surgery, and now endoscopic spine surgery.  These terms sound similar, so what is the difference? Are these terms referring to devices/instruments or to actual surgical procedures? Which of these uses the smallest incision? What does a laser or ultrasound even do?

Q: What is endoscopic spine surgery?

Answer: Dr. Zahir: In brief, endoscopic spine surgery is a procedure performed through a small scope or camera. It is a thin tube, with a camera at the tip. Through this thin tube we can pass instruments and perform surgery. For example, many of us are familiar with arthroscopic knee surgery. With knee arthroscopy, the surgeon makes a small incision (less than 1 cm) and places a scope into the knee to remove bone spurs, shave a torn meniscus, or repair an ACL. We are now using similar devices in the spine. With endoscopic spine surgery: we can remove bone spurs, open up nerves, and remove disc herniations all through an incision smaller than a dime.

Q: Is an endoscope the same as a microscope?

Answer: Dr. Zahir: An endoscope is not the same as a microscope. Most minimally invasive surgeries today will use a microscope. With a microscope, the surgeon looks through two eyepieces (similar to binoculars) and will perform the surgery with the view magnified. With a microscope, the surgeon still needs to make an incision large enough to place retractors to open the spine. Endoscopy is different because the surgeon is only inserting a thin tube into the spine. This is why spinal endoscopy results in smaller incisions than surgeries that use a microscope.

Q: What is the difference between endoscopic, laser, and ultrasonic spine surgery?

Answer: Dr. Zahir: This is a common question that I get asked in the office. The difference is in the incision size and the approach.  People have this misconception that with laser or ultrasonic spine surgery, the surgeon just presses a button and “zap” the disc herniation is gone without an incision. It doesn’t work that way. Laser and ultrasonic surgeries use devices that emit laser or ultrasonic waves to remove bone or tissue, but these are surgical tools and not surgical approaches. Endoscopic surgery is the only procedure that uses a small scope/camera that is inserted into the spine. An endoscope uses a cannula (a thin straw-like tube), while most laser and reported ultrasonic procedures will use a microscope and a retractor/tubular system that is often three to four times larger than the size of an endoscopic cannula. This is a critical difference. Endoscopic spine surgery in summary: smaller incision, less bleeding and muscle damage, uses a cannula/thin tube, no retractor, and no microscope.

Q: When did you get interested in endoscopic spine surgery?

Answer: Dr. Zahir: My interest in endoscopics began in 2012. I saw many patients who wanted to avoid spinal fusions, but who had conditions that were difficult to treat without a fusion. I was fascinated by what surgeons were accomplishing in Europe and Asia using endoscopic technology and I reviewed techniques with surgeons from around the world. This interest eventually led me to start offering the procedure in 2017. For many of my patients we were able to avoid a fusion by using an endoscopic approach.

Q: If someone is considering endoscopic spine surgery, what should they ask during their visit?

Answer: Dr. Zahir: I have seen several patients who said they saw specialists that advertised endoscopic spine surgery, but when it came time for the appointment they realized that the procedure was not performed by the surgeon. It is important for patients to ask questions during their visits: ask to see the endoscope, ask to review the steps. If a microscope is being used, it is not endoscopic spine surgery. There is also a learning curve involved with the procedure and patients should ask how many of these procedures the surgeon has performed.

Q: If someone is interested in learning more about endoscopic spine surgery, where can they learn more about the procedure?

Answer: Dr. Zahir: I encourage patients to do their own research. Another way is to make an appointment with an endoscopic spinal surgeon. Many patients come in for second opinions or to learn more about the procedure. In our current healthcare environment of quick 10 minute office visits, many patients feel rushed and feel they can’t get a comprehensive evaluation or enough time to ask questions. My practice follows a patient centered approach: my new patient visits last between 45 minutes to 1 hour. My goal is to make sure that the appointment is worth their time. Every patient gets a thorough assessment directly by me, there are no intermediaries. Furthermore, I have a responsibility to be an effective educator and a patient advocate as well – ensuring all conservative treatments have been tried first. Some patients are not good candidates for endoscopic spine surgery and so my goal is to help patients review all the available options and come up with a treatment plan that is best for them. My practice is in-network with most private insurances, Medicare, and Medicaid

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