Anthony Yeung MD began performing endoscopic spine surgery in the early 1990s. He has since built his practice along with partners Christopher Yeung, MD, and Justin Field, MD, Desert Institute for Spine Care, and a freestanding ASC in Phoenix around the technique he developed.
"I did a general orthopedic residency in the early 1970s and realized then that joint arthroscopy and joint replacement would revolutionize the open treatment of joint surgery and eliminate the need for fusion for painful traumatic or infected joint conditions," says Dr. Anthony Yeung. Fusion was the ultimate procedure considered the "gold standard" at the time. "Now, 40 years later, spine endoscopy is also revolutionizing spine surgery by providing patients alternative non-fusion surgery for similar traumatic and painful spinal degenerative conditions as well."
As general orthopedic surgeons embraced joint arthroscopy and joint replacement techniques, spine actually evolved past endoscopy and disc replacement toward fusion for painful spinal conditions. "Surgeons became more attracted to spine fusions partly because new hardware development such as pedicle screws made fusion surgery easier, more effective and faster," he says. "It also brought in other stakeholders such as interventional pain management, physical medicine and psychology/psychiatry into the treatment team."
According to Dr. Yeung, spine surgeons are shifting toward minimally invasive fusion procedures and a growing number of motion preservation techniques, driven by patient demand and a growing aversion to traditional spine fusion partly because of it's cost and post surgical morbidity. More surgeons are taking time away from their current busy practices to train with Dr. Yeung on his endoscopic techniques so they can build their own successful practice. Dr. Yeung discusses his endoscopic surgical technique and philosophy and how he overcame multiple obstacles to build a very successful minimally invasive spine practice focused on treating the patho-anatomy and pain generator.
Dr. Yeung's technique
Dr. Yeung developed his technique over a 20 year span, and has become such an expert on it that he subspecializes in endoscopic transforaminal spine surgery and he stands behind his results. Dr. Yeung carefully selects patients who will benefit from this type of procedure, aided by performing his own diagnostic and therapeutic injections. Using his injection techniques, he can get a strong indication on the outcome of his surgical procedures and improve his patient selection.
He enters the spine through the foramen with a needle directly identifying the pain source, which allows him to then direct a dilator down the needle path, followed by a cannula and an endoscope to provide visualization of the patho-anatomy and surgical site. Many surgeons are reluctant to enter the spine through the foramen because they are not trained for that approach or are not familiar with it. Dr. Yeung uses the approach for spinal decompression, ablation and irrigation of the source of pain. He uses a bipolar radiofrequency probe to modulate tissue and to stop bleeding, which allows him to use his specially designed spine endoscope to see clearly.
He does not injure normal muscle with this approach and does not destabilize the spine when he decompresses nerves. If the procedure does not provide the pain relief needed, it does not "burn any bridges" for a more traditional procedure. The patients are fully informed about their alternatives. Once fully informed, they will make a joint informed decision with Dr. Yeung.
The technique has evolved over the past 20 years, and has become his surgical philosophy of treating the pain generator rather than the X-ray. "I do my own diagnostic and therapeutic injections, pain management, disc and bone decompression, and stabilization," says Dr. Yeung. "In the transforaminal approach, I dilate the tissue plane between the longissmus and psoas muscle to gain access to the spine through the foramen."
When there are multiple surgical or non-surgical options, Dr. Yeung advises each patient with a personally designed program for each individual patient, offering the least invasive procedure first, when appropriate, and moving forward later with additional treatment steps if necessary. "My first goal in treating discogenic pain, disc protrusion or disc herniation pain is to expose the annular tear, remove the herniation and free up the spinal nerve. I then ablate and irrigate the inflammatory source of pain," he says. "I do the least invasive procedure first. If I need to do a fusion for instability or deformity, I will either do it myself or refer the patient to my partners at DISC, Christopher Yeung, MD, or Justin Field, MD. Although traditional medicine recommends fusion first, my patients benefit by also having this less invasive surgical alternative."
Transitioning from the hospital to independent private practice
When Dr. Yeung finished his training, he joined a large orthopedic group and performed his surgical cases at a hospital. During that period, he evolved his spine techniques in an effort to avoid fusion except for deformity or instability. He embraced chymopapain and arthroscopic microdiscectomy. He then learned to use lasers under endoscopic visualization in the spine to augment his endoscopic spine technique. The results were so positive that patients began flooding the hospital from all over the state. The hospital also promoted him because of this success.
"This was in the early 1990s and I was not encumbered by being broadly rather than narrowly trained. In fact, I was one of the first in my area to use percutaneous techniques and lasers in the spine," says Dr. Yeung. Higher patient satisfaction and solid results continued with this new technique.
"In 1997, I decided to further validate my technique with an IRB-approved study from St. Luke's Medical Center for a temperature controlled flexible probe by Oratec as a surgical tool for the transforaminal endoscopic approach to painful conditions of the lumbar spine," says Dr. Yeung. "In my first 50 patients, I had a 90 percent success rate. The thermal probe did not control the temperature consistently so I then switched to the bipolar radiofrequency probe."
With the surgical success rate again proven in this study, the evidence spoke for itself and Dr. Yeung was ready to make his move.
Building a surgery center
After leaving his large orthopedic group practice and the hospital setting, Dr. Yeung needed a place to perform his surgeries so he decided to build an office and surgery center on his own in 1998. He calculated that if he performed the same volume of surgeries per month that was treatable in an outpatient setting, he would be able to operate the surgery center profitably.
Dr. Yeung set up a database on his patients, incorporating pre and post-op modified MacNab criteria, SF -12, VAS and Oswestry information in the medical record. He filmed and photographed each procedure he performed, using unedited surgical videos to document the surgical process that helped evolve his technique. By visualizing the patho-anatomy and studying not only surgical successes, but carefully reviewing the causes of surgical failures, he now has visual evidence of thousands of cases to support the indications and rationale of his procedure.
Practicing surgery-based medicine
Payors and government regulators are pushing for physicians to practice evidence-based medicine in all specialties, but spine surgeons know the special challenges in gathering this type of evidence and following such a strict protocol. "It's very difficult for spine surgeons to perform a double-blind randomized study because they have to use a sham procedure, which may not be good for the patients, and no patient will agree to be the sham control. Almost no accepted surgical procedures are validated by level one evidenced based medicine", says Dr. Yeung.
There are several hurdles to proving a technique works in the literature, and even with studies supporting it, payors only have to use their own internal criteria to deny payment. "I have a cynical view of a strict dependence on studies for payment," says Dr. Yeung. "You can find evidence in the literature to support or reject almost every procedure. You can insist on level one studies, which current procedures all lack. I'd rather go to a surgeon with 20 years experience who has success and skill in a procedure, backed by surgical evidence, than rely on biased personal opinions by someone who is not familiar with the procedure."
There is no literature on Dr. Yeung's endoscopic technique that refutes his procedure. There are many patients who see this logic and choose to undergo the procedure, even if their insurance company doesn't cover it. Dr. Yeung accepts cash-pay patients and stands behind his results.
Dr. Yeung says, "I let the patient know that I anticipate they will get better, maybe not to the highest level of functionality, but better than they were before surgery." With well over 75 publications — he has published dozens of articles and book chapters — in prestigious journals, and he continues to write additional articles based on his success rate for submission in the peer review literature.
Differentiating your spine practice
Dr. Yeung was able to differentiate himself from other spine surgeons because his procedure is so unique, but it takes dedication to excellence and practice to refine this surgical procedure. Currently he trains other surgeons from around the country and around the world. There are some spine surgeons who have taken sabbaticals from their clinics to work with Dr. Yeung, and only experience will help them refine the technique.
"Now with so much demand, I can't train everyone who comes to see me," he says. "Those who really distinguish themselves in their practice are the ones who also have patients willing to go to them. Prominent opinion leaders, such as spine surgeon Hansen Yuan, MD, professor emeritus of Spine at SUNY Syracuse and past president of NASS and ISASS, have realized the value of this approach and have been proactive in supporting it."
Third-world countries are also interested in Dr. Yeung's procedure because it's more economical; providers don't have to pay for the same expensive hardware they would need for other procedures, but they have to realize that the surgical equipment is expensive since many items are disposable. Dr. Yeung is also seeing an increased interest from Central and South America, India, and China. He says, "I run my practice based on my success rate and it is wonderful to see the attention it has gained around the globe."
Dr. Yeung says, "This should get the attention of payors and regulators because it saves money while providing patients with solid surgical outcomes they desire to reduce their pain. In the end, that allows patients to get back to their families, work, and active lifestyle which is what drives me to look for the least invasive surgical options for my patients."
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