Chapters Transcript Video How biportal endoscopic spine surgery is changing the present and future of outpatient spine care So I did the very first uh endoscopic lumbar fusion using the Apple Vision Pro in the world. Um, and so, that was from beginning to the end of the surgery. Not like I put it on real quick and then took it off, but from the beginning of the surgery, and I recorded it from the beginning to the end, where, you know, we were using the Apple Vision Pro and you can see from my perspective, virtually what I see, basically. Um, and it was, it was a huge advancement in terms of, I think, visualization, because I can now visualize, instead of this 20-inch monitor that's on the, in the OR that's hanging from, you know, physically in the OR, I have this virtual screen that's 100 inches, that's 4K right in front of me. And so I can see the anatomy so clearly, and it's huge. Uh, the nerve roots are huge, the, the, the spinal anatomy, it's just right in front of my eyes. Hi, I'm Lindsay Carrillo, director of business development at UCI Health. Hi, I'm Sunil Verma, Associate Chief Medical Officer for ambulatory. I'm also a laryngologist here at UCI. Welcome to Physician Huddle by UCI Health. So today we're joined by Doctor Don Park, professor here at UCI Health and Orthopedic Surgery, as well as the director of minimally invasive spine surgery. Welcome, Doctor Park. Thank you. Thank you very much for having me. So, Doctor Park, take us through your journey, then what brought you here to UCI Health? Actually, the new Irvine Medical Campus was the uh uh big impetus for me to come to UCI Health. Um, the, the UCIA leadership, uh, including my chair, uh, Nin Bhatia, had, uh, uh, recruited me to come to UCI and they were during that recruitment trip, showed me. Kind of the, uh, the campus before it was really built and so, you know, they showed me their vision of what they wanted in that campus and I thought it aligned well with what I envisioned in terms of the endoscopic program that I wanted to develop at UCI and so, uh, that's um, that's the big reason why I came, uh, is that I thought that the two camp, the, the Irvine campus and the endoscopic program could marry well together. In terms of, you know, the state of the art, high tech, delivering the best and the, the greatest and best, uh, uh, care possible in terms of spine surgery, and that's where I thought, you know, it would be a great marriage and, uh, in terms of those two ideas coming together, and I, I then, uh, decided to come down to UCI. So tell us a little bit about endoscopic spine surgery and what that means. Sure, endoscopic spine surgery is when you take a, a high-powered camera, uh, usually now 4K camera, and This is, it's a similar concept as arthroscopy. So, you know, we've been doing arthroscopy and orthopedics for a long time, putting it in joints, putting it in, in the shoulder, the knee, the hip, the thumb. We can put it into all sorts of different places now, and now, we can put it into the spine. And so we can make millimeter incisions, so 4 or 5 millimeter incisions. The camera and about its 8 millimeter incision for the surgical instruments. Um, and that's what's called biportal endoscopic surgery. Um, and so unioral is when you make one incision, you have one camera that then also has a port for the instruments all in one. And so there's two different forms and I practice both here at UCI. Um, for different reasons. So, uh, use, uh, the unioral technique is really great for discectomies, for lumbar disc herniations that, uh, uh, are, you know, easily, uh, identifiable and, uh, uh, attainable, reachable, so that you can remove them to take the pressure off, uh, uh, the nerves that are causing radiculopathy. Um, and then biportal is actually great for more complex pathology. Uh, such as lumbar stenosis, even severe critical lumbar stenosis that develops over time with older folks. Uh, it's a very common problem that a lot of patients have, uh. And you know, you can address that just like you would with the same kind of results as open surgery, except now with tiny incisions. And these patients are able to wake up right away with no pain. They're able to walk right away, they're able to recover fast. And so there's a lot of benefits and it's, you know, uh, really uh shown throughout the literature to be quite effective in that way in terms of reducing pain significantly. Uh, making the, the recovery fast, making it so that we can do an outpatient surgery. Um, before I came here, uh, you know, most, most of the spine surgeries were done inpatient. And so I developed the, uh, endoscopic and outpatient spine program here at Irvine. And I wanted to shift a lot of the surgeries that we were doing in this hospital and as an inpatient. And, and take it to the surgery center. And that's when the Chow Center, the ASC that opened in the Irvine Medical Campus, uh, when that uh was uh finally opened, we were able to then really shift a lot of those uh pathologies, those cases to the outpatient setting. Can I ask why the lag? So minimally invasive surgery is not new, been around for a long time. So why is spine taken so long to reach this threshold? Well, minimally invasive spine surgery has been around for a long time. I learned it when I was a resident as a fellow, uh, you know, 1415 years ago. And so that's something that's been around, but it's slow to adopt because it's just not that, um. Well trained in fellowship residency programs, uh, and then if the residents and fellows aren't seeing it, then they're not gonna be looking for it. They're not gonna be trying it because then they're going to have to learn it in practice, and that's hard, and that's where there's a big learning curve for anything that you learn outside of your training program, right? And so that's where, uh, in, in minimally invasive spine surgery, it hasn't really been adopted well and endoscopic spine surgery, which is even newer. A subset of minimally invasive uh spine surgery, uh, the adoption has been quite, uh, slow. And that's because of the learning curve. When you're, when you take that learning curve during practice, it's difficult. It's a steep learning curve. You have to You know, do new things with patients that you haven't done before. So, that's scary, that's daunting. So you're not gonna be just trying that out unless you do, uh, uh, you know, your own training. You know, you go to labs, you do, uh, hands-on training, you watch surgeons, and that's what I did for 3 years, learning this. You know, from, I first learned about it in 2017 in terms of endoscopic spine surgery, and then it took me 3 years to finally do it. And uh I took a trip to go to Korea. When during COVID cause they had nothing else to do. So, uh, I went there, learned, they just, you know, they, we were doing endoscopic surgery for 10 years before that. And so then they got all the answers. They were able to really develop and hone safe practices, get protocols down, and say, if you do this, you will be safe, you'll be reproducible, you're able to accomplish the surgery. And now it's not just discectomies, it's stenosis, it's spondylolisthesis, it's, you know, fusions, it's cervical, thoracic. And so, But when I saw that, I was like, wow, it's not just this little tiny subset of uh pathology and patients that I can help with this, which I thought that was my initial impression when I first learned about it. It's actually, I can treat most common pathologies that you see every day in clinic and that you take care of in surgery uh with this endoscopic technique. And so that's where for me, um, I said, oh wow, OK, now I know I have the answers. Then I came home, came to the US, and started doing it. And so, uh, and then it's been accelerating since then. So we have a lot of spine surgeons here. You, you know, you're an addition. So how did as a system. Do you figure out a way to offer this technology to patients recognizing that you're one of the few people that do endoscopic spine surgery here? I mean, I don't think your mission here was to come and make everybody an endoscopic spine surgeon. So there still are traditional spine surgeons here. So how does a patient navigate through this system to end up with the right doctor using the right technology, right? A lot of patients are very savvy, especially in Orange County, and so they are looking for it, and I see the 4th and 5th opinion. On surgery and they're, they've been given like, oh you can do it this way, that way, you know, and, and so, uh, it is difficult sometimes to really kind of uh get the right answer sometimes with patients from, from the patient perspective. And so a lot of times patients will come to me, not just, you know, from the outside, but, uh, you know, of UCI but inside too with uh my colleagues cause they know what I do and so they're like, well, maybe this is better for you and so we're quite collaborative that way. And we're able to really say, you know, maybe endoscopic surgery would be a right answer. The patients are looking for it too. They're like, well, do you do that? And they're like, no, but we have someone who can do it for you. So then they'll refer it to me and vice versa. I'm like, I don't think you're a candidate. I wish I could do this surgery for you because, you know, I'd love to be able to apply endoscopic surgery to everything, but I can't. There are certain things like deformities that just need to be taken care of with open surgery, traditional techniques. And so then I refer those patients to my Colleagues who then do them on a day to day basis. Cause what I do, uh, when I was recruited here, it's like, OK, I only wanna do endoscopic spine surgery and outpatient spine surgery, so I really wanna make that my practice as my focus in terms of clinical care but also research and education. And so, you know, I'm just focused on endoscopic and outpatient spine surgery. So, things that are beyond that, um, you know, I used to do, but now it's, uh, I'm able to then, you know, have my colleagues take care of those patients, you know, and, you know, so they get the appropriate care, you know, because it's not, and a lot of patients come and they say, oh well, you know, Uh, I want that, you know, endoscopic technique because you can't do that, uh, with every single case. Um, there's a lot of pathology you can take care of, but there's certain things that, you know, require just traditional surgery. And what's been the response? I mean, you just touched upon. Apart from delivering clinical care, the missions of education and research, what's been the response of learners here to having a full-time endo endoscopic spine surgeon? What, what, what have the residents and fellows said to you, or, or what do they think of the cases you're doing, cause the way you sort of were illustrating it, maybe it was a black box for them before. Mhm. Yes, it was definitely a black box, and, uh, their minds are blown. Their eyes are open, and they're just like, wow, you can do it this way. Um, you know, and because I have, um, the monitors, the OR monitors, they're showing the endoscopic video, it's in 4K and so they can see what I see. And that's actually, you know, the whole staff in the OR can see what I see. So sometimes I'll see anesthesiologists, they'll look over and, and they'll watch surgery as it's happening and that's the, the, the OR staff, you know, and they're involved with the surgery. They're like, oh they know the next instrument that I want based on what they're seeing, you know, and so the residents. And fellows too. They're really engaged with this. We went from, you know, like a small uh fellowship of one fellow to now 3 fellows. We've now matched successfully, uh, you know, our top choices because of this, because now, you know, in, uh, the, the, like the applicants are, uh, uh excited about endoscopic spine surgery, so they are seeking this out and there's Maybe a handful of fellowships throughout the country who are offering endoscopic surgery, deformity surgery, trauma, tumor, the whole nine. It's like very well rounded, plus, plus here is a multidisciplinary fellowship too, right? So they're not just working with orthopedic surgeons, they're also working with neurosurgeons and then all the other members of the team as well. So I think that adds out, I would imagine adds out, uh, a lot rather to the training. Oh definitely, yeah, I think that's one of the, the huge strengths of UCI, uh, spine center is that we have neurosurgery and orthopedic surgery working seamlessly. Like we really don't, you know, interact any differently than if we were in the same department, you know, we look at each other the same. Uh, like, uh, we have rotations for the fellows, and so the rotation for, for me right now is me and Doctor Michael Oh, who is a neurosurgeon, and so, you know, it's like then they get that combined, you know, uh, experience, uh, they can see, OK, this is how you do endoscopically, this is how you do it open, or even other minimally invasive techniques, and so it really, uh, it's a well-rounded experience and education for the, the fellows and the trainees. Well, and I think obviously, you have this drive and you want to learn new things and challenge yourself, but you're breaking ground in other ways, and I imagine you're starting to get a reputation. So to that end, tell us a little bit about the Apple Vision Pro because I know you did something really unique there and I'm guessing a lot of people are starting to pay attention to that like future residents and fellows who are like, I wanna go there, right, right, yeah, so I did the very first, uh, endoscopic lumbar fusion using the Apple Vision Pro in the world. Um, and so, that was, uh, from beginning to the end of the surgery. Not like I put it on real quick and then took it off, but from the beginning of the surgery, and I recorded it from the beginning to the end, where, you know, we were using the Apple Vision Pro and you can see from my perspective, virtually what I see, basically. Um, and it was, it was a huge advancement in terms of, I think, visualization, because I can now visualize, instead of this 20-inch monitor that's on the, in the OR that's hanging from, you know, physically in the OR, I have this virtual screen that's 100 inches. That's 4K right in front of me. And so I can see the anatomy so clearly and it's huge. Uh, the nerve roots are huge. The, the, the spinal anatomy is just right in front of my eyes. I can, you know, at the time I could also put the, uh, the packs, you know, and the imaging virtually right there in the EMR right there. So if I wanted to look at, you know, all other information, I have it virtually set within my headset so I can see it within my. Within, uh, I have everything in my fingertips basically. And so I published the, uh, case report on that and then, uh, now we're, we have a series that we're gonna be publishing on, on how we've been using the Apple Vision Pro, how it reduces workload for the surgeon. So it's ergonomically better because I'm, I can set the monitor basically wherever I want virtually, um, yeah, and you know, after a while you just don't really pay attention to the, the weight of it. It's not that heavy. Um, and, and after you get used to it, and so for me there's a lot of advantages, you know, and, um, so, uh, trainees are just like blown away. They're like, wow, you're doing that, you can do that too, and, um, pretty soon we're gonna, you know, I have, uh, research funding for this, and so I, I'm getting another Apple Vision Pro for them so they can see, you know, uh, what I see, you know, we can do it together. We can have, uh, virtual, you know, reality surgery together kind of thing. Uh, simultaneously, so I think that's something that's gonna be quite interesting and, um, so a lot of, uh, yeah, trainees are just like blown away by this. They're like, wow, you're doing things that, you know, not a lot of people do around the country or even in the world, so, um, that really draws a lot of talent, I think, uh, a lot of interest, um, that, you know, to UCI. So how about, how do you answer the patient that says Jeez, spine surgery is already, you know, in such demand and there's so much technology, so you must, folks like you must be getting knocked on the door by industry all the time. Try this tool out, try this tool out. But then if I'm a patient, I'm also thinking I don't need you to experiment on me, right? Like I need you to do something you've done 4 times before and also how do you like set up that barrier, that shield that says I don't need to try every single tool out, which, how do you vet all this, right? Because you could spend your whole life doing one-offs and writing what individual case reports, um, that can't be all that satisfying. So what do you use to judge what's a good tool and, and, and what isn't? I think a tool has to make me better. It has to make the surgery better, more efficient, safer. I think those are the things, the criteria that I use to say, am I gonna use this tool or not? And so I'm vetting that all the time. So yes, I get, you know, uh, companies that say, I'll use this, and it's like, well, how does this make me better? How does it make me do the surgery better, uh, more effectively and safer for the, for the patient? And so, um, you know, say the Apple Vision Pro, that's something that Apple didn't, you know, come to me and say he use this for surgery, it's more that I was like, I wonder if this could make me better because I can see so much better. I can have, you know, I'm just like, uh, in the OR I'd always be, before I use the Apple Vision Pro, I'd have to step away from the patient, go to the, the, the monitor that had the packs, you know. Uh, have somebody scroll through it for you, yeah, because I'm scrubbed in. I know we've been there, yeah, yeah, and so, you know, I was like, oh, that's so annoying. Well, how about have it virtually there, and then I could, you know, ask Siri to, you know, bring this up or, you know, move this up or down, or I could do it with my gestures and things like that, and I was like, oh well, why don't we try that? And I was, you know, when I first, uh, started doing it, I always consent to the patient. I still do consent the patient for it, but Uh, I would tell them, well, you know, that the, if there's any failure of the technology, well, I just take it off and I just use what I have still there. It's all working in the OR anyway in terms of the OR monitor, the fax machine. It's all there. It's just now I'm doing it with this headset on my head, and then patients are like, OK, like there's no downside really. There's no risk to the patient. Um, other than, you know, uh, if it doesn't work, I just take it off and I just use what the normal, uh, techniques and the technology would be. Um, but then there's other things like, uh, you know, bone graft material and implants and things like that or, you know, disc replacements. There's all these different various companies that have similar things. So how do I, you know, uh, kind of tease them all apart. It's just more, you know, like Is there something about that product that makes this surgery better that puts that pushes it forward, not not the same thing over and over again or, you know, cause they all look the same. Are they all doing the same thing? And if it is, then it's like, oh, I don't need that. I need something that will help me because I, I really think that the, the best surgeons are the ones that know that understand how to say no more than saying yes. I think if, if surgeon is always saying yes to the newest technology and just always trying it. That I don't, I think what we really have to rely on is that we all, we will not always be first to market, you know, you have to trust that other surgeons in the area, in our field will be able to vet it, and then also vet it with just, I think, healthy skepticism as well. Um, and, and, and I think oftentimes people, there's a suspicion of academic surgeons because we are too potentially biased towards new technology. Um, and so I'm sure you face that at meetings and you face that in conversation as well. For endoscopic surgery, especially, you know, so it took me 3 years to actually do it though, you know, and during those 3 years and in the very beginning I was very skeptical. It's like show me the data. What's the research, you know, like is this safe to do? What are the complication rates, you know, um, those are things that I'm always asking, you know, with any new technique or anything, and I don't adopt it quickly. I just happened to be the first adopter of this in the US when it wasn't really adopted at all, but I, because I heard about it so early and so, but I just kept on asking. And I would stand at the podium or, you know, stand at the microphone when they're giving presentations at, at conferences. Well, what about dural tears? What about hematoma? Like what do you do with that? How do you prevent that, you know? And so they would, you know, try to answer and, you know, the best they could, and then the papers would start coming out and so you read the papers and so you're accumulating this knowledge and at a certain point I said, OK, OK, this has, this is safe. So then is it, you know, reproducible? Is it something that I can then Uh, apply easily. Is it something that will make me better? If it's harder, it takes longer. If it's, you know, uh, equivocal results, then why, why, why do that? So that's where I'm always asking those questions. Talk to us about the future of spine surgery because you know it seems like you're really scanning and looking for what's coming next. Like what are you excited about or what are you starting to hear about that maybe you think will be adopted in the next few years? Well, definitely there's a lot of talk about AI, you know, AI and spine surgery, um. You know, there's talk about using AI to help, you know, with, uh, you know, indications for surgery, selecting patients, you know, who are the, the proper, uh, patients to have surgery, you know, to, you know, as they go through thousands or millions of patients, you know, and, and get that data. But also intraoperatively too. So, you know, can we develop AI protocols or programs that help us to understand, well, what is the next best step of surgery that is the safest and most effective way of doing the surgery. You know, and so, um, you know, I think that's where AI could help us. Um, right, right now, they're developed, we're developing ways to endoscopically see through bleeding. And so you know when, when things bleed in surgery endoscopically, everything turns red. You can't see anything. And so then it's like, OK, where is that bleeding source and can AI help us identify that based on where things started, uh, and say if we haven't really shifted our viewpoint, all we did was all of a sudden things got red. Can it identify where that is relative to say something important like a nerve root, right, like, a, a nervous structure. And be safe about it because if you can't see then you know how are you going to cauterize it, you know, without injuring a nerve and those are the kind of things that I think, you know, we, uh really use visualization for in terms of, you know, our human eyes to visualize where the, the source of bleeding is so we can cauterize and stop it. But can AI help us with that? So it sounds like it's not a, a replacement, but more an adjunct, right, to, to what you're doing. I believe that that's how I think AI is gonna be from, in my perspective. And I have a very optimistic outlook on AI and robotics, uh, in the surgery and spine surgery. Uh, I don't see it replacing us, you know, it, it helps us in ways to, uh, make us better, to make us more efficient, make us safer. I think that's where AI really should come in, not to replace the surgeon. Um, you know, to help us to understand who are the right patients to have surgery, what's the probability of success, you know, uh, what's the probability of failure? Should we be doing this at all, you know, uh, those kind of things are, are, I think we, we use experience, our clinical experience, or, you know, a number of years in practice and our successes, our failures. To guide us in that decision making, right, our clinical decision making in the clinic, uh, preoperatively, intraoperatively, but then can AI with say millions of moves tell us these things, and we don't have to. Uh, follow what AI tells us, but say like it says, well, if this, if you do this next, if you take this instrument and put it here and do this, then you're actually going to be able to accomplish what you want to accomplish. And if, you know, a lot of us are very, you know, thick, you know, you know, thick skulls, and so we're gonna not want to do that, and then realize, oh well, if I had done that, then that would have been the better way to go, maybe, you know, um, so those are the kind of things I think will kind of help augment us as surgeons. So how do you, how do you balance, um, you know, a lot of one of the missions also with the spine surgery program is education of, of colleagues around the country and, and you throw a lot of conferences. So what suggestions do you make to a spine surgeon that's been in practice for 5 to 20 years, doesn't really matter, didn't have a mentor like you in in residency or fellowship, but then wants to start introducing this, but wants to do it safely and doesn't have COVID in Korea as a resource. Well, I definitely go to as many courses as possible, uh, go to as many conferences that is holding some sort of lab, whether it's, um, you know, uh, synthetic, uh, material models to do the labs and then, or cadaver labs, uh, um, and then also watch, go to the, the centers where they do a lot of them. You know, and I have surgeons come from all over the country to come and watch me do the surgery, so they're with me all day. Um, and you know, we even have, uh, a way we can do a cadaver lab before and then go to, uh, the surgery, uh, the next day and so they can watch it in practice in, in a live patient. Um, and so, uh, I think seeing how I set things up, how I hold things, how I do things with my staff, uh, to, you know, have the most efficient way of, of doing these surgeries, I think it's helpful, you know, and then, uh, and so, I think those kinds of experiences, and then, you know, I'm always available as, you know, to answer questions, to help them through any, uh, you know, issues that they may have, whether it's, you know, getting things started at their hospital or ASC. I'm always, you know, uh, open to questions and, you know, I always answer them right away. It's like, yeah, you should do this, you should do this, and this will help you a lot, um, so that way, uh, you know, they have a resource so that they are successful, cause they're successful then help me be successful too because then it's gonna be, you know, kind of, you know, expanding. And we want endoscopic surgery to expand in the US to be proliferating like it is in other parts of the world. In Asia. It's huge. It is. There's patients will refuse to go to anyone not doing endoscopic surgery nowadays. And so everyone then has to learn how to do this. So their adoption is sky high. It's through the roof. As a, as a swallowing specialist, you know, it's, it's gratifying for me to hear about this because a good amount of the patients I see are status post ACDF. And have dysphagia or have a Zenker's diverticulum attraction diverticulum afterwards just because of the proximity of the esophagus and pharynx to the operated operative spine or operated spine. And so to me, I just see the value and benefit in minimizing dysphagia, voice problems for patients if we can offer them a technology that is minimally invasive, um, and thus has less morbidity. I think that in the, in the anterior cervical spine, you know, there's, it's difficult to do without, you know, uh, an anterior approach, ACDF cervical disc replacement, but the, the profiles of the plates and the screws are getting thinner and thinner and who knows if we have this conversation 5, 10 years, you know, you may not, you may say, hey, we've figured it out, we've been able to do it differently, but I think that's sort of, you know, for me, one of the holy grails of, of spine surgery and dysphagia, right, right, and definitely reducing. The, uh, the trauma to the anterior cervical spine, you know. So yeah, if you can do it posteriorly, I mean, we're, we're, um You know, this is kind of goes along the lines of what we were talking about before, but um there are surgeons in Korea who are doing endoscopic ACDF so, I say, OK. That's interesting. I'm gonna watch that for a while. I like that. I'm gonna, yeah, I'm not gonna just so when can I do that next? More like, OK, how are you doing that? What's the advantage of this, and is there, is there some sort of, you know, problem that can occur doing it inside with all that water is flowing out through the neck, like, is that OK? Like those are the things I'm asking, you know, I'm always asking, is it safe? Is this the right thing to do? Nice. Well, great conversation. Thank you. Yeah, thank you both so much for being with us. This has been Physician Huddle by UCI Health. Thank you for joining us. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shahen, Angelica Yagubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, view the show notes or visit clinical connection. UCIhealth.org. Created by
