Advanced Technologies

The History and Future Value of Endoscopic Intradiscal Therapy and Foraminoplasty

Anthony Yeung¹, Kai-Uwe Lewandrowski², ³, ⁴

¹ Clinical Professor, University of New Mexico School of Medicine, Albuquerque, New Mexico, Desert Institute for Spine Care, Phoenix, AZ, USA

² Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson AZ, USA

³ Departmemt of Orthopaedics, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia, USA

⁴ Department of Neurosurgery in the Video-Endoscopic Postgraduate Program at the Universidade Federal do Estado do Rio de Janeiro — UNIRIO, Rio de Janeiro, Brazil

Abstract

The utilization of spinal endoscopic surgery techniques is on the rise in routine clinical practice and treating painful annular tears, herniated disc, and spinal stenosis. Over the past ten years, we have witnessed an increasing number of surgeons recognizing spinal endoscopy's value. Many of them had difficulty finding access to adequate training while facing reimbursement and acceptance problems. In this chapter, the authors describe the implementation issues at play that they perceive as relevant in the discussion between the healthcare equation's stakeholders. Included in this chapter on the forward-looking perspective of spinal endoscopy is the first author's involvement in the role and value of laser and electrothermal therapy, which is still pertinent but has evolved with advancements in technology and endoscopes and instrumentation.

Keywords: Endoscopic surgery, Foraminoplasty, History & Future, Intradiscal therapy.

* Corresponding author Anthony Yeung: Clinical Professor, University of New Mexico School of Medicine, Albuquerque, New Mexico, Desert Institute for Spine Care, Phoenix, AZ, USA and ; E-mail: [email protected]

INTRODUCTION

Surgeons and surgically trained non-surgeons will advance the future success of endoscopic spinal surgery. The number of endoscopic and minimally invasive spinal surgeries has been predicted to increase the spine surgery market at a compound annual growth rate of 7.57 percent between 2016 and 2020 in North America and Europe alone [1]. The explosion of endoscopic spine surgeries in

Asia has been recently illustrated by analyzing the country of residence of the authors of scholarly articles published in peer-reviewed SCI(E) journals within the last five years [2]. Authors from China, South Korea, the USA, Germany, and Japan have published the vast majority of papers. The most prolific authors came from a few number of well-recognized institutions, including the Wooridul Spine Hospital in Seoul, South Korea, The Tongji University and the Third Military Medical University in China, the University of Witten/Herdecke in Germany, Brown University, The Center For Advanced Spine Care of Southern Arizona, and from the Desert Institute of Spine Care, Phoenix, in the USA. Endoscopic spinal surgery is expected to become more mainstream globally by increasingly augmenting or replacing traditional open spinal surgeries with less aggressive procedures that are less invasive but equally, if not more beneficial to the patient.

The expanding number of indications that surgeons now identify as appropriate for endoscopic treatment of the spine's common degenerative conditions suggest that there is more to it than merely miniaturizing incisions and performing surgery under local anesthesia sedation. The direct visualization of the intradiscal pathology, pathology in the epidural space, and neural elements in the axilla allow for the diagnosis of pain generators that previously have not been visualized and recognized as treatable conditions. Even more relevant is the ability to correlate the pathophysiology of pain with visualized pathoanatomy with the endoscope. Examples include toxic and painful annular tears, epidural adhesions, scar tissue, and inflammatory granulomas. Other pain inducing patho-anatomy include superior foraminal ligament and facet impingement, facet joint cysts and impaction, tethering of the nerve roots to the pars interarticularis, the pedicles or the intertransverse membrane. Inflammatory irritation of the annulus, posterior longitudinal ligament, lateral and shoulder osteophytes (Tables 1 and 2), and a myriad of endoscopically visualized intradiscal conditions ranging from fissuring, delamination of the endplates, to gaseous degeneration of the intervertebral disc leaving it hollow, and void of any functional tissues round out the myriad of patho-anatomy documented with the endoscope (Fig. 1) [3].

With current diagnostic tools, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI), these conditions are difficult to establish before surgery. These pain generators may be insufficiently imaged with routine preoperative studies or just not included in imaging reporting by the radiologist, hence, leaving a large portion of patients that by new measures are considered either too young, or too old or having too much surgical morbidity without surgical treatment of their painful conditions. However, it will be in this grey area where highly qualified and experienced providers will use the endoscope to correlate the pathophysiology of the patients' symptoms with intraoperatively visualized pathoanatomy that can be decompressed, ablated, thermally modulated, and irrigated to provide pain relief from chemical as well as mechanical irritation and structural defects.

Fig. (1))

Illustration of 9 common, and 19 endoscopically documented painful conditions and their anatomic locations in the foramen.

Table 1 Nine common endoscopically lumbar conditions visualized during foraminoplasty.

Table 2 Additional conditions visualized during routine lumbar endoscopy.

This endoscopic surgical platform's success depends on the practitioner's cumulative clinical and intraoperative experiences, validated by the direct correlation of a responsive patient under modern monitored anesthesia care (MAC), and recorded response to the endoscopic surgery [4]. Rather than relying on a surgical plan that is deducted mainly from preoperative imaging studies, which by definition limit the list of plausible pain generators virtually only to instability and neural impingement, the clinical approach to employing spinal endoscopy relies on the personalized and individualized diagnostic workup of each patient with much greater attention to detail of the relevant patho-anatomy and its pathophysiological role in the patient's pain syndrome.

Invariably, this not only leads to less aggressive but also to earlier, staged, interventions. Rather than waiting for the advanced clinical end-stage of the degenerative condition to develop, treating pain generators in the early stages of the degeneration of the lumbar motion segment, in the authors’ opinion, will be the largest area of expansion of endoscopic spinal surgery. The senior author with 29 years of experience, and early clinical involvement in chymopapain and laser clinical research, has demonstrated his approach to identifying pain generators intraoperatively by interactive feedback with the patient along with surgical case examples with recorded audio and video feedback available for viewing on youtube.com and his website (www.sciatica.com). The viewer will follow the authors' editorialized opinions on performing endoscopic surgery on the sedated yet awake patient's relevant pain generators in these videos. In this chapter, a historical review on the evolution and value of the various intradiscal therapies, including laser and electrothermal technologies and foraminoplasty, is provided as experienced first-hand by the first author.

THE POLITICS, BUSINESS, AND REIMBURSEMENT FOR ENDOSCOPIC SPINE SURGERY

Internationally, spinal endoscopy is already accepted and practiced extensively in Asia. However, its recognition as a mainstream method to treat common degenerative conditions of the spine lags in North America and Europe. A recent opinion survey amongst 430 spine surgeons the world over corroborated this statement [5-7]. Surgeons in Asia reported fewer hurdles to implementation, less concern with the cost of capital equipment and disposables, fewer problems with health insurance authorization, and fewer problems with rejection by the medical establishment in their respective countries [8]. Surgeons in North America, and Europe on the other hand, were not only by far fewer, but they were also chiefly concerned with low reimbursement and fear of being called out for operating outside the norms established by the coverage and treatment guidelines of their national professional societies, the health insurance industry, and local governing bodies [5, 7, 8]. Some of these concerns were also echoed by surgeons from Latin America who reported better overall acceptance of endoscopic spinal surgery into the mainstream than surgeons from North America and Europe [5]. These responding surgeons from the Americas and Europe were keenly aware of their advanced endoscopic spinal surgery program colliding with established treatment guidelines by challenging the necessity of aggressive and extensive open spinal surgeries which they are seeking to replace with small targeted endoscopic interventions. This dynamic creates a conflict of opinions and conflict between the stakeholders of this ongoing debate. They represent various economic and political agendas in the healthcare industry as a whole. It is the makeup of the politics of medicine. The high responsiveness of surgeons to the surveys cited herein clearly shows how keenly aware spine surgeons seeking to innovate their clinical practice are of this debate [5-8].

The three elephants in the room silently partaking in this ongoing discussion whether spinal endoscopy is too experimental, too costly, and unproven on the one hand, or cutting edge, cost saver, and advanced medicine on the other hand are the stakeholders in the health insurance, hospital, and medical device industry. All three may have a competing economic interest in the revenue cycle of medicine, which ultimately impacts the surgeon innovator's ability to justify the cost of implementation. The burden of proof of its economic viability is typically placed on the practitioner in the context of clinical superiority. While it is easy to understand that medical device companies are looking to grow sales with innovative products and directly or indirectly contribute to the rise in healthcare costs, even if the individual products and services may help outcomes and make accepted procedures achieve better outcomes, health insurance companies are held to a higher moral standard as they are expected to operate as a real business but should do it to benefit their insured in an economically viable manner. Therefore, most health insurance companies have formulated extensive medical coverage guidelines and implemented a vigorous preauthorization of service bureaucracy to facilitate appropriate utilization without abuse. These coverage guidelines are typically based on a comprehensive review of the evidence-based literature, which is often graded by its quality as level I – high-quality randomized trial or prospective study (RCT), level II - lesser quality RCT; prospective comparative study; retrospective study; untreated controls from an RCT; lesser quality prospective study; development of diagnostic criteria on consecutive patients; sensible costs and alternatives and meta-analysis, level III - case-control study (therapeutic and prognostic studies); retrospective comparative study, level IV - Case series; case-control study (diagnostic studies); poor reference standard; analyses with no sensitivity analyses, and level V – personal opinion. By definition, evidence-based medicine analyzes the effectiveness of various protocols in managing disease in a population as a whole. Simultaneously, such an approach to determine the medical necessity of an intervention or surgery of the spine is at odds with the personalized approach to spine care with endoscopy. All accepted levels of evidence begin with level 5 expertise. Therefore, the evidence-based medicine approach, which may be appropriate for determining drug-based therapies' effectiveness, seems rather ill-fitted for modern personalized spine care that does not fit the double-blind level 1 and 2 trials criteria. Furthermore, contrary to its intent, it may increase the cost by mandating rigid sequential care protocols with ineffective services before definitive care with endoscopic surgery is deemed indicated. To this author's surprise, this dilemma was even recognized by the SPORT trial authors who recently accepted the need for more patient-specific, individualized tools for presenting clinical evidence on treatment outcomes [9] after their initial studies suffered from a high percentage of patient crossover [10, 11].

It is evident that the current debate suffers from intersectional barriers between the stakeholders with business illiteracy on the surgeons' side, and a lag of medical accolades on the commercial and regulatory side where the parties involved simply do not have sufficient knowledge of each other's expertise to the extent that innovation could be vetted more expeditiously and implemented if proven safe, efficacious, and cost-effective regardless of the health care market dynamics in an individual country. This dynamic has played out in Asia, where private reimbursement is not as critical, and there is government-provided health care. Acceptance of spinal endoscopy into the mainstream in North America and Europe will depend on how this debate will be steered by payer systems and by the traditional open surgery-oriented spine surgeons skeptical of percutaneous and endoscopic procedures that they are not trained to perform and are competing with their successful traditional techniques [12].

It is clear though that the U.S. Department of Health and Human Services via its Centers for Medicare & Medicaid Services (CMS) is incentivizing institutions and surgeons alike to move simple spinal decompressions from being performed as an inpatient to an outpatient ambulatory surgery center (ASC) to provide more cost-effective, high-value spine care. New current procedural terminology (CPT) codes have been allowed to perform many spinal surgeries in ASC [13]. In 2017, The American Medical Association (AMA) for the first time included a new spinal endoscopy CPT code (62380) [14]. The new code covers endoscopic decompression of the spinal cord, nerve root, including laminotomy, partial facetectomy, foraminotomy, discectomy, and excision of a herniated intervertebral disc, one lumbar interspace [15]. However, CMS did not assign a final value to CPT 62380 in its final 2017 ruling instead of assigning contractor pricing. Effectively, this means that each Medicare Administrative Contractor (MAC) will set reimbursement determination [16]. As a result, it remains to be seen how this endoscopic CPT role plays out in each healthcare market with sufficient reimbursement for the facility- and professional fee being of concern for ASCs and surgeons. Ultimately, spinal endoscopy is intended to replace more costly open inpatient spinal surgeries. However, financial disincentives may come to bear mainly if the actual reimbursement of endoscopic procedures is lower than the procedures it replaces, and if capital equipment and disposable cost are insufficiently covered. The authors expect that this transition from open to endoscopic procedures will not be swift. Slow embracement of spinal endoscopy by mainstream spinal surgeons in North America and Europe coupled with low reimbursement and lack of formal inclusion into coverage and treatment guidelines will leave the field by default to a smaller group of endoscopic surgeons and multidisciplinary pain management and rehabilitation physicians who do not have nor accept the need for additional surgery training. The latter is simply needed and required for the procedure to be mainstream. Endoscopic spinal surgeons must demonstrate that the procedures they adopt remain safe, efficient, and practical or more effective than the current contemporary techniques they are trying to replace [17].

THE REASON WHY ENDOSCOPIC SPINE SURGERY SHOULD REQUIRE HIGH STANDARDS

U.S. regulatory approval is not needed for physicians to perform endoscopic spinal surgery since physicians are licensed and are overseen by their medical boards, and not the Food and Drug Administration (FDA) who does not regulate the practice of medicine. Credentialing of core privileges at hospitals and surgery centers typically requires that the surgeon presents evidence of having had training in the surgeries she or he is intending to perform. Examples of this include kyphoplasty and fusion surgeries. Kyphoplasty became popular in the United States 20 years ago and gained significant traction 15 years ago. Fusion surgeries have seen a similar rise in utilization within the same time frame. While it is understandable that hospitals require training in more complex and riskier fusion surgeries, having to show evidence of training in kyphoplasty as a by far less aggressive procedure may not seem evident to surgeons. Spinal endoscopy may fall in a similar category where surgery through a small incision may be considered as a smaller, less risky surgery that can be carried out by nearly anyone who had some postgraduate residency or fellowship training in neuro- or orthopedic spinal surgery. This is not the case in endoscopic spine surgery. The casual approach to training future expert surgeons capable of executing endoscopic spinal surgeries in a highly reliable and consistent manner is inappropriate. Many KOLs have published results of their clinical series after many years of trial and error practice to hone in their skills in mastering this demanding procedure that by many is recognized to have a steep learning curve and may not be for everyone [17]. Integration of formal spinal endoscopy training into the core curriculum of neurosurgical and orthopedic residency program should be not just considered but required, and will most likely remain part of the debate.

Besides the complex technical aspects of spinal endoscopy, there is the issue of understanding its indications and surgical principles of best clinical practice. There is no doubt that spinal endoscopy is not merely replacing existing surgeries and their standard clinical indications to the authors. The intradiscal and epiduroscopic visualization during spinal endoscopy has and will continue to recognize pain generators either hitherto unknown or ignored because of the lack of adequate diagnostic and treatment protocols (Fig. 2) [17]. In other words, it is a new world distinctly different from traditional spine surgery that is simply focused on relieving neural element compression in consideration of instability and deformity; a new world that requires any practitioner embarking on the spinal endoscopy voyage to think differently, and to become familiar with the in's and out's of a successful endoscopic spine practice. At its core, a successful endoscopic spine practice requires close investigative interaction with the patient to treat the pain generator causing the disability [17].

Fig. (2))

a) Epidurogram of paracentral HNP demonstrating blockage of the traversing nerve b) epidural gram and incidental discogram. The leakage of contrast identifies and extruded HNP. A therapeutic injection providing good relief provides a good prognosis for endoscopic decompression.

In that sense, the endoscopic spine technology's successful application employs new concepts that are "disruptive" to traditional degenerative spine surgery concepts. In the authors’ opinion, open surgery for many of the degenerative conditions of the spine are appropriate, but has the propensity to be more surgically aggressive than required and may be associated with greater collateral damage from associated muscle de-innervation and the destabilizing effects of the decompression. Ultimately, postoperative adjacent segment disease and epidural fibrosis may add to additional disability and more follow-up surgeries, which in the patients' minds seems outdated and creates apprehensions before spine surgery [18]. The patients demand us to do better by modernizing the approach to managing their sciatica-type low back- and leg pain or their cervical and thoracic pain syndromes. Patient demand, coupled with a push by government and payers to develop more reliable, less complicated, and less costly ways to manage the socioeconomic impact of spine-related pain syndrome. Pain management, however, is NOT a minimally invasive subspecialty of surgical pain care.

In current practice, authorization for health insurance coverage of surgical indications is primarily dependent on interpreting the CT and MRI imaging by the reading radiologist [19]. When the radiologist's report on paper does not support the treatment requested by the surgeon, denial for a preauthorization insurance company for surgery is often the consequence. This disconnect between these traditional protocols run by payers and governmental review boards and protocols used by the disruptive spine surgeon has the potential to lead to significant undertreatment. This has recently been corroborated in a study that found that up to 30% of patients who underwent successful endoscopic decompression for a lumbar herniated disc and spinal stenosis were classified as MRI false negative [19]. These MRI false-negative patients underwent successful surgery with a resolution of symptoms despite the MRI report suggesting that stenosis was not present at the surgical level. Therefore, the Interventional Pain Management Surgery approach will require the definition and validation of more useful clinical prognosticators of a successful outcome after endoscopic spinal surgery [19].

THE ROLE OF INJECTIONS AS PROGNOSTICATORS OF OUTCOME

The interpretation of preoperative advanced imaging studies may be further validated and documented by discography, transforaminal epidurography, and transforaminal therapeutic epidural steroid injections (TESI) containing a local anesthetic, or transforaminal foraminal nerve root blocks by injecting just a local anesthetic to identify the pain generator (Fig. 2). Diagnostic transforaminal injections containing a local anesthetic are an excellent prognosticator of favorable outcomes after a lumbar transforaminal decompression procedure. The concepts of developing new prognosticators of successful surgical outcomes lie in the pathophysiology's correlation with the intraoperative endoscopic visualization of the patho-anatomy responsible for the patient's pain. Correlation between the patient's response to a preoperative interventional work with lidocaine containing TESI has been conclusively demonstrated in a recent study carried out over nine years [20]. Of the 1839 patients, 1750 had intraoperatively visualized stenosis in the lateral recess at the surgical level, and 89 patients did not. The analysis showed true positive (1578); false negative (172), as compared with TESI responses in patients without visualized compressive pathology: false positive (26); and true negative (63). The sensitivity (90.17%), specificity (70.79%), and the positive predictive value (98.38%) of preoperative lidocaine containing TESI concerning the successful clinical outcome of the subsequent endoscopic decompression surgery were calculated. This study demonstrated that diagnostic lidocaine containing transforaminal epidural steroid injection – if it produces more than fifty percent VAS pain score reduction – is a valuable diagnostic tool in predicting improved clinical outcomes after lumbar endoscopic transforaminal decompression.

The only person able to validate this correlation intraoperatively in close interaction with the sedate yet awake patient is the surgeon. The surgeon's evaluation and validation of the preoperative prognosticators, whether imaging studies or diagnostic injections, during surgery cannot be replaced by any other technological prognosticator. Since pain relief relies on the correlation between the pathophysiology and the intraoperatively visualized patho-anatomy for each patient's specific condition, a successful outcome depends on this critical patient surgeon interaction. It cannot be replaced by a rule book of medical necessity criteria or by rigid adherence to advanced imaging reporting discounting the importance of the interaction between the patient and the surgeon [21, 22].

THE ROLE OF IMPROVED ENDOSCOPES AND INSTRUMENTATION

Historically, companies marketing spinal endoscopes, endoscopic- devices, and instruments had to budget significant money for training to stimulate their sales. Advances in endoscopes and surgical equipment will also help the development and adoption of endoscopic surgery [23, 24]. The development of endoscopic implants for the spine may further galvanize the push towards endoscopic spine surgery, particularly if viable reimbursement is associated with these procedures. The feasibility of a stand-alone lumbar interbody fusion cage being placed entirely using an endoscope and instruments adopted for the percutaneous endoscopic transforaminal placement of the cage into the spine has recently been demonstrated [25]. It is evident that creating sustainable revenue cycles for physicians and facilities is needed to retool clinical practices from traditional open to minimally invasive endoscopic spinal surgeries.

The Role Of Physician and Certification

For a surgeon to achieve success in the future subspeciality of Endoscopic Surgical Pain Care employing the disruptive techniques of correlating patho-anatomy and pathophysiology of pain generators, providers who embrace these spinal endoscopy principles should have surgical training. They should also:

1. Continue research and development of the endoscopic platform. Examples of future impactful developments include intraoperative robotic mechanical and image recognition guidance.

2. Continue to develop endoscopic designs and instrumentation to improve surgeon effectiveness and competence.

3. Support commercially viable manufacturing, marketing, distribution, and training operations to facilitate the expansion of spinal endoscopy to be incorporated into mainstream postgraduate training at a contemporary level.

All physicians who employ spinal endoscopy must be adequately and formally trained. Ideally, surgeon training moves away from weekend cadaver courses run by vendors. It should be included in the core curriculum of neurosurgical and orthopedic residency programs and, at a minimum, be taught in MIS spine fellowship programs. The most effective way to formalize training in spinal endoscopy is to establish standards for certification. The formalization of such minimum required standards for certification and skill level in spinal endoscopy may be challenging to define. It will most likely continue to be at the center of the debate. Despite this perceived difficulty, it is essential and will be demanded by licensing and neurosurgical and orthopedic governing boards for them to be able to endorse it.

THE PATIENT’S POINT OF VIEW & PLACEMENT OF SPINAL ENDOSCOPY

Patients who can seek the best surgeons and are often willing to pay cash and supplement what is not covered by insurance, for not just the best endoscopic surgeons, but surgeons with a known track record for safety and excellent clinical results [26]. Such surgeons will be sought out, similar to recruiting the best professional athletes. Cultural biases may also influence patients in their quest to search out the most appropriate way to treat spine pain. Asians, for example, have accepted specific methods of non-traditional medicine for thousands of years. One can only speculate whether the higher acceptance of alternative medicine in Asia has made it easier for spinal endoscopy in Asian countries to be adopted widely. Every culture has its own biases toward ethnic methods such as Asian alternative medicine methods, including acupuncture, exercise, massage, stretching techniques, reflexology, and naturopathic medicine [27]. Hence, other ethnic groups may have their level of acceptance and methodologies.

In the authors' opinion, the verdict is straightforward: Innovation in medicine in general, besides many other factors, requires money. Therefore, acceptance of endoscopic procedures and technologies as a surgical procedure or minimally invasive spinal surgical technique rather than interventional pain management is the most appropriate way to place a fair monetary value on its application, implementation, and expansion into day-to-day clinical practice. Adoption by the majority of surgeons and their respective professional governing boards and specialty societies will depend upon its continued safety, low complication rates, and effectiveness with ongoing innovation. These three factors will always heavily depend on each physician's skills [27, 28].

CONCLUSION

Spinal endoscopy will likely become more mainstream in the years to come. Formalized postgraduate training programs are expected to improve training, helping surgeons to master the learning curve. The substantiation of clinical guidelines should follow to formalize payment schedules that provide adequate reimbursement to build viable endoscopic spinal surgery programs capable of replacing traditional open spinal surgery protocols.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENT

Declared none.

REFERENCES

Evidence Based Medicine versus Personalized Treatment of Symptomatic Conditions of the Spine Under Local Anesthesia: the Role of Endoscopic versus Spinal Fusion Surgery as a Disruptive Technique

Anthony Yeung¹, Kai-Uwe Lewandrowski², ³, ⁴

¹ Clinical Professor, University of New Mexico School of Medicine, Albuquerque, New Mexico, Desert Institute for Spine Care, Phoenix, AZ, USA

² Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson AZ, USA

³ Departmemt of Orthopaedics, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia, USA

⁴ Department of Neurosurgery in the Video-Endoscopic Postgraduate Program at the Universidade Federal do Estado do Rio de Janeiro — UNIRIO, Rio de Janeiro, Brazil

Abstract

Runaway cost for surgical spine care has led to increased scrutiny on its medical necessity. Consequently, the beaurocracy involved in determining coverage for these services has grown. The call for high-grade clinical evidence dominates the debate on whether endoscopic surgery has a place in treating painful conditions of the aging spine. The cost-effectiveness and durability of the endoscopic treatment benefit are questioned every time technology advances prompt an expansion of its clinical indications. The authors of this chapter introduce the concept of early-staged management of spine pain and make the case for personalized spine care focused on predominant pain generators rather than image-based necessity criteria for surgery often applied in population-based management strategies. The authors stipulate that future endoscopic spine care will likely bridge the gap between interventional pain management and open spine surgery. This emerging field of interventional endoscopic pain surgery aims to meet the unanswered patient demand for less burdensome treatments under local anesthesia and sedation. The very young and old patients often are