The Three Minimally Invasive Spinal Muskateers-Kambin,Kamson And Kaul
A vision, some knowledge and an abundance of courage are the essential components of innovation. The human spine provides the foundation on which civilization has literally been built, for without a fully functioning bony column, it would have been both metaphorically and actually handicapped. The medical minds, whose forward thinking dispositions, led to the spinal equivalent of the information reformation, are three physicians who pioneered and academically promoted an advanced understanding of the clinical application of spinal intervention.
Dr.Parvez Kambin, Dr.Solomon Kamson and Dr.Richard Arjun Kaul are the names that will forever be associated with the evolution of spine surgery. Commencing in approximately 1980, Dr.Kambin, a US based orthopedic surgeon of Iranian ancestry, with no fellowship training is spine, made the observation of how his colleagues were using an endoscope to address knee and shoulder pathologies. The advances in fiber-optic technology permitted a surgeon to correct damaged tissue in the joints without having to utilize wide incisions. Patients were able to have the procedures performed on a same day basis, with a minimization of both blood loss and post operative pain, due to the markedly reduced skin and muscle dissection. Dr.Kambin had the thought that the surgical endoscope used in the joints could also be employed in the spine, but before doing so he had to delineate the exact anatomical features that would permit the safe placement of the endoscope. The result of his cadaveric dissections is now referred to as Kambins Triangle, and is the space between the vertebral body and the superior articular process where the nerve root exits from the spinal canal. Kambin described the margins of the ‘safe’ zone and with the introduction of a mobile fluoroscopic unit was able to remove herniated fragments of intervertebral discs.
The movement up the technological ladder continued and in 1998,Dr.Solomon Kamson, an interventional pain physician of Nigerian ancestry, based in Seattle, was the first physician to perform an endoscopic discectomy on an outpatient same day basis. Advances in anesthetic technique, with the expertise Dr.Kamson possessed in Fluroscopic Guidance and Interpretation-FGI- allowed him to relocate the performance of Minimally Invasive Spine Surgery (MISS) from the hospital into the ambulatory surgical center. In addition and arguably more significant, was the fact that he advanced the medical scope of practice of the interventional pain (IP) community. His efforts and success led to the first skirmish between the neurosurgical and IP communities in what later became widely known as The Spine Turf Wars (STW). Dr.Kamson paid a professional price for his innovative actions and had his medical license suspended by the neurosurgically influenced state medical board for three months. However, and in a far more independent forum, he won a civil medical malpractice case in which a jury found that he was appropriately qualified to perform minimally invasive spine surgery. This key legal decision opened the door further to other Interventional Pain and Radiological Physicians, who as a consequence of their expertise in FGI, increasingly migrated into the emerging specialty of MISS.
Dr.Richard Arjun Kaul, an Indian physician that emigrated to the US in 1989, after having completed medical school in London at the Royal Free Hospital School of Medicine, was the next free thinking ‘out of the box’ intellect, who floored the IP peddle and in 2005 performed the first outpatient lumbar interbody spinal fusion. While attending a spine conference in Chicago 2004 he was introduced to a device called the Optimesh, a mesh cage manufactured from Dacron that was developed to repair fractures of the vertebral bodies. The placement of the cage into the vertebral body, under FGI and in a collapsed configuration, was followed by the insertion of bone or cement to reconstitute the vertebral body. Dr.Kaul immediately recognized how this device could be utilized for the percutaneous placement into the intervertebral disc space to achieve a lumbar fusion and in 2005 successfully carried out the first surgery. A major contributing factor to his motivation to develop a technique for a safer more effective spinal fusion, originated in his own medical practice. He observed a disturbingly high rate of poor outcomes in patients who had undergone spinal fusions, all performed by either orthopedic or neurosurgeons, that resulted in the destruction of the surrounding muscles, ligaments and bones necessary for spinal mobility. The wide open aggressive techniques involved significant rates of postoperative infection, intraoperative blood loss and prolonged periods of pain and rehabilitation with a large percentage of these individuals unable to return to work. In addition, their pain became chronic and frequently uncontrollable, despite the prescribing of powerful synthetic opiates.
To effectively perform a spinal fusion requires that the spinal segment be internally stabilized with pedicle screws and rods to minimize postoperative motion which facilitates the process of bony healing. Dr.Kaul, as with many advances in both medicine and science, brought together existing technologies in an original manner. His recognition of how to combine the percutaneous placement of both intervertebral devices and pedicle screws revolutionized the ability of physicians to perform safe effective fusions on an outpatient basis in ambulatory surgical facilities. In addition he is credited with having advanced the scope of practice of the specialties of IP and IR, into the heart of MISS, and bringing a victorious conclusion to the STW. As a consequence of his groundbreaking work Dr.Kaul garnered global attention, which led to the development of global training programs for both neurosurgeons and interventional spine physicians.
The ultimate benefactors of the pioneering work of the above three physicians, are and will continue to be, patients whose lives are affected by spinal pain, and whose lives will be forever improved by the life changing combination of technology and thinking ‘outside of the spinal box’.
