쉐도잉 연습: Meet the Masters: 2026 Spine Endoscopy Masterclass Talk - 영상으로 영어 말하기 배우기

I was assigned a very simple topic called Global Consensus Endoscopy as the New Standard.

As a disclosure, I am a consultant for Eloquence.

And what I want to talk about is what I call LESS,

Lumbar Endoscopic Spine Surgery, which you have to admit is a very cool name for a melaninvasive procedure.

But I call this procedure, for me, the oldest state-of-the-art procedure that I have in my toolbox because it has been around for a long time.

So back in 1999, this paper was published.

That means that it's been around for like 30 years.

And even before that, there's been other papers.

And since then, that paper was the transferaminal uniportal approach.

we now can do interlaminar surgery.

We can do it in the cervical, thoracic, and lumbar spine.

And we can do it from uniportal, and we can do it biportal.

And a lot has happened.

So the first thing I want to point out is that there's still people that demand more evidence, more proof that this works.

So just at any time, go to PubMed and just type in something that you want to compare traditional mini open surgery for with endoscopic.

So this is the most common one.

You have a herniated disc.

What are the results of?

Lumbar microdiscectomy.

And you get a bunch of studies, like a thousand.

What do you think happens when you type in lumbar endoscopic spine surgery?

Over a thousand.

And if you do this for the treatment of spondy, fusions, a bunch of stuff, you'll be surprised at how many peer-reviewed publications are out there for endoscopic surgery.

It's tremendous.

So the question of does endoscopy work?

that that's that's like old news it totally works all the data shows

that it works to me the more important question than

that about whether it works is if it's

so great how come the adoption rate is

so low how come is it

that in all of san diego there's just two people

that does like real endoscopy like full on endoscopy two people in california there's probably no more than like five or ten,

at least on the level of like Dr. Kang and I.

So the important question is if it's so great why is the adoption so poor?

I'm not sure what the answer is but there's probably two reasons.

The first is this whole reimbursement and cost issue.

That's not an area of expertise for me.

The second one is the learning curve and I think we all recognize these two issues but it's

so uncommon for us to ask the next question.

So here's the next question in my mind that's important.

Not only do we kind of appreciate that the learning curve is difficult, we have to ask a very important question.

How can we improve upon it?

And we don't have that discussion nearly as often as we should.

And I'm not here to tell you what what the answer to that is, but I can tell you that a lot of the discussions that I hear,

we have to have some goals when we adopt a new technology.

And if you really think hard about it, if you're a resident, you can do a case and be in the learning curve.

But if you're already in attending, in practice, there's very few patients that you'll sit in front of and think to yourself,

this patient doesn't matter to me as much.

I think I can try this and

if it doesn't go well it's going to be okay

that patient hardly ever comes up and it should never come up

so we have to work backwards you have to make the first case go well

so i can tell you three things of what not to do

when you first do your endoscopic case you ready what not

to do is number one do not be unprepared number two do not be unorganized and number three do not unrealistic.

These are all three things that you can solve pretty much immediately if you put your mind to it.

Now I'll give you an example.

One of the biggest problems when you start endoscopy is that everything is totally new.

The room setup is new.

You have two monitors potentially up, one for flora and one for endoscopy, and you've got foot pedals, and you have to look around.

So if you don't have everything set up, if you don't have all the equipment coming at you

when you want it and not having missing items for your first case, that makes things a lot easier.

You just need to worry about the surgery.

Not on your first case, is everything there when I need it.

So look at the picture on the left.

That's my old way of keeping a checklist.

And I would demand that they print that out.

And if something's missing, I ask them, like, let me see the checklist

and they have to produce a piece of those pages with checks check marks on it

if they don't and something's missing it gets ugly in the

OR so here's the problem on a checklist like

that the first 80 things is easy it's the last five things that's buried in the checklist

so one thing you can easily do is have a checklist that's easy to use it's 2026 make it

so that it's electronic.

Another example, setting up the room.

You want everything where you want it

because you have to look up at a screen

and you can use the picture on the left or you can use an interactive model on the right.

Here's another example in terms of being realistic.

I can't tell you how many times somebody picks the hardest first case to do

and also thinking that you're going to remember everything.

So it's all about the first few cases because what I noticed is that if you can get through the first three,

four, five cases successfully and then on the sixth case you have a problem, you'll probably do a seventh case because you'll think, I know what I did wrong.

My other five patients are doing great.

I'm going to go again.

If you have a problem on the first case, it's very likely that you're going to think, this is not for me.

This doesn't work.

This is BS.

I'm never doing this again.

It's almost like a really awkward first date.

You just don't even want to see that person ever again.

So you can deal with right now.

So all of you that's just going to start up and just do it, do that, but do not make those first three mistakes.

So having said that, and there's a lot more work to do, what else could we do to drive adoption?

Now, if you just look at the history, you know how I said this is 30 years old?

In the last five years, there's been this unbelievable adoption of endoscopic surgery.

And the single biggest reason is the advent and adoption and recognition of bipolar endoscopic surgery.

So I'm often at the podium proudly stating

that the best spine surgeons in the world are the Korean spine surgeons from Korea.

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because they were the, they did a lot of MIS and if it wasn't for Biportal,

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I think we'd still be struggling and I think this is going to help drive what I call the tipping point.

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So this whole discussion, somebody asked me like, talk about Biportal, will you?

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Because you're a Uniportal guy and I'm like the straw man here.

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So what do I think about Uniportal versus Biportal?

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I kind of look at it like this like left twix

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versus right twix in my mind it doesn't really matter

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that much what's more important is that it's endoscopic not whether it's uniportal

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or biportal and just imagine a world where you can do multi-portal

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and I just did that yesterday there's no reason why you can't make three ports

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so example your biportal you can't get through the other side for some reason, you just make a port on the other side.

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Yesterday I had to do an interlaminar and a transraminal approach on the same level,

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which kind of sucked, but still there's no reason to open it or do a fusion on something like that.

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The way I deal with this whole situation is I encourage you to look to the future

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because right now it is very nice to be able to use somebody else's equipment, use a bunch of old equipment, put it all together like we're in Cuba or something like

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that and prove to somebody like how well it works

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but in my mind the future is

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that we're spine surgeons we get our own equipment we own our own equipment

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and that equipment is purely designed to accomplish the goals

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that we want not a system that was designed for the knee

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or the shoulder that we configured to the spine using a combination of open stuff

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and other anatomy stuff so simple thing is that

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if you have a uniportal system you can go by portal anytime i start everything uniportal, same target site, same work,

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and I only create the second port if I need it.

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If I don't need it, I just don't.

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If I need it, I say, give me the knife.

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I make the second port, give me the T-handle, and then open up the basic spine trait.

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So in the interest of time, I'm going to pass through this, but one simple advantage is that you can find the second port without necessarily chop-slicking the whole time.

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You can do it in direct vision, and you can swap back and forth where you work.

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So let me give you a case example.

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She's in her 80s.

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She's got back pain and neurogenic claudication.

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Flexing extension views with these findings.

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All right, now I want you guys to think about how you would treat this patient.

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Now this patient is my 84 year old mom.

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This is her now at age 90.

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How many of you would do a two level MIS-T lip or a diffusion of some type?

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How many of you would just do a decompression only?

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How many of you guys think I just did a How many of you guys think she had an MIS-T lift?

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I didn't do it.

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Okay, she had a two-level MIS-T lift But that was six years ago

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If she presented today I would want her to have a biportal endoscopic laminectomy

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Because I remember the day when I thought there's nothing better than a blackberry

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and then I'm like oh my god The iPhone I remember

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when I used to love going to Blockbuster on the weekends with my family

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and going back and forth into the aisles I was picking a video.

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Now we do that just sitting in front of the TV.

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I remember when I had a package of wires everywhere.

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Now I just do everything by magic and the ether.

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And all this is related to what I call a simple process called evolution.

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Because all surgeries evolve to become less invasive.

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And there's nothing more less invasive than endoscopic surgery.

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So with that, thank you.

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I have no idea if I ran over, but I suspect I did.

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Hello.

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Again, Ivan Samanov from Mexico.

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I was wondering, how do you deal with insurance companies when doing navigation on endoscopic surgeries?

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Because at least in our country, if you explain that you are going to do navigation on an obese patient,

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the insurance first asks you to send the patient to bariatric surgery

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or something else so that's like a huge problem to us i was wondering

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if you have like the same issues here thanks yeah you know i have the same issues

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so to address the obesity question right

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if it is emergency like the klanakwana you have no choice right

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but for elective t-lifts you have i think of you you know you have to prove to the insurance

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and also So for the benefit of the patient and to make your surgery easy,

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do everything to have that patient reduce some weight.

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And especially with the GLP-1 agonists out there, that job has gotten a lot easier.

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But there are some people who actually, despite the medications, do not lose weight.

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They try everything for whatever reason.

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And it turns into a vicious cycle because they're in pain.

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They're not moving they're not exercising, they cannot do therapy, and they don't move,

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their muscles decondition, so their condition worsens, and then it becomes a vicious cycle, and you have to cut it somewhere,

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and I feel like if you can provide surgical care to get rid of the pain at least, they can actually move around more and hopefully better themselves.

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And with regard to reimbursement, actually in the United States if you use stereotactic navigation there is an added code

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that we can attach to our billing and you end up making more money

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so hopefully that will encourage some of the surgeons to utilize navigation for the benefit of the patients

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or you know I use navigation regularly for T-lifts I do

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not use navigation for decompression only unless it's thoracic disc or something rare where I really need to localize the anatomy.

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And yeah, so that's been helpful.

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Let's go in the west coast.

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I love navigation, but I think our problem is different.

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You're talking about the mandates and the policies of insurance people and the payers.

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We don't have that problem.

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Our problem is that the hospitals and the facilities that we operate at, they have to pay for the navigation because insurance companies don't pay that much.

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So we have a big obstacle in terms of cost efficiency.

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And right now it's okay because the hospital is very cost inefficient, but I anticipate in the next five to ten years there's going to be two types of spine surgeons.

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Just like there are two types of knee surgeons.

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You know, there's a knee surgeon that does a knee replacement.

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If you need an ACL reconstruction or a meniscectomy done with an endoscope, arthroscopy, you go to another doctor.

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So I think there's going to be a large group of young, highly motivated, energetic, entrepreneurial spine surgeons.

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They're going to gravitate toward the ambulatory surgery center and hardly ever go to the hospital.

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And some spine surgeons that are almost always at the hospital never go to the surgery center.

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And the growth is going to be in the surgery centers.

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And that's where the issue of robotics, navigation, in the setting of endoscopy is going to be a real barrier because of the cost to the facility.

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The second quick question.

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When you talk about your mom's case, you told that she was pretty good right now.

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She improved all of her symptoms without mis relief do you think

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that doing an endoscopic decompression also the back pain could be could relieve her symptoms nowadays yes

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and i want to answer that question in a couple of different ways i know a lot of spine surgeons

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if you ask me how many spine surgeons have had a lumbar fusion on themselves

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or their immediate family members like their wife their children

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or their parents I can't name more than about five

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so that's the first thing so if you ask yourself what would I do

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if this is my family member which is what I usually do things change

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so six years ago and my ICF was the great operation

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but today I would say that I do an endoscopic decompression only

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and I would be confident that maybe the back pain wouldn't be as well, maybe, because she has no back pain either,

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but she had mostly neurogenic claudication, so she's not a back pain patient.

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It wouldn't even be close.

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Plus, her facet joints didn't have a lot of facet fluid, so I'm confident that they would have a great result.

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The complication profile would be much less,

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and that says a lot that I would treat my own mom two totally different ways six years ago versus now.

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That's how much endoscopy is advanced because I take care of a lot of patients that I would normally do a fusion.

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I'm just like, key, I hardly ever do any fusions anymore.

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And I love that surgery.

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I wish I could do more, but most patients don't want it.

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And then the ones that I do the decompression, even though I tell them, I think you're going to need a fusion, most of them do not need the fusion.

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So I just keep moving more toward non-fusions right now.

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I don't know where that line is going be

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but i think the fusion line is going to be much

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further out than it is today the use of antibiotics do you use antibiotics on the irrigation fluid

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or on the iv

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and another question is for the far lateral herniations the the use of by portal endoscopy is it really useful

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or would you do only only portal for far disc herniation thank you all right

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so i do not use any antibiotics in the saline i think saline itself is like sterile

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and and you know never say never thankfully haven't had infections

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so i think there's some literature suggesting

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that the infection rate is really low with that water-based

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or saline-based endoscopy to begin with

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and then for far lateral disc herniation uh i you know

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i can 5-1 may be challenging whether you are a uniportal guy

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or a biportal guy

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but the four five you know three four i've used the biportal uh without issues

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and then i've shown a case of a thoracic lateral approach um endoscopy is a tool

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but you know my general recommendation is use whatever works in your hands

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if you're an open surgeon that's probably the safest surgery that you're going to do it for that patient.

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So it's just a tool that we're using.

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I'm a golfer.

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I don't think, yeah, but I think I agree with you.

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But here's the way I look at it.

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If I have a far lateral disc herniation, I'm going to do uniportal because it's easier, it's faster, and there's no need to go biportal.

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If I do a 4-5 or 5-1 disc herniation, I go uniportal.

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If I have to do like a decompression, I'm ready to go biportal.

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If I have to do something complex like an L12 or so, I want to be able to do both.

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And my guess is that if you saw me do a far lateral endoscopic discectomy uniportal

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and you saw somebody do a biportal, you'd end up doing a uniportal.

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So depends on how you ask that question.

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If you have access to both systems, I strongly encourage you to learn how to do both.

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I think the reason as to why bipolar endoscopy has taken off is that, you know, if you think about the cases that you do,

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the majority of cases, right,

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90 plus, maybe 95 plus of degenerative lumbar decompression work with is inner laminar approach.

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So I think for that multi-portal endoscopy seems to do better for multiple reasons,

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including you know, being able to utilize some of the more aggressive tools because I mean,

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for me personally, I don't want to stay in the operating room for two, three hours during one level landing.

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You know, in 30 minutes is my limit.

쉐도잉이란? 영어 실력을 빠르게 키우는 과학적 방법

쉐도잉(Shadowing)은 원래 전문 통역사 훈련을 위해 개발된 언어 학습 기법으로, 다언어 학자인 Dr. Alexander Arguelles에 의해 대중화된 방법입니다. 핵심 원리는 간단하지만 매우 강력합니다: 원어민의 영어를 들으면서 1~2초의 짧은 지연으로 즉시 소리 내어 따라 말하는 것——마치 '그림자(shadow)'처럼 화자를 따라가는 것입니다. 문법 공부나 수동적인 청취와 달리, 쉐도잉은 뇌와 입 근육이 동시에 실시간으로 영어를 처리하고 재현하도록 훈련합니다. 연구에 따르면 이 방법은 발음 정확도, 억양, 리듬, 연음, 청취력, 말하기 유창성을 크게 향상시킵니다. IELTS 스피킹 준비와 자연스러운 영어 소통을 원하는 분들에게 특히 효과적입니다.

쉐도잉 연습: Meet the Masters: 2026 Spine Endoscopy Masterclass Talk - 영상으로 영어 말하기 배우기

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