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Dr. Bitan in the operating room at Lenox Hill Hospital in Manhattan
Fabien Bitan lives in New York City where has been Chief of Spine Services since 2005 at Lenox Hill Hospital in Manhattan's Upper East Side. Rather than run the sort of assembly line medical practice that government and HMOs have ushered in, he has organized a limited "boutique" type of practice centered on personalized relationship and care.

What is exactly a "boutique" practice?
"My practice functions with a low volume of patients," he said in a recent interview. "I decided to work mostly out of network and be able to spend sometimes hours with new patients." This type of patient sometimes has had three, four unsuccessful operations or more that have altered their lives professionally, privately and socially. No one can pretend having a global understanding of this type of problem in a 15 minutes visit. You have to sit down and listen; a little bit as if you were having dinner with them. You can't do this when you have to see 30 patients in a day. I try to take care of them like family. Most patients I operate on have my cell phone number. I wasn't sure at first if this was a good idea, but so far none of them has used it abusively."

Dr. Bitan in his office at Lenox Hill Hospital

Over the last seven years Dr. Bitan has put together a unique team. "In most other places, for the sake of staff training, they assign every morning a different team. People who don't know your routine, sometimes who are not even familiar with the operation and every day you have to reinvent the wheel. You have to control every single detail yourself: making sure that equipment is adequate, that the personal walking around respects sterile techniques etc. your mind is not 100% focused on surgery."

"No matter how meticulous you are you cannot control everything. When you operate your eyes are on the patient. You cannot do the job and think about other things. Having a team that you trust is irreplaceable. I've work with the same scrub tech for the last seven years, the same assistant, the same anesthesiologist, the same nurse. We are friends and are loyal to me and my patients. This organization allows me to safely delegate many tasks to focus my attention on the surgical technique. For example our rate of infection has been close to zero over the last 7 years (three cases out of 1,500 procedures)."

Behind this decision to create a boutique practice lies a remarkable variety of experience, not only medical and surgical but also cultural. Dr. Bitan has worked with surgeons in China, Germany, Israel and in his native France. He has participated in both the most technologically advanced aspects of his profession as well as in traditional medicine largely ignored in the West. In both of these directions he is looking to push himself outside the comfort of routine in order to find what works the best.

Dr. Bitan routinely uses acupuncture and traditional Chinese medicine in his practice
in New York City.

The use of acupuncture is one example of these openings. This is part of what Dr. Bitan took away from his work in China. "Chinese surgeons are becoming more and more Westernized, but they combine traditional Eastern medicine with Western techniques. That's actually what I do in New York, the other way around. I like to introduce some Eastern medicine in my conservative treatment. I use a lot of alternative medicine such as Chinese medicine - acupuncture, relaxation. With all due respect to pain management physicians I don't think using narcotics should be part of our arsenal."

Dr. Bitan with Professor Jin Dai De and his team of surgeons in Guanzhou, China

Acupuncture has limits and stories of surgeries done under acupuncture are mythical or anecdotal. In China general anesthesia is always used during surgery (although acupuncture often accompanies anesthesia). Dr. Bitan feels that acupuncture has a specific place in the healing process: "Recently there have been studies, especially in America, to quantify the results of acupuncture. It seems acupuncture works very well to alleviate back pain in conjunction with other methods (physical therapy for example). It's like an interaction that works best. There's another recent study of people with back problems. One group was made up of firm believers in alternative medicine while the other was not. An independent observer measured differences in the use of acupuncture between the two groups and there was no difference. For even the skeptical people the results were good." And then, to underscore the point, he notes: "My daughter is a vet, and she showed me videos of an out-of-control dog that required five people to hold him down. An acupuncturist placed needles on specific points and the dog fell asleep right away."

The allure of new techniques in back surgery
But most of Dr. Bitan's work has involved investigating new areas of technology that show the promise of delivering better, safer results for his patients. He puts the interest in new technology in a broad context.

"Talking about progress in spinal surgery is relative. If you look at surgical practices over the weeks, the months and even the last year or two, you hardly notice any changes. It's like watching grass grow. But then if you cast your eye over the last fifty years it's absolutely incredible. For example, take childhood scoliosis (irregular curvature of the spine). Fifty years ago if you operated on a child with scoliosis, the child would have to spend eighteen months in a cast and in a bed. Now, if you operate on the same type of scoliosis, the kid is out of the hospital after five days and is just asked him to refrain from aggressive sports."

Dr. Bitan's early training in spinal surgery took place in France and involved work with some of the most innovative surgeons of the period. After graduating from medical school in Paris he spent a year the "Institut Calot" in northern France following the steps of Dr. Cotrel who revolutionized the treatment of spinal deformities by inventing what became known as "Cotrel-Dubousset Instrumentation." This was the first step to radically change the approach to scoliosis and kyphosis (curving of the spine), liberating children from a period of interminable recuperation in castes.

What about artificial discs?

Charite Disc implant (from an ABC News Feature)
After ten years of academic and private practice in France Dr Bitan came to the United States where he spear-headed the adoption of a new technique for the treatment of badly diseased discs. He served for four years as the principal investigator for the Food and Drug Administration (FDA) trial of the Charite Artificial Disc (pictured above) until its approval in 2004. Dr. Bitan became one of the country's leading practitioners of artificial disc replacement. The Charite disc was first developed at the Charite Hospital in Berlin where Dr. Bitan also trained. (A recent five-year follow-up study of the Charite implant, of which Dr Bitan has done over three hundred, has demonstrated a success rate superior to the traditional disc fusion technique.)

Minimally invasive surgery
During the decade of the 2000s the general migration of surgery towards minimally invasive techniques that had won over so many orthopedists eventually made its way to spine surgeons. However, minimally invasive surgery in the case of the spine has proved to have unique complexities. Dr. Bitan describes some of the peculiarities of spine surgery.

"The indications for spine surgery are often difficult to assess. Most back problems eventually go away of themselves. Moreover, unlike heart surgery where a cardiologist can state with almost 100% certainty that surgery is required, or a gastroenterologist that abdominal surgery is required, there is no "spinologist" who can do the same thing for the spine surgeon. So the decision to do surgery is often not clear."

If the indications for surgery are not always clear, the peculiar techniques of back surgery are also unusual.

For example, as counter-intuitive as it seems, some disc replacement surgery involves entry by the abdomen (anterior spinal surgery). Minimal surgery using this approach would seem on the surface to be impossible, and that was the assumption until just a few years ago.

Lateral approach of the spine for fusion

From an "XLIF" (Extreme Lateral Interbody Fusion) animation. XLIF is a minimally invasive surgical technique that allows an anterior spinal fusion of the lumbar or thoracic spine.

"Someone came up with the idea of doing a very small incision on the side of the flank and put a tube through the muscle to the spine, put a camera in there and he claimed you could do an anterior fusion this way. Now, I do that three times a month. This technique - which is listed on my web site - is known as "XLIF". That refers to "lateral access surgery" and "XLIF" is one of them but many companies have similar products."

Sacro-iliac minimally invasive fusion

Model used to illustrate the IFUSE technique for the fusion of the sacroiliac joint.
Another minimal surgery that Dr. Bitan has specialized in is known as the "IFUSE Technique.

In the past such a fusion could only be accomplished through an extensive procedure followed by a long recovery period and uncertain results. IFUSE allows the surgeon to accomplish the thing using a minimally invasive approach.

Endoscopic spinal surgery
But the minimally invasive approach Dr. Bitan feels may have the most promise for a wide group of patients is a form of endoscopic disc surgery which he began to study in Germany two years ago. This surgery, he believes, has no equivalent in America. It is highly complex to master, but its results are remarkable. "There's a center in Germany, near Dusseldorf, where they use an endoscopic technique for spinal surgery. It is similar to having a knee scope or a shoulder scope. This seems very strange in the case of the spine, because the spine is such a complex structure.

"Until now there has been very few serious endoscopic spine surgery in this country. Some claim doing a simple disc decompression which in my book doesn't mean much the particular problem hasn't been solved"

Endoscopic surgery being performed on a damaged disk

"But then I heard of the German center which is doing thousands of cases a year. You can't do thousands a year without the procedure really working. So I went over and spent some time there. I was shocked what they were able to do with the scope. The vision is much more clear than through a microscope during an open procedure. But it took me quite a while to convince myself to go there and look into it, and now I am really convinced. The only problem is that this technique has a very steep learning curve.

I finally met with Dr Kai Liu, in New Jersey, who has extensive experience and who also has traveled all over the world to master this technique. He became an expert with several thousand cases. I went to visit him and was convinced of his expertise I now work with him for my endoscopic cases.

Downsides of minimally invasive surgery
But Dr. Bitan quickly adds a general caveat about minimally invasive surgery:

"What a patient needs to appreciate is that minimally invasive surgery is worthwhile only if you can do the same quality of work as with traditional surgery. If you have to sacrifice quality or the safety of the patient, it isn't indicated. After all, the goal is not to have a small scar; the goal is to fix your spine problem. At the beginning of a new technique the rate of complication is higher than traditional surgery. In traditional surgery you open the whole spine area so you see what you are doing, so minimally invasive surgery is dangerous until you reach a certain level of expertise when it becomes safer."
Dr Bitan is the author of dozens of peer-reviewed publications about spinal surgery, and is a frequent presenter at spine surgery meetings around the world.

The curiosity for new or alternative methods - both on the medical and cultural level - is what makes Dr. Bitan and his practice unusual. The latest techniques discovered during surgical trips around the world are joined with age-old techniques (often equally ignored in much of the world). In Dr. Bitan's boutique, high-tech is controlled by the hands of a family doctor. The only criterion is the future well-being of the patient.

"If I had to describe myself in terms of adopting new technology, I'm very aggressive, to the point of spending months abroad to learn new techniques, which means I have to leave my practice, which is at least short term, detrimental. Yet, long term, it probably benefits my patients. In terms of taking a patient to the operating room, I am very conservative. We have to accept the fact that a lot of patients with spine problems just get better if you give them more time. This pays back, because patients have more confidence."