More than 20 years ago, the Intervertebral Disc Center of the Third People's Hospital of Henan Province was a common pain medicine department. And a bold decision -- to perform the first minimally invasive "transforaminal endoscopic discectomy" in Henan Province -- set the development direction of the department. Since then, their multiple innovative techniques have filled the gap of domestic and overseas medical field, and have promoted the rapid development of endoscopic spine surgery techniques.

In this episode of Healing with Benevolence, Prof. ZHOU Honggang, Assistant of President of the Third People's Hospital of Henan Province, will talk about how the Intervertebral Disc Center achieved breakthroughs in difficulties, made continuous innovations and achievements, and finally becomes a first-class specialty in Henan Province and a well-known specialty in China.

ZHOU Honggang

President Assistant and Chief Expert of Intervertebral Disc Center

Having worked on minimally invasive spine surgeries for more than 20 years, Prof. ZHOU Honggang is proficient in treating all kinds of spine diseases and has rich clinical experience in the diagnosis and treatment of key and complex spine diseases. He is the first in China to develop advanced techniques for cervical, thoracic, and lumbar spine diseases with his team, such as endoscopic spine techniques and computer-guided endoscopic techniques. By now, he and his team have performed up to 30,000 endoscopic spine surgeries in and out of the hospital.

Highlights of Healing with Benevolence (Episode 06)

Date of Interview: August 4, 2023

1.Please share the story between you and the Third People's Hospital of Henan Province.

I have been working at the Third People's Hospital of Henan Province for more than 20 years and there are many stories. One of them has a huge influence on my whole life and even on the development of our department.

From 2007 to 2008, the development of our department hit a bottleneck. At the early stage, we used the techniques like collagenase chemonucleolysis, oxygen-ozone therapy, radiofrequency ablation, and discectomy. However, there are limitations in these techniques -- easy to be copied, which means other spine surgery teams can master the same techniques. Therefore, the development of our department hit a bottleneck.

How could your department continue to grow in difficulties?

In 2010, we got to know endoscopic spine surgery. After we watched the first surgery, we were sure that it must be an disruptive technique and we had to master it. It would be the only way to develop our department further in the future. But we needed to master it first before developing it.

So we asked around for a place to learn and tried to buy the equipment for the surgeries. At that time, I found a commercial agent of medical devices of Henan Province and took him to meet our president. Then our president agreed, “If you install the equipment for us today, we will pay you the fee the next day.” However, after waiting for three months, the agent refused to sell us the equipment because our department, which was called the Department of Pain Medicine back then, had no experience in surgical treatment and it would be hard to develop the technique. The agent said, "I had a hard job to get the position of the commercial agent of Henan Province but it was too difficult to sell the equipment. No matter how much you pay, I won't sell it to you.."

At that time, we were very anxious, because there was only one brand that produced thisendoscope for spine surgery. It was not like today when we have many choices so we can buy whichever available. Later, we managed to buy the equipment from an agent of another province. Then our surgeons put on a lead apron and performed the surgery step by step following the procedures of the first surgery that we had watched. Back then, as a Pain Medicine Department, we had some advantages. We were skilled in punctures and the resection of the disc. Several surgeons wore lead aprons, marked the incision under the C-arm X-ray, and performed the MISS. After we performed 70 or 80 surgeries, we became very familiar with it. And we have been developing this technique until now.

The process from buying equipment to developing the technique is like China's building the first aircraft carrier. For all these years, the memory has been imprinted on my mind and I won't forget it in my whole life. It is of great significance for the development of our department.

2.The Intervertebral Disc Center of the Third People's Hospital of Henan Province is one of the National Units of Key Clinical Specialty Construction. Could you please introduce it?

The Intervertebral Disc Center has been seeing cultivating endoscopic spine surgeons and benefiting patients as its duty. We established the first inter-provincial Minimally Invasive Spine Surgery Specialist Union in China. And there are 79 member units in Henan Province and 35 from other 20 provinces, cities and autonomous regions joining this specialist union. We have been providing non-profit training courses of endoscopic spine surgery technique for spine surgeons from 157 county hospitals of 18 cities of Henan Province. And we have held 25 international forums on endoscopic spine surgery and 101 academic salons on mono-portal and biportal endoscopic spine surgery.

We are recognized in the medical field of both China and the world and have attracted colleagues from 31 provinces, cities and autonomous regions, as well as the Taiwan Region, and more than 4,000 specialists of more than 400 hospitals in China, USA, Germany, India, Pakistan, Iraq, Malaysia, etc. to come to our hospital for academic exchanges. This shows that we are well recognized, but we should still keep moving ourselves forward to reach a higher level of our expertise and team construction.

3. Which surgeries does the Intervertebral Disc Center perform the most? What is the annual surgery volume?

Now we mainly use TESSYS-ISEE technique and unilateral biportal endoscopic (UBE) technique. We have developed from simple discectomy to the treatments for spinal stenosis, from lumbar spine to cervical and thoracic spine, and from the simple decompression to fusion. Now our treatment spectrum covers all the degenerative spinal diseases. The annual surgery volume is about 1,800.

4. The Intervertebral Disc Center of your hospital is the first in China to treat thoracic spinal stenosis with transforaminal endoscopes,which is percutaneous transforaminal endoscopic surgery (PTES) under 3D navigation. Apart from this, is there any other technical innovation?

We have been focusing on MISS for 26 years and have made innovations. Except the endoscopic treatment with local anesthesia for thoracic spinal stenosis, as you just mentioned, the successive development of techniques also fill the gap of domestic and overseas medical field, such as endoscopic posterior cervical surgery using the Delta large-channel technique for cervical spondylosis, lateral interbody fusion with endoscopic surgery for lumbar disc herniation combined with lumbar instability, and endoscope-assisted anterior cervical discectomy and fusion (ACDF) for cervical spondylosis.

Currently, we've developed safer and more precise domestic and overseas MISS techniques. We have applied endoscopic spine surgery techniques first to discectomy, then to other treatments for spinal stenosis, developed treatment for lumbar spine first, then to cervical and thoracic spine, and developed from simple decompression to fusion. Now our treatment spectrum covers all the degenerative spinal diseases. By now, we have performed more than 30,000 endoscopic spine surgeries in and out of our hospital.

5.There are 79 member units in Henan Province and 35 from other 19 provinces, cities and autonomous regions joining the Minimally Invasive Spine Surgery Specialist Union of your hospital. What is the meaning of establishing the Specialist Union?

First, when we established the Minimally Invasive Spine Surgery Specialist Union in 2017, the development of MISS techniques in China was unbalanced and most of the spine departments only performed discectomy. In our hospital, we call it the Era 1.0. But at that time, with continuous innovations, our hospital had already achieved a technical breakthrough from Era 1.0 to 4.0 and was in the lead in China and even the whole world. By then, we had performed more than 10,000 in-hospital endoscopic surgeries with skilled techniques and received good feedback from patients. Therefore, we thought that endoscopic surgeries would benefit more people, then we decided to develop and promote our techniques.

Second, at that time, many colleagues came to our hospital to learn the endoscopic techniques. But it would take a long time for them to learn the cores, master and be qualified for the surgeries. By establishing this Specialist Union, we could support and help other hospitals to develop the techniques in local area so that people can enjoy highly advanced medical treatment without traveling around.

In addition, in 2017, the State Council released the plans for the construction and development of Medical Consortiums which included the establishment of inter-regional specialty unions led by major hospitals who have leading techniques. Therefore, the establishment of Specialist Union also answered the call of national policy to benefit more people in a wider range in China with advanced and new technologies.

6.The Intervertebral Disc Center has organized 162 International Endoscopic Spine Surgery Training Course. What is the aim of offering these courses?

In China, endoscopic spine surgery techniques have developed rapidly these years. It's no longer a highly difficult technique that can only be mastered by a few surgeons of a few hospitals in big cities as it was at the early stage, but now is a clinical skill that can be well performed in hospitals of county level and above. The aim of receiving fellow surgeons from all over China is to build an innovative and open communication platform for deeper and more efficient academic exchanges, so as to narrow the difference among regions, promote the rapid progress and development of MISS departments, and further provide patients all over China with homogenized and high-level medical care. We welcome more colleagues and specialists to visit our hospital for academic exchanges. We believe that with our joint efforts, the cause of MISS will be developed towards a better and brighter future!

This August, Dr. Daniel J. Rosenthal, an international spine master and the Director of the Department of Spine Surgery of Hochtaunus-Kliniken gGmbH Bad Homburg, Germany, visited the Third People's Hospital of Henan Province and carried out a series of academic exchange activities. Dr. Rosenthal said that the Intervertebral Disc Center of the hospital is one of the largest MISS centers that he has ever seen, and that their clinical focus, MISS technique, is in the lead among Chinese hospitals.

7.What did Dr. Rosenthal's visit bring to your hospital?

His arrival brought us many inspiring surprises. First, with his great achievement and rich experience in spine surgery, Dr. Rosenthal provided our team with precious professional guidance and a learning opportunity. He did outpatient service with our colleagues, attended discussions and gave guidance on complex spinal disease cases, and provided the most advanced treatments and techniques for the cases.

Besides, Dr. Rosenthal also gave public lectures, sharing his research results and clinical experience with medical professionals in and out of our hospital, to promote academic exchanges and collaborations. His visit definitely brought new inspirations and improvements to our team, and helped us provide medical services of higher level for patients.

8. Given that you are a professor with multiple responsibilities, what do you think of the relationship among clinical work, teaching and research? How could you balance your time for these three aspects?

Generally speaking, clinical work, teaching and research are three crucial aspects of the career as a doctor. They improve and support one another. Clinical work is the primary duty of doctors. We provide medical services for patients via clinical practice.

Teaching is an important way to pass on professional knowledge and experience to young doctors, students and medical communities so as to cultivate medical professionals for the new generation. Research is to promote the development of medicine. We improve medical practice via research and innovation to provide more effective treatment and medical techniques.

To balance these three aspects, doctors need to have a good time management ability and organization skill. They may allocate more time for clinical work to provide the best care and treatment for patients. Meanwhile, they would find some time to take part in teaching and share experience and knowledge with students and young doctors. In addition, they might spend some time in scientific research, such as in research projects and thesis writing, to promote progress in medicine.

Doctors have to balance the three aspects according to the specific situation, and manage time and allocate resources based on their interests, professional targets, and work demands. Sometimes, they might focus on one aspect and maintain certain involvement in the other two. In general, doctors should find the balance among clinical work, teaching and research to guarantee high-quality medical services, cultivate medical talents for the new generation, and promote the advancement of medicine.

What else would you like to share with us?

No matter in clinical work, teaching or scientific research, I hope everyone can make contributions to public healthcare and the people's well-being with your ability and passion in these three areas. And I hope our efforts will lead to a brighter future! Wish you all the best!