What's needed for endoscopic spine to take off: Q&A with Dr. Saqib Hasan

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Saqib Hasan, MD, is an endoscopic spine pioneer, completing California's first endoscopic lumbar fusion with robot-assisted technology.

That case was done in August, and Dr. Hasan said he created his own workflow to integrate robotics into the endoscopic procedure. Thinking about the future of endoscopic spine surgery, he told Becker's what will be needed to make it more widespread.

Note: These responses were edited for style and length.

Question: What was the biggest learning curve when integrating robot-assisted technology with endoscopic spine surgery?

Dr. Saqib Hasan: The biggest learning curve was conceptually understanding how to leverage the value of these technologies in an efficient manner. Currently, there is no robotic system which allows easy integration of robotic and endoscopic technologies. I had to essentially create a workflow and then I went to the lab to try it out. The lab was successful, so I decided to utilize this workflow in a one-level fusion case. The case turned out well; she was discharged the next day and continues to do excellent at about six months postoperatively.

Q: How can robotics help with endoscopic spine adoption?

SH: The bottom line is that robotic navigation in spine surgery is not there yet; it certainly has value in streamlining pedicular instrumentation, particularly when performing multilevel percutaneous fusion constructs. I think once spine robots receive FDA clearance for uses beyond user-operated trajectory planning, it may allow for more spine surgeons to feel comfortable with different endoscopic approaches.

Q: What areas of endoscopic spine surgery education and adoption still need improvement?

SH: The biggest issue with endoscopic education is that there is no quality control on training. There are many surgeons who are performing endoscopic techniques who simply went to a course or two and then dive right into cases without proper mentorship. I have heard of and even seen many surgeons getting into some real problems because of overconfidence.

Endoscopic spine surgery can be humbling as it requires precise targeting and thorough understanding of relative anatomy – being off by a few millimeters or having the wrong angle can easily double the time of a surgery. For surgeons who are seriously interested in adopting these techniques, I would encourage them to visit and spend time with surgeons who are not only facile with the different approaches but also comfortable with performing these procedures in the cervical and thoracic spine.

There are many excellent endoscopic spine surgeons in academic centers who are training residents and fellows. Christoph Hofstetter, MD, at Seattle-based University of Washington, Albert Telfeian, MD, PhD, at Providence, R.I.-based Brown University, Raymond Gardocki, MD, at Nashville, Tenn.-based Vanderbilt University, Mark Mahan, MD, at Salt Lake City-based University of Utah, Peter Derman, MD, at Plano-based Texas Back Institute and Meng Huang, MD, at Houston Methodist are just a few surgeons that come to mind when I think of more advanced techniques.

There are organizations such as the Endoscopic Spine Academy (ESPINEA), whose mission is to standardize teaching by creating educational programs led by international endoscopic spine experts. ESPINEA has been accredited by the oldest surgical college in the world, the Royal College of Surgeons of Edinburgh, and includes experts like Jian Shen, MD, and Paul Houle, MD, from the U.S., Dr. Alfonso Garcia from Mexico, Ralf Wagner, MD, and Vincent Hagel from Germany, Dr. Muhammed Assous from Jordan and Junseok Bae, MD, from South Korea to name a few.

Q: What will be needed for endoscopic spine surgery to be widely adopted? 

SH: Time. Endoscopic spine surgery is already a global phenomenon and the numbers don't lie. Every year I see a steady increase in the number of publications related to endoscopic techniques and the number of surgeons utilizing endoscopic techniques. There are numerous publications highlighting high levels of adoption of these techniques across Europe and Asia.

The U.S. is tricky because many of the "old guard” are resistant to change. The common debate typically revolves around cost, efficiency, learning curve and reimbursement. Interestingly, a recent randomized controlled trial from the Netherlands showed that endoscopic spine surgery may be more cost effective than open techniques when looking at quality-adjusted life years. Regardless, it is intuitive for patients to want to have a surgery performed by a miniature camera. They are already used to that idea from arthroscopic and laparoscopic surgery.

I have had many patients that have had previous open surgeries who I utilized endoscopic spine surgery techniques on. Every single patient had said the comparison between the two is "night and day." The problem is, to truly demonstrate that this difference is meaningful in a clinical evidence-based sense, we need a highly powered study with minimal procedural variability between surgeons. Part of this is related to the limitations of current standardized patient reported outcome measures. Even if we somehow can show these techniques are superior, spine surgeons who are not committed to spend time learning these techniques due to the learning curve will likely dismiss it due to reimbursement and efficiency-related issues. The truth is, adopting these techniques is more for the patient than for the surgeon. I try to keep sight of that when I am performing a case that would likely take a shorter amount of time if I did it in a standard open way.

Q: What advice would you give to a practice thinking about adding an endoscopic service line?

SH: I think practices will find having surgeons who are skilled in performing endoscopic techniques will help establish an excellent spine referral base, as many patients are amazed at their recovery and often tell their friends and family. From an ASC perspective, I think incorporating endoscopic spine surgery requires an upfront capital investment that eventually pays dividends via increased referrals to that center for more patients seeking these procedures over time. It is also helpful to have a conversation with payers about any potential carveouts they can offer with regard to facility reimbursement when considering incorporating endoscopic spine surgery into the private ASC setting.

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