Although endoscopic spine is still in its early phase of U.S. adoption, many spine surgeons expect it to grow into the next game changer in minimally invasive care.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker’s invites all spine surgeon and specialist responses.
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Editor’s note: Responses were lightly edited for clarity.
Question: How have recent advancements in endoscopic spine surgery changed the landscape of minimally invasive spine treatments?
Tan Chen, MD. Geisinger Musculoskeletal Institute (Danville, Pa.): Endoscopic spine surgery in one form or another has been around since the 1970s but has only more recently seen significant growth in popularity with better visualization, innovative techniques, expandable implants, and integration with navigation. While the technology is certainly exciting especially for outpatient spine surgery, I think there still remain significant hurdles to overcome for widespread adoption in terms of the long-term outcomes and patient safety profile of endoscopy over other MIS techniques, as well as insurance reimbursements.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Endoscopic spine surgery I think will carry the day and eventually lead the way in terms of ASC-based spine surgery. I think it is important we all get more comfortable. In terms of pushing the envelope, we have to keep problems to a minimum and focus on picking the right surgery instead of force-feeding patients on a technical aspect of a case. I do think most spine surgeons will be pretty darn good at this in the next three to five years.
Brandon Hirsch, MD. DISC Sports and Spine Center (Newport Beach, Calif.): Recent advancements in endoscopic spine surgery are disrupting the landscape of minimally invasive spine care. For some procedures, the incremental benefit of endoscopy is small and there is debate about whether it is clinically meaningful. However, for certain more complex procedures, the benefits of spinal endoscopy for patient and surgeon are dramatic. The two main scenarios where this applies are in the treatment of certain types of foraminal stenosis and in the treatment of ventrally based spinal cord compression in thoracic spine.
Historically, surgeons have recommended spine fusion in cases of foraminal stenosis due to the perceived need to remove much (or all) of the facet joint in order to achieve decompression of the nerve root. Removing a significant amount of the facet joint (at least 50%) is known to destabilize the spinal segment such that fusion is required to prevent postoperative instability and recurrent stenosis. Spinal endoscopy is changing that line of thinking due to the enhanced visualization made possible by an endoscope. Because the endoscope places the surgeon’s viewpoint (camera) inside the spine, we can see and access much more of the foramen with much less bone removal than traditional techniques. The 15-degree to 30-degree angle on many endoscopes, as well as the different transforaminal approach options, further improves our ability to visualize foraminal pathology. In my opinion, endoscopic foraminal decompression techniques have created a motion-preserving surgical treatment option for patients who would traditionally be recommended for fusion. This applies to many but not all cases of foraminal stenosis. Cases with significant disc height loss causing “pedicle to pedicle” stenosis are probably still best treated with an interbody technique.
Endoscopic transforaminal approaches are beginning to revolutionize the treatment of thoracic spinal stenosis from ventral pathology such as disc herniations, infection and/or neoplasms. Traditionally, these problems have been treated either with less invasive retropleural approaches using a tubular retractor or with an open thoracotomy. The morbidity of these approaches related to lung/chest cavity function can be significant. With an endoscope, surgeons can now achieve the same (or superior) visualization of the ventral thoracic spinal canal with minimal to no trauma to the chest cavity. This transforms the postoperative course from a multi-day hospital stay to an outpatient recovery where patients are discharged home the same day. Surgeons should understand that this type of endoscopy is technically challenging and comes with a steep learning curve. Although it has great promise, it will be crucial that we ensure adequate training as more surgeons adopt the technique.
Choll Kim, MD, PhD. Excel Spine (San Diego): We are headed toward two types of spine surgeons, similar to the world of knee surgeons. Our orthopedic sports medicine colleagues do everything in the ASC, while the joint replacement surgeons mostly stay in the hospital. I expect the same will happen in the spine world. The reasons are compelling. The towers are already there. Ortho, ENT, GI, urology and bariatrics use them. No need for an additional spine-specific operating microscope. When we consider the increasing bureaucracy of the hospital, and the fact that hospital administrators now greatly outnumber surgeons, the ASC is even more attractive. The next wave of energetic, entrepreneurial spine surgeons will naturally follow our colleagues in sports and urology, seeking greater freedom, efficiency, and control of the ASC, which will drive the use of the endoscope for most bread-and-butter spine cases. It is natural selection and a freight training coming.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): From this trained observer, recent graduates have expressed interest and a paltry completion of a handful of these procedures, which to the microscopically, open proceduralist, have resulted in a high percentage of takebacks and prolongation of a historically reliable and successful method. Most nursing personnel reserve concerns about time allotments and express worry over potential dural intrusions and repair. That being stated, the introduction of many procedures requires both time and discipline to enable advancement and assurances in any field. Minimally invasive surgery is the soon to be established normalcy, being more frequently requested by patients and family.
