Endoscopic spine surgery has a growing following among surgeons and patients. As it grows its presence in spine care, leaders consistently cite one of its biggest barriers to wider adoption is the difficult learning curve.
Surgeons typically need 40 to 60 cases to become proficient in the technique, according to Daniel Refai, MD, a spine surgeon at Atlanta-based Emory Healthcare who has worked on several international consensus statements on endoscopy. Much of that time goes to simply getting oriented: operating through a camera in a fluid-filled field, often relying on X-ray, without a precise sense of where instruments sit in the anatomy.
Dr. Refai’s answer is a workflow technique he’s established in his practice — continuous navigation. In May, he performed the world’s first continuously navigated endoscopic transforaminal lumbar interbody fusion, according to a news release from Amplify Surgical. He said the bigger story is what the approach does for surgeons still learning endoscopy.
“Basically, you’re not lost,” Dr. Refai told Becker’s. “As a result of it, your learning curve is reduced, your accuracy increases, your surgical performance increases and patient outcomes are better.”
Navigating every step
Emory has offered endoscopic spine surgery for about four years and is among the busiest endoscopic spine centers in the U.S., Dr. Refai said. He started with uniportal endoscopy, an approach well suited to disc problems and bony stenosis.
About 18 months ago, he moved into biportal endoscopy, which pairs an arthroscope in one hand with standard working instruments in the other. That expands what surgeons can do endoscopically, including fusions.
Navigation is already common in spine surgery. But less common in endoscopic procedures where even when endoscopic surgeons do navigate, they typically stop, remove their instrument, insert a navigation probe to confirm their position and then go back in.
Dr. Refai and his team spent about 12 months breaking the biportal procedure into individual steps and navigating each one: incision planning, docking, camera placement, the working channel and every instrument used for discectomy, laminectomy, screw placement and cage placement. That meant customizing trackers originally built for larger open-surgery instruments and working around the fluid-filled field, which can reduce navigation fidelity.
“The traditional navigation tools won’t work for an endoscopic procedure because they were never meant to be used in endoscopic procedures,” he said. “So, we had to recreate the entire procedure step by step.”
The team performed continuously navigated endoscopic laminectomies, diskectomies and synovial cyst resections before moving to fusion. “We still are the only individuals that can continuously navigate a biportal endoscopic procedure from start to finish,” Dr. Refai said.
Every biportal case Dr. Refai has done has been navigated from the start, and his partners now navigate their cases as well.When asked if the technique would be a game-changer for endoscopic spine, Dr. Refai responded confidently.
“100%,” he said. “We are already seeing changes.”
30-minute training sessions
The payoff is clearest in training, Dr. Refai said. For a recent course, he taught surgeons an endoscopic approach on a model in about 30 minutes, a skill he said would otherwise take many four-hour sessions. The surgeons already knew how to operate and how to navigate; continuous navigation gave them a familiar reference point alongside the endoscope view.
“They’re not dealing with, ‘I don’t even know where I am geographically because I’m in a camera underneath water and I’m looking upside down and I’m lost,'” he said.
With the endoscope and navigation screens correlated, a surgeon can see which side they are on, how much bone remains to be removed and where the disc and nerve sit — “and you don’t have to take the instrument out and bring in a probe and stop the flow of your surgery,” he said.
Dr. Refai is scheduled to teach the technique in South Korea next month. He argued the technique’s biggest effect is on adoption rather than on the surgery itself. “It doesn’t make the endoscopy better; it makes the surgeons more comfortable,” he said. “So more surgeons will do endoscopy, and more patients will have access to it, so they don’t have to go to super centers.”
Today, only a handful of U.S. surgeons are major users of endoscopy, and patients often travel long distances to reach them, he said. Residents and fellows trained at Emory are already taking the procedures to their own communities. “Five years from now, this is going to be a ubiquitous procedure,” Dr. Refai said.
Endoscopy has also changed Dr. Refai’s own practice. Because the approach disrupts less tissue — and navigation makes tissue removal more precise — many patients he once would have fused no longer need a fusion, he said. He now performs far more endoscopic decompressions than fusions; the TLIF remains his only continuously navigated fusion to date.
It is also too early to measure outcomes tied specifically to continuous navigation, he said, since he is one of the only surgeons doing it. Reimbursement is still taking shape as well, though he said payers are seeing endoscopy patients go home sooner.
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