Access to Technology and Education for the Development of Minimally Invasive Spine Surgery Techniques in Latin America

Abstract

To evaluate access to the technologies and education needed to perform minimally invasive spine surgery (MISS) in Latin America. We designed a questionnaire to evaluate surgeons' practice characteristics, access to different technologies, and training opportunities for MISS techniques. The survey was sent to members and registered users of AO Spine Latin from January 6-20, 2020. The major variables studied were nationality, specialty (orthopedics or neurosurgery), level of hospital (primary, secondary, tertiary), number of surgeries performed per year by the spine surgeon, types of spinal pathologies commonly managed, and number of MISS performed per year. Other variables involved specific access to different technologies: intraoperative fluoroscopy, percutaneous screws, cages, tubular retractors, microscopy, intraoperative computed tomography, neuronavigation imaging, and bone morphogenetic protein. Finally, participants were asked about main obstacles to performing MISS and their access to education on MISS techniques in their region. The questionnaires were answered by 306 members of AO Spine Latin America across 20 different countries. Most answers were obtained from orthopedic surgeons (57.8%) and those with over 10 years of experience (42.4%). Most of the surgeons worked in private practice (46.4%) and performed >50 surgeries per year (44.1%), but only 13.7% performed >50 MISS per year, mainly to manage degenerative pathologies (87.5%). Most surgeons always had access to fluoroscopy (79%). Only 26% always had access to percutaneous screws, 24% to tubular retractors, 34.3% to cages (anterior lumbar interbody fusion, lateral lumbar interbody fusion, or transforaminal lumbar interbody fusion), and 43% to microscopy. Regarding technologies, 71% reported never having access to navigation, 83% computed tomography, and 69.3% bone morphogenetic protein. The main limitations expressed for widely used MISS technologies were the high implant costs (69.3%) and high navigation costs (49.3%). Most surgeons claimed access to online education activities (71%), but only 44.9% reported access to face-to-face events and 28.8% to hands-on activities, their limited access largely because the courses were expensive (62.7%) or few courses were available on MISS in their region (51.3%). Most surgeons in Latin America have limited resources to perform MISS, even in private practice. The main constraints are implant costs, access to technologies, and limited face-to-face educational opportunities.