Minimally Invasive Spine Surgery Research Articles

2nd and 3rd generation full endoscopic lumbar spine surgery: clinical safety and learning curve.

2nd and 3rd generation endoscopic spine surgery techniques offer visualisation of familiar inter-laminar anatomy to spinal surgeons. We have prospectively evaluated the clinical outcome, complications and learning curve associated with these techniques in patients with lumbar spine radiculopathy. This is a prospective study of 50 consecutive patients with radicular pain from disc herniation and/or lateral recess stenosis. In 6 patients, endoscopy couldn't be done. Operating times, PROM's (VAS, ODI and EQ-5D scores) and complication rates of 44 patients were evaluated after mean FU of 52months (range 39-65). MRI was used to divide these into protrusions (n = 19), extrusions (n = 17) and lateral recess stenosis (n = 8). Evidence about the learning curve was gathered by curvilinear regression analyses. Using a composite clinical success criterion, 95% patients had a successful outcome, with no major complications. ODI, VAS and EQ-5D scores had a statistically significant improvement and achieved MCID. Revision discectomy rate was only 4.5% (n = 2). MRI based grouping, case sequence and degree of difficulty influenced the duration of surgery and a learning curve was found for protrusions and lateral recess decompressions, but not for extrusions. A learning curve effect was also observed with respect to the ODI. Although anatomy visualised in 2nd and 3rd generation endoscopy is familiar to spinal surgeons, our learning curve experience suggests a careful and MRI pathology based take up of this technique in clinical practice, despite its clinical safety in our series. Level 3, prospective cohort study.

Temperature change of epidural space by radiofrequency use in biportal endoscopic lumbar surgery: safety evaluation of radiofrequency.

Articles evaluating radiofrequency (RF) safety are insufficient. Thus, the purpose of this study was to investigate RF safety during biportal endoscopic lumbar decompressive laminotomy by measuring epidural temperature after RF use. Both in vitro cadaveric study and in vivo study were performed. The epidural temperature was measured at epidural space after RF use in three cadavers. The epidural temperature was measured and analysed according to RF mode, RF power, RF usage time, and saline irrigation patency. In the in vivo study, the epidural temperature was measured after biportal endoscopic surgery. Epidural temperatures were measured around ipsilateral and contralateral traversing nerve roots after 1-s use of RF. In the in vivo study, epidural space temperature was increased by 0.31 ± 0.16°C ipsilaterally and 0.29 ± 0.09° contralaterally after RF use in coagulation mode 1. The epidural temperature of epidural space was increased by 0.21 ± 0.13°C ipsilaterally and 0.15 ± 0.21°C contralaterally after RF use in high mode 2. In the in vitro study, epidural temperature was significantly increased with a long duration of RF use and a poor patency of irrigation fluid. The use of RF in biportal endoscopic spine surgery might be safe. In order to reduce indirect thermal injuries caused by RF use, it might be necessary to reduce RF use time and maintain continuous saline irrigation patency well.

A Narrative Review of Biportal Endoscopic Spine Surgery in the Cervical and Thoracic Spine: Insights into Its Capabilities, Limitations, and Possibilities

Biportal spinal endoscopy has been successfully utilized for the surgical treatment of common spinal conditions, mainly in the lumbar spine. Surgeons recently have translated this technique to the cervical and thoracic spine. Little is known regarding the clinical effectiveness and safety profile of the biportal endoscopic technique in the cervical and thoracic spine. This is a narrative review of the applications of biportal spinal endoscopy in the cervical and thoracic spine, dis- cussing its current capabilities, limitations, and possible future applications.

MANAGEMENT OF DURAL TEARS IN ENDOSCOPIC LUMBAR SPINE SURGERY – A SYSTEMATIC REVIEW STUDY

Lumbar degenerative disorders are the most common cause of low back pain with or without radicular pain(1) .Lumbar decompression and discectomy are two major and commonly performed surgeries for patients not responding to conservative management. Microscopic lumbar discectomy and decompression are gold standard to treat these diseases(2). Endoscopic lumbar spine surgeries are being done at more and more centers since last decade(3). Dural tears are common but troublesome complication of Endoscopic Spine surgeries. Management of the same is well dened in Microscopic lumbar discectomy but not clearly dened for tears during endoscopic surgeries. Therefore, this study is an attempt to establish management principles after extensive reviewing of studies on management principles of iatrogenic dural tears during endoscopic spine surgeries till date. PRISMA (Preferred Methodology: reporting items for systematic reviews and meta-analyses) guideline was used. A search of articles in PubMed, MEDLINE, Embase published between were included in the screening process. For identication of studies included detailed computerized literature search strategies were carried out in these databases. Total of 1569 studies on 'Dural tear Study selection: s ' were identied from electronic database from year 1947 to 2023 searching. Out of those 1569 studies, 180 studies were regarding Dural tears in endoscopic spine surgeries. After exclusion, 7 studies qualied the inclusion criteria and were included as per eligibility criteria for further analysis. Objective of this study is to do a systematic review on present guid Objective: elines for management of dural tears in endoscopic spine surgery

Risk factors for ninety-day readmissions following full-endoscopic transforaminal lumbar discectomy for 1542 patients in the biggest spine institutes in Korea.

Endoscopic techniques are becoming popular among spine surgeons because of their advantages. Though the advantages of endoscopic spine surgery are evident and patients can be discharged home within hours of surgery, readmissions can be sought for incomplete relief of leg pain, recurrent disc herniation, and recurrent leg pain. We aim to find out the factors related to the readmission of patients treated for lumbar pathologies. This is a retrospective analysis of the data between the time duration of 2012 and 2022. Patients in the age group of 18-85years, with lumbar disc herniation treated by transforaminal endoscopic lumbar procedures, were included. The patients who were readmitted within 90days were included in the R Group and those who were not were included in the NR group. Univariable and multivariable logistic regression analyses were used to find the risk factors for 90-day readmission. There were a total of 1542 patients enrolled in this study. Sex, number of episodes before admission, hypertension, smoking, BMI, migration, disc height, disc height index, spondylolisthesis, instability, pelvic tilt (PT), and disc cross-sectional area (CSA) were found significant on univariable analysis. Age, spondylolisthesis, instability and muscle CSA were the only variables that were found to be statistically significant on multivariable analysis. This study shows that the elderly age group, presence of spondylolisthesis, segmental instability and decreased muscle cross-sectional area are independent risk factors for 90-day hospital readmissions. Patients having the above risk factors should be carefully counseled regarding the possibility of readmission in the future.

Survey research of patient's preference on choosing microscopic or endoscopic spine surgery for lumbar discectomy.

There are several surgical methods of lumbar discectomy which provide the similar clinical outcomes. There is no clear evidence for how to select the procedures. To better understand the patient's opinion and decision process in the selection of surgical methods between microscopic lumbar discectomy (MLD) and endoscopic lumbar discectomy (ELD). A cross-sectional survey study. Summary information sheet was created by reviewing the comparative literatures, and tested for quality and bias. Participants read the summary information sheet then were asked to complete the anonymous questionnaire. Seventy-six patients (71%) of patients who had no experience in lumbar discectomy selected ELD while 31 patients (29%) selected MLD. There were significant differences of score between patients who selected MLD and ELD in this group for wound size, anesthetic method, operative time, blood loss and length of stay (P< 0.05). In patients who had experience in discectomy group, 22 patients (76%) who underwent MLD still selected MLD if they could select surgical methods again for themselves, while 24 patients (96%) who underwent ELD still selected ELD if they could select again. The most important factor in patients who selected MLD was outcomes of treatment. The most important factor in patients who selected ELD was wound size. There were significant differences of scores between patients who selected MLD and ELD in this group for wound size, anesthetic method, operative time, complication, cost and length of stay (P< 0.05). About two thirds of the participants preferred ELD after reading the summary evidence information. The most important factor in MLD group was outcomes of treatment while the most important factor in ELD group was wound size.

Surgeon reported practice patterns related to full endoscopic cervical decompression procedures.

The microsurgical anterior approach to the cervical spine is commonplace. Fewer surgeons perform posterior cervical microsurgical procedures on a routine basis for lack of indication, more bleeding, persistent postoperative neck pain, and risk of progressive misalignment. In comparison, the endoscopic technique is preferentially performed through the posterior approach. Many spine surgeons and even surgeons versed in lumbar endoscopy are often reluctant to consider endoscopic procedures in the cervical spine. We report the results of a surgeon survey to find out why. A questionnaire of 10 questions was sent to spine surgeons by email and chat groups in social media networks including Facebook, WeChat, WhatsApp, and LinkedIn to collect practice pattern data about microscopic and endoscopic spine surgery in the lumbar and cervical spine. The responses were cross-tabulated by surgeons' demographic data. Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using the statistical package SPSS Version 27.0. The survey response rate was 39.7%, with 50 of the 126 surgeons who started the survey submitting a completed questionnaire. Of the 50 surgeons, 56.2% were orthopedic, and 42% neurological surgeons. Most surgeons worked in private practice (42%). Another 26% were university-employed, 18% were in private practice affiliated with a university, and the remaining 14% were hospital employed. The majority of surgeons (55.1%) were autodidacts. The largest responding surgeon groups were between 35-44years (38%) and between 45-54years of age (34%). Half of the responding surgeons were routinely performing endoscopic cervical spine surgery. The other half did not perform it for the main hurdle of fear of complications (50%). Lack of appropriate mentorship was listed as second most reason (25.4%). More concerns for not performing cervical endoscopic approaches were the perception of lack of technology (20.8%) and suitable surgical indication (12.5%). Only 4.2% considered cervical endoscopy too risky. Nearly a third (30.6%) of the spine surgeons treated over 80% of their cervical spine patients with endoscopic surgeries. Most commonly performed were posterior endoscopic cervical discectomy (PECD; 52%), posterior endoscopic cervical foraminotomy (PECF; 48%), anterior endoscopic cervical discectomy (AECD; 32%), cervical endoscopic unilateral laminotomy for bilateral decompression (CE-ULBD; 30%), respectively. Cervical endoscopic spine surgery is gaining traction among spine surgeons. However, by far most surgeons performing cervical endoscopic spine surgery work in private practice and are autodidacts. This lack of a teacher to shorten the learning curve as well as fear of complications are two of the major impediments to the successful implementation of cervical endoscopic procedures.

Preoperative Dyeing Technique for Decreasing Radiation Exposure in Unilateral Biportal Endoscopic Spine Surgery

Minimally invasive surgery has many advantages, including early recovery and cosmetic preservation. However, the higher radiation exposure to physicians and patients has drawbacks. Preoperative tissue dyeing techniques are feasible options for reducing radiation exposure and procedure time, but their efficacy has not yet been evaluated. Therefore, this study aimed to evaluate surgical outcomes and reduce radiation exposure during unilateral biportal endoscopy surgery. This was a prospective, case-controlled analysis in a tertiary hospital. Patients receiving experimental tissue dye and controls in the nondye group were compared from May 2020 to September 2021. The ipsilateral posterolateral approach (IPA) and the far lateral approach (FLA) were analyzed separately among all single-level spinal procedures without instrumentation. Operative details (operation time, improvement of back and leg pain, and length of hospital stay) and radiation exposure (dose and duration) were compared. A total of 88 cases were included, consisting of 64 interlaminar approaches (experimental: 33, control: 31) and 24 FLAs (experimental: 13 and control: 11). In the IPA approach, the patient and physician radiation exposure doses and duration decreased significantly. Conversely, for the FLA, only the duration of the physician exposure decreased significantly. Preoperative tissue dyeing techniques using IPA can reduce radiation exposure for physicians and patients. However, a decrease in the duration of radiation was observed only in physicians using the FLA. The dyeing technique is effective in IPA, but the efficacy of FLA is doubtful.

STUDY OF FUNCTIONAL OUTCOME OF DORSOLUMBAR SPINE FRACTURES TREATED WITH MINIMAL INVASIVE SPINE SURGERY

Introduction – Spine disorders including spinal instability, bone spurs, ruptured discs, scoliosis, or spinal malignancies, minimally invasive spine surgery (MIS) aims to stabilize the vertebral bones and spinal joints as well as relieve pressure on the spinal nerves. Aims &amp; Objectives - To study the functional outcome of dorsolumbar spine fractures treated with minimal invasive surgery, to study complications of post minimal invasive spine surgery and the course of recovery and physical activity in the study patients, also to evaluate the neurological status post minimal invasive spine surgery. Materials And Methods – 35 patients were included in the study. Inclusion and exclusion criteria was followed. Routine investigations were carried out. Along with it radiographic examination , CTscan &amp; MRI of cervical / thoracic / lumbar spine were also taken based on history. Results - The mean VAS In the present study group was 8.40 at presentation which came down to 1.65 at 6 month follow up which was statistically signicant (p value= &lt;0.001). The mean ODI score in the present study was 61.00% preoperatively which gradually decreased to 24.3% at the end of 6 months which was statistically signicant (p &lt;0.001). According to the modied Mcnab criteria at the nal follow up at 6 months,9 (25.71%) patients were excellent, 15 (42.85%) were good,6 (17.14%) were fair , 5 (14.28%) patients were poor. Conclusion - Minimal invasive spine surgery is safe and efcient technique when compared to traditional open spine surgery

Remote patient monitoring following full endoscopic spine surgery: feasibility and patient satisfaction.

The utilization of telemedicine in healthcare has increased dramatically during the recent COVID-19 pandemic. This study aimed to investigate the feasibility to perform remote patient monitoring after full endoscopic spine surgery via a smartphone application that also allows communication with patients. A smartphone application (SPINEhealthie) was designed at the University of Washington and used to collect patient-reported outcome measures (PROMs) and to provide chat communication between patients and their care team. A total of 71 patients were included in the study and prospectively followed for 3 months postoperatively. Patient demographic characteristics, compliance with surveys, and frequency of chat utilization were recorded. The ease of use, the participants' experiences with the app interface design, and the usefulness of the app were assessed by using the mHealth App Usability Questionnaire (MAUQ). Of all eligible patients, 71/78 (91.0%) agreed to participate. Of these, 60 (85%) patients provided at least 1 postoperative PROM. There was good coverage of the immediate postoperative period with 45 (63.4%) patients providing ≥ 5 PROMs within the 1st week after surgery. The authors observed a 33.2% increase in patient compliance in postoperative PROMs and a 45.7% increase in chat function utilization between the first and last of the three enrollment periods of the study, during which continuous updates were made to improve the app's functionality. Sixty-two (87.3%) patients responded to the user satisfaction survey after using the app for at least 40 days. The MAUQ results revealed excellent rates of satisfaction for ease of use (78.6% of the maximum score), app interface design (71.4%), and usefulness (71.4%), resulting in a total mean MAUQ score of 110 (74.8%). Communication with the doctor (38 votes) was found to be the top feature of the app. Additionally, physical therapy instructions (33 votes) and imaging review (29 votes) were the top two features that patients would like to see in future app versions. Lastly, the authors have presented a case example of a 68-year-old man who used the app for postoperative monitoring and communication after undergoing a two-level lumbar endoscopic unilateral laminotomy for bilateral decompression. Postoperative remote patient monitoring and communication after full endoscopic surgery is feasible using the SPINEhealthie app. Importantly, patients were willing to share their medical information using a mobile device, and they were eager to use it postoperatively as a supplementary tool.

Advancing Education in Endoscopic Spinal Navigation: Novel Methods and Technical Note

This report aims to demonstrate how to teach anatomy and understanding of spinal endoscopic vision and navigation using mnemonics. The authors present a new surgical technique for teaching endoscopic spinal navigation in a didactic manner with tips such as the "rule of the hand" and decomposition of the endoscopic navigation movement. We demonstrate how the surgery is seen and illustrate how images are projected onto the screen, then divide the navigation into spatial orientation and self-navigation. The article describes the proper puncture technique, how to introduce the working portal, and how to assimilate this new anatomical vision using the "rule of the hand." The surgeon projects their hand on the video screen to guide themselves when starting the navigation and uses the same technique to localize regions of interest during surgery. Finally, the authors break down the navigational movement into three components: forceps positioning, triangulation, and joystick motion. One of the biggest challenges when learning spinal endoscopic surgery is understanding the anatomy seen through the endoscope. By decomposing movements required for navigation, one can understand how to make proper use of the equipment as well as improve their knowledge of this "new anatomy." The learning methods taught in this article have the potential to decrease the learning curve and radiation exposure to those that are still acquainting themselves to spinal endoscopic navigation. We recommend that further studies measure and quantify the impact of these methods on surgical practice.

The Role and Future of Endoscopic Spine Surgery: A Narrative Review.

Many types of surgeries are changing from conventional to minimally invasive techniques. Techniques in spine surgery have also changed, with endoscopic spine surgery (ESS) becoming a major surgical technique. Although ESS has advantages such as less soft tissue dissection and normal structure damage, reduced blood loss, less epidural scarring, reduced hospital stay, and earlier functional recovery, it is not possible to replace all spine surgery techniques with ESS. ESS was first used for discectomy in the lumbar spine, but the range of ESS has expanded to cover the entire spine, including the cervical and thoracic spine. With improvements in ESS instruments (optics, endoscope, endoscopic drill and shaver, irrigation pump, and multiportal endoscopic), limitations of ESS have gradually decreased, and it is possible to apply ESS to more spine pathologies. ESS currently incorporates new technologies, such as navigation, augmented and virtual reality, robotics, and 3-dimentional and ultraresolution visualization, to innovate and improve outcomes. In this article, we review the history and current status of ESS, and discuss future goals and possibilities for ESS through comparisons with conventional surgical techniques.

Complications and Management of Endoscopic Spinal Surgery.

In the past, the use of endoscopic spine surgery was limited to intervertebral discectomy; however, it has recently become possible to treat various spinal degenerative diseases, such as spinal stenosis and foraminal stenosis, and the treatment range has also expanded from the lumbar spine to the cervical and thoracic regions. However, as endoscopic spine surgery develops and its indications widen, more diverse and advanced surgical techniques are being introduced, and the complications of endoscopic spine surgery are also increasing accordingly. We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and key words were set as "endoscopic spinal surgery," "endoscopic cervical foramoinotomy," "PECD," "percutaneous transforaminal discectomy," "percutaneous endoscopic interlaminar discectomy," "PELD," "PETD," "PEID," "YESS" and "TESSYS." We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic lumbar surgery was divided into full endoscopic interlaminar and transforaminal approaches and a unilateral biportal approach. We performed a comprehensive review of available literature on complications of endoscopic spinal surgery. This study particularly focused on the prevention of complications. Regardless of the surgical methods, the most common complications related to endoscopic spinal surgery include dural tears and perioperative hematoma. transient dysesthesia, nerve root injury and recurrence. However, Endoscopic spinal surgery, including full endoscopic transforaminal and interlaminar and unilateral biportal approaches, is a safe and effective a treatment for lumbar as well as cervical and thoracic spinal diseases such as disc herniation, lumbar spinal stenosis, foraminal stenosis and recurrent disc herniation.

Endoscopic and Nonendoscopic Approaches to Single-Level Lumbar Spine Decompression: Propensity Score-Matched Comparative Analysis and Frailty-Driven Predictive Model.

The endoscopic spine surgery (ESS) approach is associated with high levels of patient satisfaction, shorter recovery time, and reduced complications. The present study reports multicenter, international data, comparing ESS and non-ESS approaches for singlelevel lumbar decompression, and proposes a frailty-driven predictive model for nonhome discharge (NHD) disposition. Cases of ESS and non-ESS lumbar spine decompression were queried from the American College of Surgeons National Surgical Quality Improvement Program database (2017-2020). Propensity score matching was performed on baseline characteristics frailty score (measured by risk analysis index [RAI] and modified frailty index-5 [mFI-5]). The primary outcome of interest was NHD disposition. A predictive model was built using logistic regression with RAI as the primary driver. Single-level nonfusion spine lumbar decompression surgery was performed in 38,686 patients. Frailty, as measured by RAI, was a reliable predictor of NHD with excellent discriminatory accuracy in receiver operating characteristic (ROC) curve analysis: C-statistic: 0.80 (95% confidence interval [CI], 0.65-0.94) in ESS cohort, C-statistic: 0.75 (95% CI, 0.73-0.76) overall cohort. After propensity score matching, there was a reduction in total operative time (89 minutes vs. 103 minutes, p = 0.049) and hospital length of stay (LOS) (0.82 days vs. 1.37 days, p < 0.001) in patients treated endoscopically. In ROC curve analysis, the frailty-driven predictive model performed with excellent diagnostic accuracy for the primary outcome of NHD (C-statistic: 0.87; 95% CI, 0.85-0.88). After frailty-based propensity matching, ESS is associated with reduced operative time, shorter hospital LOS, and decreased NHD. The RAI frailty-driven model predicts NHD with excellent diagnostic accuracy and may be applied to preoperative decisionmaking with a user-friendly calculator: nsgyfrailtyoutcomeslab.shinyapps.io/lumbar_decompression_dischargedispo.

Current Indications for Spinal Endoscopic Surgery and Potential for Future Expansion.

Endoscopic spine surgery (ESS) has evolved as a safe, effective, and efficient alternative for minimally invasive spine surgery (MISS). The innovation of full-endoscopic systems makes definitive decompression surgery through different approaches feasible. The approach can be determined according to the location of the target lesion or the surgeon's preference. During the past 2 decades, ESS has expanded its indications from lumbar to cervical spines. Except for decompression, endoscopy-assisted fusion surgery is also developing. However, ESS is still evolving and has a steep learning curve. The revolution of technologies and ESS techniques will enable surgeons to treat various spinal diseases more practically. In recent years, the application of the computer-assisted navigation system and augmented reality have reformed imaging quality and interpretation. The endoscopic rhizotomy techniques have opened a new way for MISS of chronic low back pain. This review introduces the current indications of ESS and its potential future expansion.

Why Endoscopic Spine Surgery?

Why Endoscopic Spine Surgery?

Biportal Endoscopic Posterior Thoracic Laminectomy for Thoracic Spondylotic Myelopathy Caused by Ossification of the Ligamentum Flavum: Technical Developments and Outcomes.

Advanced biportal endoscopic surgery techniques can be used to treat thoracic myelopathy secondary to ossification of the ligamentum flavum (OLF). This case series elaborates on a feasible biportal endoscopic technique for thoracic OLF removal and evaluates clinical and radiological outcomes. A biportal endoscopic posterior thoracic laminectomy was performed to remove the thoracic OLF. Surgical techniques have evolved from inside-out piecemeal removal methods to outside-in en bloc removal methods. Preoperative computed tomography was performed to analyze dural ossification and OLF types. Intraoperative videos were reviewed to observe dural ossification and to determine the surgical method. Neurological outcomes were assessed using the Japanese Orthopaedic Association (JOA) score. Clinical symptoms and neurological function improved markedly after surgery (JOA score, preoperative: 12.6 ± 1.0, final follow-up: 15.6 ± 1.2). The mean operation time per segment was not short (106.6 ± 38 minutes). At early experience stages, inside-out piecemeal decompression was used and it caused intraoperative spinal cord injury. However, outside-in en bloc decompression technique did not induce neural complications. Postoperative segmental instability and correlated mechanical back pain were not observed. The biportal endoscopic posterior thoracic approach is an attractive surgical option to treat thoracic spondylotic myelopathy secondary to OLF. Piecemeal inside-out decompression can induce irreversible spinal cord injury, especially in the early experience stages. Outside-in decompression is more efficient and safer than inside-out pattern procedures by minimizing dural manipulation. Nonetheless, this technique is technically demanding and should only be performed in selected patients after acquiring abundant experience with endoscopic spine surgeries.

Determination of Work Related to Endoscopic Decompression of Lumbar Spinal Stenosis.

Background: Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT®) code 62380. However, no work relative value units (wRVUs) are currently assigned to the procedure. A physician's payment needs to be updated to commensurate with the work involved in the modern version of the lumbar endoscopic decompression procedure with and without the use of any implants to stabilize the spine. In the United States, the American Medical Association (AMA) and its Specialty Society Relative Value Scale Update Committee (RUC) proposes to the Centers for Medicare and Medicaid Services (CMS) what wRVUs to assign for any endoscopic lumbar surgery codes. Methods: The authors conducted an independent survey between May and June 2022 which reached 210 spine surgeons using the TypeForm survey platform. The survey link was sent to them via email and social media. Surgeons were asked to assess the endoscopic procedure's technical and physical effort, risk, and overall intensity without focusing just on the time required to perform the surgery. Respondents were asked to compare the work involved in modern comprehensive endoscopic spine care with other commonly performed lumbar surgeries. For this purpose, respondents were provided with the verbatim descriptions of 12 other existing comparator CPT® codes and associated wRVUs of common spine surgeries, as well as a typical patient vignette describing an endoscopic lumbar decompression surgery scenario. Respondents were then asked to select the comparator CPT® code most reflective of the technical and physical effort, risk, intensity, and time spent on patient care during the pre-operative, peri- and intra-operative, and post-operative periods of a lumbar endoscopic surgery. Results: Of the 30 spine surgeons who completed the survey, 85.8%, 46.6%, and 14.3% valued the appropriate wRVU for the lumbar endoscopic decompression to be over 13, over 15, and over 20, respectively. Most surgeons (78.5%; <50th percentile) did not think they were adequately compensated. Regarding facility reimbursement, 77.3% of surgeons reported that their healthcare facility struggled to cover the cost with the received compensation. The majority (46.5%) said their facility received less than USD 2000, while another 10.7% reported less than USD 1500 and 17.9% reported less than USD 1000. The professional fee received by surgeons was <USD 1000 for 21.4%, <USD 2000 for 17.9%, and <USD 1500 for 10.7%, resulting in a fee less than USD 2000 for 50% of responding surgeons. Most responding surgeons (92.6%) recommended an endoscopic instrumentation carveout to pay for the added cost of the innovation. Discussion and Conclusions: The survey results indicate that most surgeons associate CPT® 62380 with the complexity and intensity of a laminectomy and interbody fusion preparation, considering the work in the epidural space using the contemporary outside-in and interlaminar technique and the work inside the interspace using the inside-out technique. Modern endoscopic spine surgery goes beyond the scope of a simple soft-tissue discectomy. The current iterations of the procedure must be considered to avoid undervaluing its complexity and intensity. Additional undervalued payment scenarios could be created if technological advances continue to replace traditional lumbar spinal fusion protocols with less burdensome, yet no less complex, endoscopic surgeries that necessitate a high surgeon effort in terms of time required to perform the operation and its intensity. These undervalued payment scenarios of physician practices, as well as the facility and malpractice expenses, should be further discussed to arrive at updated CPT® codes reflective of modern comprehensive endoscopic spine care.

A Modified Endoscopic Access for Lumbar Foraminal Pathologies; Posterolateral "Intertransverse" Endoscopic Approach to Minimize Postoperative Dysesthesia Following Transforaminal Approach.

To present an innovative, modified endoscopic approach for foraminal/extraforaminal pathologies, to reduce postoperative dysesthesia (POD) following the conventional transforaminal endoscopic approach (the access angle more than 45° from the midline), since POD is one of the major documented disadvantages that may compromise patient satisfaction. We introduce a modified posterolateral technique, termed the intertransverse approach, utilizing a steeper access angle less than 25° through the intertransversarii muscle and the intertransverse space with expanding Kambin triangle via lateral facetectomy/foraminoplasty, to reduce dorsal root ganglion/exiting nerve root irritation under direct visualization and lower the incidence of POD. Consecutive patients undergoing endoscopic spine surgery via the intertransverse approach for foraminal and/or extraforaminal disc herniations or bony stenosis were retrospectively reviewed. Clinical outcomes were reviewed with the primary outcome being POD. Twenty-two patients were included in the review. Patients showed significantly improved clinical outcomes (visual analogue scale leg and back pain and Oswestry Disability Index) postoperatively. There was a low rate of dorsal root ganglion (DRG)-related POD (9.1%, 2 of 22) that was minimal and resolved soon. The inter-transverse endoscopic approach is feasible for lumbosacral foraminal and extraforaminal decompression with significantly improved clinical outcomes and the added advantage of a low rate of DRG-related POD compared to traditionally reported rates in the literature for the conventional transforaminal approach.

Commentary on "Complications and Management of Endoscopic Spinal Surgery".

See the article "Complications and Management of Endoscopic Spinal Surgery" in Volume 20 on page 56.