Saqib Hasan, MD, a complex spine surgeon with expertise in minimally invasive techniques, spoke to Becker's Spine Review about how endoscopic spine surgery has benefited his practice and why he anticipates more surgeons adopting endoscopic approaches in the future.
Note: Responses are lightly edited for style and clarity.
Question: Do you see more surgeons adopting endoscopic techniques as spine procedures continue to migrate to the outpatient setting?
Dr. Saqib Hasan: I think the migration to endoscopic procedures is just one component of the larger shift to the outpatient setting. This move is largely facilitated by more surgeons utilizing minimally invasive techniques and leveraging technologies to provide reliable outcomes and faster postoperative recovery. However, most simple decompression surgeries are typically already done as outpatient procedures. The move toward endoscopic spine surgery is more intuitive — if you can utilize a 7mm camera to achieve equivalent or superior outcomes compared to current standard techniques, the question becomes, "Why wouldn't I use endoscopic techniques?"
Many surgeons themselves would likely prefer receiving an endoscopic discectomy over a standard microdiscectomy — I know I would. Numerous randomized-controlled trials have shown the significant benefits of endoscopic techniques in the context of less postoperative pain and faster recovery, which lends to the wider trend toward the ambulatory care setting.
Q: What do you attribute the lack of endoscopic spine surgery programs to?
SH: Endoscopic spine surgery is already very popular in Asia and Europe, and more U.S. surgeons continue to adopt these techniques. Training always lags behind new technology. Only after a critical mass of spine surgeons begin utilizing endoscopic techniques will you start to see it as part of a normal spine surgical curriculum in the U.S. Many of my attendings in residency learned arthroscopic techniques after they had completed their training. Arthroscopic surgery really revolutionized orthopedic surgery because of the paradigm shift from open surgery.
Unfortunately, I believe early iterations of endoscopic spine surgery were not ready for prime time. The technology and techniques were not there, hence, the clinical data didn't stack well against what was tried and true. With the current picture quality and instrument improvements, endoscopic spine surgery today allows for an elegant and versatile method of treating both simple and complex spinal pathology.
Q: Do you see more institutions adopting endoscopic-based fellowships in the coming years?
SH: Endoscopic-based techniques are not currently a part of the normal landscape of spine surgical training. I had an interest in arthroscopic techniques in residency, which carried over into my spine surgical training. I did a significant amount of research on endoscopic spine surgery, and I truly believed it would be a standard tool spine surgeons would use in the future. This led me to seek an advanced endoscopic spine surgery fellowship after completing my spine fellowship. The problem was, there were no fellowships dedicated to teaching endoscopic spine surgery in an academic setting. I found my way to a discussion with Christoph Hofstetter, MD, at the University of Washington in Seattle.
Dr. Hofstetter was utilizing endoscopic techniques for the cervical, thoracic and lumbar spine — techniques I had never seen in my training. The combination of the breadth and volume of endoscopic cases performed in an academic training environment allowed for the creation of the first U.S.-based full-endoscopic spine fellowship. There are currently no other U.S.-based advanced fellowship programs that provide comprehensive training in the full gamut of endoscopic spine techniques of the cervical, thoracic and lumbar spine.
However, I do not think advanced endoscopic-based fellowship programs will become the norm. I do think endoscopic spine techniques will find their way into the armamentarium of more and more surgeons, broadening the exposure to trainees. There may be a time when certain training programs may be considered more "endoscopic-heavy," akin to the "deformity-heavy" programs of today.
Q: What is the most difficult aspect of endoscopic spine surgery training?
SH: There are certainly some initial difficulties. The magnified anatomy from an unfamiliar perspective combined with the mechanical peculiarities of handling a uniportal endoscope can be daunting for novice surgeons. However, the mechanics and relative anatomy can be learned fairly easily. Like most things in surgery, the wisdom is in knowing when not to use a particular technique. I believe the most difficult aspect is understanding which scenarios endoscopic techniques provide a benefit for both the surgeon and the patient. I think when you understand what the endoscope can and cannot do, you prepare yourself for success.
Q: What advice do you have for those looking to learn endoscopic spine surgery?
SH: For the average surgeon (not in training) who wants to learn these techniques, I'd recommend going to some of the industry-sponsored endoscopic courses to get your hands familiar with the technology. I encourage anyone interested in learning to really do a deep dive into transforaminal anatomy — something that is not stressed traditionally. I also think a mentorship model is critical in providing guidance and feedback as you begin your endoscopic journey. Understanding some of the finer nuances will come with experience.
Q: What are the optimal cases for endoscopic spine surgery?
SH: We recently published a paper that focused on "The Benefit Zone of Endoscopic Spine Surgery." The gist of that article was that the benefits of endoscopic techniques are really realized when the alternative options become increasingly invasive and complex. The best example of that would be a calcified thoracic disc herniation — the treatment options include a large transthoracic surgery, [video-assisted thoracoscopic spinal surgery], trans-pedicular approach, etc., all of which have varying levels of morbidity.
These are not small procedures. Then you take an endoscopic thoracic discectomy, and you've turned that very complicated surgery into a relatively easy procedure with great outcomes. I think as more spine surgeons learn and apply endoscopic techniques to the easier surgeries, we'll see great opportunities for the more complex surgeries. I try to use endoscopic techniques whenever possible because they are my happiest patients.
Q: What is your opinion on interventional pain management physicians performing endoscopic spine surgery?
SH: I am a firm believer that physicians should not perform a procedure unless they are comfortable handling any potential complications from that procedure. Any endoscopic procedure involving the neural elements should be performed by spine surgeons. There are a variety of endoscopic-based pain procedures such as an endoscopic radiofrequency ablation, which have better outcomes than standard RFA. I think it is reasonable for an appropriately trained pain management physician to perform these procedures. I would strongly recommend close mentorship with an experienced surgeon as, even in the most benign pain-based application, there is potential for serious nerve injury.