Endoscopic spine surgery is a critical skill for every spine surgeon to have in their armamentarium or at least be familiar with. I was exposed to endoscopic spine surgery by chance in 2018 when I was a spine fellow interviewing for staff positions around the country. At one of my job interviews, an interviewer suggested that I should learn endoscopic spine surgery. I had no idea what he was talking about. When I got to my hotel room that evening, I looked up a video of endoscopic spine surgery on YouTube, and watched Dr. Albert Telfeian perform a lumbar microdiscectomy via a transforaminal approach. I was immediately sold!
At that time, most of these surgeries were being performed in Europe and Asia. I therefore attended the 2018 Asian Congress of Neurological Surgeons meeting where I got to meet two of my future mentors, Dr. Harrison Kim from South Korea and Dr. Marcio Ramalho from Brazil. Dr. Kim was the instructor at my pre-meeting donor-cadaver course, and I ended up spending 6 weeks with him in Seoul later that year. In 2019, I spent a few days shadowing Dr. Ramalho in Brazil. In 2021, I decided to take a sabbatical to do an endoscopic spine fellowship with Dr. Christoph Hofstetter in Seattle, where I got to work one-on-one with a world-renown expert. I can say that Dr. Hofstetter’s promise of “fast-forwarding my development as an endoscopic spine surgeon by 5 years” by spending 6 months with him was an understatement.
The first year or two of starting an endoscopic practice is an exhilarating process. By the end of the process, every surgeon figures out where endoscopy fits in their practice. For some surgeons, almost all cases become endoscopic including lumbar fusions. For others, only one or two procedure-types are better in their hands than the traditional open or tubular approaches. I would say I settled much closer to the former than the latter.
How has endoscopy improved our ability to take care of patients? First, due to the much smaller diameter of the working channel when compared to a tube, endoscopy respects tissue planes and does not place muscle fibers on as much stretch throughout the procedure. Moreover, less tissue is strangulated during the surgery, which minimizes tissue devascularization and possible necrosis. These characteristics likely contribute to decreased immediate postoperative pain in endoscopic spine patients. Second, endoscopy allows a surgeon to perform the same operation as more traditional approaches but with decreased/minimal bony removal due to use of angled endoscopes. This aspect of endoscopy allows for more native structures to remain untouched and theoretically decreases the chances of any future iatrogenic destabilization. Third, with the use of the transforaminal approach (an approach that cannot be done the same way without an angled endoscope), less nerve/spinal cord retraction is needed than with more traditional approaches. This theoretically can decrease retraction injury and resultant neurologic deficits. Fourth, the water pressure from the endoscope acts as a “retractor” to better protect against dural tears and is also a gentler method of dissecting tissue planes than utilizing curettes entirely as is done traditionally. Lastly, endoscopic surgeons have much improved visualization of anatomy due to bringing the camera closer to the lesion when compared to a microscope or loupes. This aspect of endoscopy is especially important in the care of high BMI patients. Unlike in traditional surgery where they are significant challenges, instrument reach and visualization are independent of BMI in endoscopic spine surgery. Notice I did not say anything about incision size, as to me, decreased incision size is just a byproduct. However, patients do love barely seeing any incisions on their bodies after the conclusion of the healing process!
What is a procedure where endoscopy is an absolute game-changer? In my opinion, endoscopy can become the new standard of care in the treatment of thoracic disks. When I counsel a patient with a thoracic disk regarding the benefit of endoscopy, I inform them of two possible outcomes. In the best case scenario, the entire lesion is resected successfully, and the patient is home recovering that evening or the next day. In the worst case scenario (assuming no unexpected neurologic complications), attempting the discectomy with an endoscope makes any traditional anterolateral or posterolateral approach more straightforward as the disk is already partially detached by the first procedure. A second condition where endoscopy is revolutionary is in lumbar foraminal/extraforaminal stenosis with concomitant central or lateral recess stenosis. Typically, these conditions are treated with fusions due to the significant facet joint violation it takes to perform an adequate decompression. With the transforaminal approach and angled endoscopes, a surgeon can decompress the extraforaminal, foraminal, and intracanalicular portions of the stenotic lesion through one incision without the need for a fusion.
How do you start? If you are a resident, I would recommend applying for spine fellowships that include a substantial endoscopic component. Thankfully, endoscopic fellowship options have expanded greatly as almost every major institution has at least one surgeon who performs spine endoscopy. If you are practicing surgeon and can take time off to completely focus on endoscopy, I would recommend spending time with an expert endoscopic surgeon, wherever in the world that might be, either via a sabbatical or observership. If unable to take time off, I would work with an industry partner to guide you through the learning curve. Any skilled, self-critical surgeon can learn endoscopy in a safe manner; all it takes is a level of dedication and willingness to decrease surgical productivity initially.
It is important to take other factors into account regarding whether to include endoscopy into your practice or not. First, patients are well-informed and not infrequently ask if their surgeries can be performed endoscopically. A prominent spine surgeon in New York City once told me that 40% of his patients ask if their procedures can be done endoscopically. Second, forward-thinking hospital systems are looking for surgeons with this skillset. I recently moved my practice to the New York Presbyterian hospital system and the posted job description noted that “minimally-invasive spine surgery skills are required and endoscopic skills are recommended.” It would not be a surprise to me to have endoscopic skills change from being recommended to required in competitive markets in the future. Lastly, learning endoscopy will allow adopters to be ideally-equipped in the future to give their patients the most up-to- date care when multiple technologies such as robotics, artificial intelligence, and augmented reality merge with endoscopy in unified platforms. As such, a surgeon without an endoscopic skillset could risk being left behind when this technology wave continues to barrage through spine surgery and change the way we take care of patients. Due to the reasons mentioned in this article and many more, I again believe that endoscopic skills are important for all spine surgeons to at least be familiar with. Just put your loupes in the loupe-box, cover up your microscope, and enjoy the ride!