Surgeons are increasingly touting the advantages of endoscopic spine surgery, but its widespread adoption is restricted by a lack of training programs, its reimbursement structure and challenging learning curve.
Here, three surgeons detail their experience with endoscopic spine surgery and offer advice for overcoming the learning curve:
Tony Mork, MD. (Newport Beach, Calif.): I think there's a steep learning curve. The physician must have an interest and perhaps be thinking that maybe there's a better way to treat back or neck problems than with a fusion. The problem is there's not currently a detailed guided pathway. It requires a lot of practice. If you start with the easy cases and begin developing your skill set, while becoming comfortable with the process, you can master the easier cases, and move on to more difficult ones. If you do some of the more difficult cases in the beginning, you might fall off the horse and not want to get back on.
Saqib Hasan, MD. Webster Orthopedics (Oakland, Calif.): 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.
Ashish Patel, MD. DuPage Medical Group (Downers Grove, Ill.): The learning curve is real; it's a different skill set. Orthopedic spine surgeons have this comfort with arthroscopy. Being able to use a camera through a small incision has been part of my training in orthopedic surgery. My learning curve will consist of doing the more straightforward cases first. Once I've mastered those, I will push myself to do the more complex cases. The straightforward, most accessible cases would be disc herniation cases at L2-3, L3-4, L4-5.
Once you've mastered those, you proceed to L5-S1 and perform disc herniation cases that have gone into the foramen or the far lateral region to do more central disc herniations. After you master these and feel comfortable with all disc herniations in the lower back, you then move onto lumbar stenosis cases, which would be more of a midline approach using slightly different equipment. Then, you can move on to cervical cases, such as laminoforaminotomies or thoracic cases. Once you have a comfort in that, you then proceed to what surgeons are now working toward, which is lumbar fusions through the endoscope.