Full endoscopic resection of ventral thoracic osteophyte and repair of spontaneous CSF leak.

Spontaneous CSF leaks frequently cause headaches, meningismus, and nausea due to intracranial hypotension. When conservative treatment fails, surgical repair is indicated. Especially ventral leaks necessitate invasive approaches with substantial blood loss and tissue trauma. Full endoscopic spine surgery (FESS) enables circumferential access via the transforaminal approach. Here, the authors show the successful repair of a ventral CSF leak in the thoracic spine after removal of bony osteophytes utilizing FESS with placement of a dural substitute and sealant. Lasting symptom relief was reported. These results suggest that FESS is safe and efficient for the repair of spontaneous and incidental CSF leaks. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23209.

Economic implications of dural tears in lumbar microdiscectomies: a retrospective, observational study.

STUDY DESIGN: Retrospective cohort study. Level of Evidence Level III. Dural tears (DT) are a frequent complication after lumbar spine surgery. With this study we sought to determine the incidence of DT and the related impact on healthcare expenditures after lumbar discectomies. All patients with first-time single level lumbar discectomies at our institution that underwent minimally-invasive surgery from 2015 to 2019 were reviewed. Age, sex, weight, height, body mass index (BMI), costs, revenues, length of stay (LOS), American Society of Anesthesiology (ASA) score, Charlson Comorbidity Index (CCI) and operation time (OT) were assessed. Exclusion criteria were age < 18 years, previous spine surgery, multiple or traumatic disc herniations but also malignant and infectious diseases. The follow-up time was at least 12 months postoperatively. 358 patients with lumbar discectomies were identified and 230 met the inclusion criteria. The DT incidence was 3.5%. The mean costs (p < 0.001), the loss (p < 0.01) and the operation time (p < 0.0001) were found to be significantly higher in the DT group when compared to the control group of patients without a DT. The revenues were not statistically different between both groups (p > 0.05). Further analysis of the control group by profit and loss revealed significantly higher BMI (p < 0.05), LOS (p < 0.0001) and OT (p < 0.0001) in the loss group. DT represent a significant socioeconomic burden in lumbar spine surgery and cause severe secondary complications. The DT-related impact on healthcare expenses is primarily based on significantly higher OT and a higher mean LOS.

Endoscopic decompression of a C1 osteophyte causing bow hunter's syndrome in a 22-year-old male.

The patient is a 22-year-old male with a history of C1 avulsion fracture causing vertebral artery compression with pseudoaneurysm and symptomatic stroke. Cerebral angiography demonstrated dynamic compression of the V3 segment of the vertebral artery due to a chronic C1 avulsion fracture. The authors utilized a full endoscopic approach with intraoperative angiography for proximal control and Doppler ultrasound to confirm adequate decompression. The surgery duration was 3 hours with blood loss < 5 ml. The patient was discharged on postoperative day 1 with no complication and has been asymptomatic since surgery. This is the first documented use of endoscopic decompression to treat this condition. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23234.

Full endoscopic resection of large bilateral synovial cysts in lumbar spine.

Synovial spinal cysts cause radiculopathy and back pain, with rare reports of cauda equina syndrome. Hypermobility and instability are cornerstones for synovial cyst formation. The incidence is around 5%, and data for bilateral cysts are lacking. Surgery is indicated after conservative measures fail. Recurrence is common and is potentially due to joint violation and destabilization from open surgery. This could be prevented via ultra-minimally invasive approaches. The authors present full endoscopic removal of bilateral synovial cysts in a patient with grade 1 stable spondylolisthesis and include a 360° view for confirmation of complete decompression. Postoperatively, the patient reported immediate pain relief. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23208.

Endoscopic Posterior Cervical Foraminotomy Under Lateral Decubitus Position with Local Anesthesia.

BACKGROUND: Endoscopic posterior cervical foraminotomy is gaining popularity among endoscopic spine surgeons for the treatment of radiculopathy caused by foraminal stenosis. METHODS: This study describes a technique using the lateral decubitus position for endoscopic posterior cervical foraminotomy under monitored anesthesia care and local anesthesia only. RESULTS: A total of 10 patients with contraindications to general anesthesia underwent the procedure, resulting in improvement in cervical radicular pain with no perioperative complications. CONCLUSIONS: The findings suggest that this approach is a viable alternative for patients at high risk of general anesthesia care, expanding the surgical options for the treatment of radiculopathy.

An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery.

STUDY DESIGN: Clinical practice guideline development. OBJECTIVES: Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). METHODS: A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS: The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. CONCLUSIONS: It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

Smartphone applications for remote patient monitoring reduces clinic utilization after full-endoscopic spine surgery.

INTRODUCTION: The rising number of outpatient spine surgeries creates challenges in postoperative management and care. Telemedicine offers a unique opportunity to reduce in-person clinic visits and improve resource allocation. We aimed to investigate the impact of a validated smartphone application on clinic utilization following full-endoscopic spine surgery (FESS). METHODS: We evaluated patients undergoing FESS from 2020 to 2022 and a pre-COVID control group (CG) from 2018 to 2019. Subsequently, we divided the patients into three groups: one using the application (intervention group, IG), and two CGs (2020-2022, CG and 2018-2019, historical control group (HG)). We analyzed the post-surgical hospitalization rate, all follow-ups, and virtually transmitted patient-reported outcomes. RESULTS: A total of 115 patients were included in the IG. The CG consisted of 137 and the HG of 202 patients (CG and HG in the following). Group homogeneity was satisfactory regarding patient age (p = 0.9), sex (p = 0.88), and body mass index (p = 0.99). IG patients were treated as outpatients significantly more often [14.78% vs. 29.2% vs. 37.62% (p < 0.001)]. Additionally, IG patients showed significantly higher follow-up compliance [74.78% vs. 40.14% vs. 37.13% (p < 0.001)] 3-month post-surgery and fewer in-patient follow-up visits [(0.5 ± 0.85 vs. 1.32 ± 0.8 vs. 1.33 ± 0.7 (p < 0.001)]. CONCLUSION: Our results underline the feasibility, efficacy, and safety of remote patient monitoring following FESS. Furthermore, they highlight the opportunity to implement a virtual wound checkup, and to substantially improve postoperative follow-up compliance via telemedicine.

Pain alleviation and functional improvement: ultra-early patient-reported outcome measures after full endoscopic spine surgery.

OBJECTIVE: Questions regarding anticipated pain improvement and functional recovery postsurgery are frequently posed in preoperative consultations. However, a lack of data characterizing outcomes for the first postoperative days only allows for anecdotal answers. Hence, the assessment of ultra-early patient-reported outcome measures (PROMs) is essential for patient-provider communication and patient satisfaction. The aim of this study was to elucidate this research gap by assessing and characterizing PROMs for the first days after full endoscopic spine surgery (FESS). METHODS: This multicenter study included patients undergoing lumbar FESS from March 2021 to July 2023. After informed consent was provided, data were collected prospectively through a smartphone application. Patients underwent either discectomy or decompression. Analyzed parameters included demographics, surgical details, visual analog scale scores for both back and leg pain, and the Oswestry Disability Index (ODI) score. Data were acquired daily for the 1st postoperative week, as well as after 2 weeks, 3 months, and 6 months. RESULTS: A total of 182 patients were included, of whom 102 underwent FESS discectomy and 80 underwent FESS decompression. Significant differences between the discectomy and decompression groups were found for age (mean 50.45 ± 15.28 years and 63.85 ± 13.25 years, p < 0.001; respectively), sex (p = 0.007), and surgery duration (73.45 ± 45.23 minutes vs 98.05 ± 46.47 minutes, p < 0.001; respectively). Patients in both groups reported a significant amelioration of leg pain on the 1st postoperative day (discectomy group VAS score: 6.2 ± 2.6 vs 2.4 ± 2.9, p < 0.001; decompression group: 5.3 ± 2.8 vs 1.9 ± 2.2, p < 0.001) and of back pain within the 1st postoperative week (discectomy group VAS score: 5.5 ± 2.8 vs 2.8 ± 2.2, p < 0.001; decompression group: 5.2 ± 2.7 vs 3.1 ± 2.4, p < 0.001). ODI score improvement was most pronounced at the 3-month time point (discectomy group: 21.7 ± 9.1 vs 9.3 ± 9.1, p < 0.001; decompression group: 19.3 ± 7.8 vs 9.9 ± 8.3, p < 0.001). For both groups, pain improvement within the 1st week after surgery was highly predictive of later benefits. CONCLUSIONS: Ultra-early PROMs reveal an immediate pain improvement after FESS. While the benefits in pain reduction plateaued within the 1st postoperative week for both groups, functional improvements developed over a more extended period. These results illustrate a biphasic rehabilitation process wherein initial pain alleviation transitions into functional improvement over time.

Assessing the impact of obesity on full endoscopic spine surgery: surgical site infections, surgery durations, early complications, and short-term functional outcomes.

OBJECTIVE: An increasing number of obese patients undergoing elective spine surgery has been reported. Obesity has been associated with a substantially higher number of surgical site infections and a longer surgery duration. However, there is a lack of research investigating the intersection of obesity and full endoscopic spine surgery (FESS) in terms of functional outcomes and complications. The aim of this study was to evaluate wound site infections and functional outcomes following FESS in obese patients. METHODS: Patients undergoing lumbar FESS at the participating institutions from March 2020 to March 2023 for degenerative pathologies were included in the analysis. Patients were divided into obese (BMI > 30 kg/m2) and nonobese (BMI 18-30 kg/m2) groups. Data were collected prospectively using an approved smartphone application for 3 months postsurgery. Parameters included demographics, surgical details, a virtual wound checkup, the visual analog scale for back and leg pain, and the Oswestry Disability Index (ODI) as a functional outcome measure. RESULTS: A total of 118 patients were included in the analysis, with 53 patients in the obese group and 65 in the nonobese group. Group homogeneity was satisfactory regarding patient age (obese vs nonobese: 55.5 ± 14.7 years vs 59.1 ± 17.1 years, p = 0.25) and sex (p = 0.85). No surgical site infection requiring operative revision was reported for either group. No significant differences for blood loss per level (obese vs nonobese: 9.7 ± 16.8 ml vs 8.0 ± 13.3 ml, p = 0.49) or duration of surgery per level (obese vs nonobese: 91.2 ± 57.7 minutes vs 76.8 ± 39.2 minutes, p = 0.44) were reported between groups. Obese patients showed significantly faster improvement regarding ODI (-3.0 ± 9.8 vs 0.7 ± 11.3, p = 0.01) and leg pain (-4.4 ± 3.2 vs -2.9 ± 3.7, p = 0.03) 7 days postsurgery. This effect was no longer significant 90 days postsurgery for either ODI (obese vs nonobese: -11.4 ± 11.4 vs -9.1 ± 9.6, p = 0.24) or leg pain (obese vs nonobese: -4.3 ± 3.9 vs -3.5 ± 3.8, p = 0.28). CONCLUSIONS: The results highlight the effectiveness and safety of lumbar FESS in obese patients. Unlike with open spine surgery, obese patients did not experience significant increases in surgery time or postoperative complications. Interestingly, obese patients demonstrated faster early recovery, as indicated by significantly greater improvements in ODI and leg pain at 7 days after surgery. However, there was no difference in improvement between the groups at 90 days after surgery.

Validation of smartphone app-based digital patient reported outcomes in full-endoscopic spine surgery.

PURPOSE: Patient reported outcome measures (PROMs) are important tools to assess patient function, pain, disability, and quality of life. We aim to study the efficiency and validity of digital PROMs collection using a smartphone app compared to traditional paper PROMs. METHODS: Patients undergoing evaluation for full-endoscopic spine surgery were recruited from the outpatient clinic at Harborview Medical Center. Visual analogue scale (VAS), Oswestry disability index (ODI), and EQ5-5D PROMs were administered on paper and through a smartphone app called SpineHealthie. Compliance rates were collected, and PROM results were assessed for correlation between paper and digital methods. RESULTS: 123 patients were enrolled. 57.7% of patients completed paper PROMs, 82.9% completed digital PROMs, and 48.8% completed both. Of the patients that completed both, Spearman's correlation was greatest for VAS leg, ODI, and EQ5 index scores. Correlation was weaker for VAS back pain, neck pain, and upper extremity pain. Patients tended to report lower disability and higher quality of life on the digital PROM compared to the paper PROM. CONCLUSION: The SpineHealthie app effectively and accurately collects PROMs digitally, showing strong concordance with traditional paper PROMs. We conclude that digital PROMs constitute a promising strategy for monitoring patients after spine surgery over time.

Comparative analysis of perioperative characteristics and early outcomes in transforaminal endoscopic lumbar diskectomy: general anesthesia versus conscious sedation.

PURPOSE: To better understand how anesthesia type impacts patient selection and recovery in TELD, we conducted a multicenter prospective study which evaluates the differences in perioperative characteristics and outcomes between patients who underwent TELD with either general anesthesia (GA) or conscious sedation (CS). METHODS: We prospectively collected data from all TELD performed by five neurosurgeons at five different medical centers between February and October of 2022. The study population was dichotomized by anesthesia scheme, creating CS and GA cohorts. This study's primary outcomes were the Oswetry Disability Index (ODI) and the Visual Analog Scale (VAS) for back and leg pain, assessed preoperatively and at 2-week follow-up. RESULTS: A total of 52 patients underwent TELD for symptomatic lumbar disk herniation. Twenty-three patients received conscious sedation with local anesthesia, and 29 patients were operated on under general anesthesia. Patients who received CS were significantly older (60.0 vs. 46.7, p < 0.001) and had lower BMI (28.2 vs. 33.4, p = 0.005) than patients under GA. No intraoperative or anesthetic complications occurred in the CS and GA cohorts. Improvement at 2-week follow-up in ODI, VAS-back, and VAS-leg was greater in patients receiving CS relative to patients under GA, but these differences were not statistically significant. CONCLUSION: In our multicenter prospective analysis of 52 patients undergoing TELD, we found that patients receiving CS were significantly older and had significantly lower BMI compared to patients under GA. On subgroup analysis, no statistically significant differences were found in the improvement of PROMs between patients in the CS and GA group.

Incidence and management of dural tears in full-endoscopic unilateral laminotomies for bilateral lumbar decompression.

PURPOSE: To report incidence of dural lacerations in lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) and to describe patient outcomes following a novel full-endoscopic bimanual durotomy repair. METHODS: Retrospective review of prospectively collected database including 5.5 years of single surgeon experience with LE-ULBD. Patients with no durotomy were compared with patients who experienced intraoperative durotomy, including demographics, ASA score, prior surgery, number of levels treated, procedure time, hospital length of stay (LOS), visual analogue scale, perioperative complications, revision surgeries, use of analgesics, and Oswestry Disability Index (ODI). RESULTS: In total, 13/174 patients (7.5%) undergoing LE-ULBD experienced intraoperative durotomy. No significant differences in demographic, clinical or operative variables were identified between the 2 groups. Sustaining a durotomy increased LOS (p = 0.0019); no differences in perioperative complications or rate of revision surgery were identified. There was no difference in minimally clinically important difference for ODI between groups (65.6% for no durotomy versus 55.6% for durotomy, p = 0.54). CONCLUSION: In this cohort, sustaining a durotomy increased LOS but, with accompanying intraoperative repair, did not significantly affect rate of complications, revision surgery or functional outcomes. Our method of bimanual endoscopic dural repair provides an effective approach for repair of dural lacerations in interlaminar ULBD cases.

Full-endoscopic trans-pars interarticularis approach for far lateral lumbar discectomy.

PURPOSE: Surgical management of far lateral disc herniations remains challenging. Current transforaminal full-endoscopic approaches require non-visualized docking in the Kambin's triangle and have been associated with significant risk of inadvertent nerve injury. We develop a full-endoscopic approach based on reliable bony landmarks allowing for visualization of the exiting nerve root prior to the far lateral discectomy. METHODS: The surgical details of a full-endoscopic trans-pars interarticularis approach for far lateral discectomy are described. These descriptions include high quality intraoperative images and important surgical pearls. A small patient cohort is presented to demonstrate feasibility and safety of the procedure. RESULTS: We demonstrate the feasibility of this approach in 14 patients with a mean age of 59.5 ± 14.7 years. At a mean follow up of 21.9 ± 6.8 months, improvement of the visual analogue scale (VAS) for leg pain was 4.3 ± 1.0 resulting in minimally clinically important difference in 78.6% of the patients. The mean improvement in VAS for the back pain was 2.6 ± 0.8 and for Oswestry disability index (ODI) was 20.6 ± 5.3. Nuances of the trans-pars surgical techniques are presented in a patient with a right-sided L4-5 far lateral disc herniation. Preoperative imaging studies, steps of the surgical progression, and intraoperative views are described in detail. CONCLUSION: Using the pars interarticularis as the bony target area allows for safe visualized access to the extraforaminal compartment of the exiting nerve root. This novel surgical technique has the potential benefit of decreasing inadvertent neural injury and subsequent postoperative dysesthesias.

Full-endoscopic technique mitigates obesity-related perioperative morbidity of minimally invasive lumbar decompression.

PURPOSE: Obesity is associated with increased surgical complexity and postoperative complications in spine surgery. Minimally invasive procedures have been shown to lessen some of the increased risk in obese patients. This study investigated whether utilization of a working channel endoscope can further mitigate obesity-associated challenges in spinal surgery. METHODS: A retrospective review of a single-surgeon database was conducted for all adult patients undergoing full-endoscopic unilateral laminotomies for bilateral decompression between November 2015 and March 2021. Data collected included body mass index, in operating room preparation time, procedure time, length of hospital stay, use of analgesics, complications, and quality of life measured by Oswestry Disability Index. RESULTS: Our cohort included 174 patients. Of these, 74 (42.5%) were obese. The average age was 63.6 years. In-operating room preparation time was 70.0 ± 1.7 min for obese patients and 64.4 ± 1.5 min for non-obese patients (p = 0.02). There was no difference in operative time, durotomy rates or other perioperative complications between obese and non-obese patients. Hospital length of stay trended toward longer in the obese group, but did not reach significance. A greater percentage of obese patients were still using both narcotic and non-narcotic pain medications 2 weeks after surgery. There was no significant difference in functional outcomes between groups. CONCLUSION: Full-endoscopic unilateral laminotomies for bilateral decompression are safe and effective in both non-obese and obese patients. The use of an endoscope can partially mitigate obesity-related morbidity in lumbar decompression. However, obesity is significantly related to increased postoperative analgesic use.

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

OBJECTIVE: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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 35-44 years (38%) and between 45-54 years 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. CONCLUSION: 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.

Learning curve for endoscopic posterior cervical foraminotomy.

PURPOSE: While anterior cervical discectomy and fusion as well as cervical disk arthroplasty are gold standard treatments for the surgical treatment of cervical radiculopathy, posterior endoscopic cervical foraminotomy (PECF) as a substitute procedure is gaining popularity. To date, studies investigating the number of surgeries needed to achieve proficiency in this procedure are lacking. The purpose of the study is to examine the learning curve for PECF. METHODS: The learning curve in operative time for two fellowship-trained spine surgeons at independent institutions was retrospectively assessed for 90 uniportal PECF procedures (PBD: n = 26, CPH: n = 64) performed from 2015 to 2022. Operative time was assessed across consecutive cases using a nonparametric monotone regression, and a plateau in operative time was used as a proxy to define the learning curve. Secondary outcomes assessing achievement of endoscopic prowess before and after the initial learning curve included number of fluoroscopy images, visual analog scale (VAS) for neck and arm, Neck Disability Index (NDI), and the need for reoperation. RESULTS: There was no significant difference in operative time between surgeons (p = 0.420). The start of a plateau for Surgeon 1 occurred at 9 cases and 111.6 min. The start of a plateau for Surgeon 2 occurred at 29 cases and 114.7 min. A second plateau for Surgeon 2 occurred at 49 cases and 91.8 min. Fluoroscopy use did not significantly change before and after surmounting the learning curve. The majority of patients achieved minimally clinically important differences in VAS and NDI after PECF, but postoperative VAS and NDI did not significantly differ before and after achieving the learning curve. There were no significant differences in revisions or postoperative cervical injections before and after reaching a steady state in the learning curve. CONCLUSION: PECF is an advanced endoscopic technique with an initial improvement in operative time that occurred after as few as 8 cases to as many as 28 cases in this series. A second learning curve may occur with additional cases. Patient-reported outcomes improve following surgery, and these outcomes are independent of the surgeon's position on the learning curve. Fluoroscopy use does not change significantly along the learning curve. PECF is a safe and effective technique that current and future spine surgeons should consider as part of their armamentarium.

Full-Endoscopic Lumbar Discectomy Approach Selection: A Systematic Review and Proposed Algorithm.

STUDY DESIGN: A systematic review of the literature to develop an algorithm formulated by key opinion leaders. OBJECTIVE: This study aimed to analyze currently available data and propose a decision-making algorithm for full-endoscopic lumbar discectomy for treating lumbar disc herniation (LDH) to help surgeons choose the most appropriate approach [transforaminal endoscopic lumbar discectomy (TELD) or interlaminar endoscopic lumbar discectomy (IELD)] for patients. SUMMARY OF BACKGROUND DATA: Full-endoscopic discectomy has gained popularity in recent decades. To our knowledge, an algorithm for choosing the proper surgical approach has never been proposed. MATERIALS AND METHODS: A systematic review of the literature using PubMed and MeSH terms was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient samples included patients with LDH treated with full-endoscopic discectomy. The inclusion criteria were interventional research (randomized and nonrandomized trials) and observation research (cohort, case-control, case series). Exclusion criteria were case series and technical reports. The criteria used for selecting patients were grouped and analyzed. Then, an algorithm was generated based on these findings with support and reconfirmation from key expert opinions. Data on overall complications were collected. Outcome measures included zone of herniation, level of herniation, and approach (TELD or IELD). RESULTS: In total, 474 articles met the initial screening criteria. The detailed analysis identified the 80 best-matching articles; after applying the inclusion and exclusion criteria, 53 articles remained for this review. CONCLUSIONS: The proposed algorithm suggests a TELD for LDH located in the foraminal or extraforaminal zones at upper and lower levels and for central and subarticular discs at the upper levels considering the anatomic foraminal features and the craniocaudal pathology location. An IELD is preferred for LDH in the central or subarticular zones at L4/L5 and L5/S1, especially if a high iliac crest or high-grade migration is found.

Use of prophylactic perioperative antibiotics for lumbar spinal fusions: A nationwide population-based cohort study.

BACKGROUND: Perioperative prophylactic antibiotic (PPA) use in spine surgery is known to reduce the rate of surgical site infections. In the past decade, several evidence-based guidelines have been published and surveillance systems to monitor the proper use of antimicrobials had been adapted by many institutes. OBJECTIVE: To report the trends of PPA prescription in lumbar fusion surgeries nationwide in the Republic of Korea. METHODS: This is a nationwide registry study. Using the population-based data from the Republic of Korea provided by the Korean Health Insurance Review and Assessment Service, data of all lumbar spinal fusion surgeries performed between 2010 and 2018 in adult patients (age ≥19 years) were reviewed. RESULTS: The most frequently used antibiotics were first-generation cephalosporins, which accounted for 38.2 % of total PPA prescriptions and were prescribed in 58.96 % of lumbar fusion surgeries. A gradual increase in prescription trends was observed. The second most frequently used PPAs were second-generation cephalosporins, which showed decrease in use from 2016. The frequency of vancomycin prescriptions gradually increased over the observation period and showed an almost four-fold increase in 2018 compared to 2010. First- and second-generation cephalosporins were prescribed less frequently to patients with renal disease. CONCLUSION: The pattern of PPA use has changed remarkably over the observation period. Furthermore, specific differences in PPA prescriptions were observed among patients with certain co-morbidities.