Polytomous Rasch Analyses of Surgeons' Decision-Making on Choice of Procedure in Endoscopic Lumbar Spinal Stenosis Decompression Surgeries.

BACKGROUND: With the growing prevalence of lumbar spinal stenosis, endoscopic surgery, which incorporates techniques such as transforaminal, interlaminar, and unilateral biportal (UBE) endoscopy, is increasingly considered. However, the patient selection criteria are debated among spine surgeons. OBJECTIVE: This study used a polytomous Rasch analysis to evaluate the factors influencing surgeon decision-making in selecting patients for endoscopic surgical treatment of lumbar spinal stenosis. METHODS: A comprehensive survey was distributed to a representative sample of 296 spine surgeons. Questions encompassed various patient-related and clinical factors, and responses were captured on a logit scale graphically displaying person-item maps and category probability curves for each test item. Using a Rasch analysis, the data were subsequently analyzed to determine the latent traits influencing decision-making. RESULTS: The Rasch analysis revealed that surgeons' preferences for transforaminal, interlaminar, and UBE techniques were easily influenced by comfort level and experience with the endoscopic procedure and patient-related factors. Harder-to-agree items included technological aspects, favorable clinical outcomes, and postoperative functional recovery and rehabilitation. Descriptive statistics suggested interlaminar as the best endoscopic spinal stenosis decompression technique. However, logit person-item analysis integral to the Rasch methodology showed highest intensity for transforaminal followed by interlaminar endoscopic lumbar stenosis decompression. The UBE technique was the hardest to agree on with a disordered person-item analysis and thresholds in category probability curve plots. CONCLUSION: Surgeon decision-making in selecting patients for endoscopic surgery for lumbar spinal stenosis is multifaceted. While the framework of clinical guidelines remains paramount, on-the-ground experience-based factors significantly influence surgeons' selection of patients for endoscopic lumbar spinal stenosis surgeries. The Rasch methodology allows for a more granular psychometric evaluation of surgeon decision-making and accounts better for years-long experience that may be lost in standardized clinical guideline development. This new approach to assessing spine surgeons' thought processes may improve the implementation of evidence-based protocol change dictated by technological advances was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the International Society for Minimal Intervention in Spinal Surgery (ISMISS), the Mexican Spine Society (AMCICO), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Society (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS).

Comparative Analysis of Learning Curve, Complexity, Psychological Stress, and Work Relative Value Units for CPT 62380 Endoscopic Lumbar Spinal Decompression vs Traditional Lumbar Spine Surgeries: A Paired Rasch Survey Study.

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 (RVUs) are currently assigned to the procedure. An international team of endoscopic spine surgeons conducted a study, endorsed by several spine societies, analyzing the learning curve, difficulty, psychological intensity, and estimated work RVUs of endoscopic lumbar spinal decompression compared with other common lumbar spine surgeries. METHODS: A survey comparing CPT 62380 to 10 other comparator CPT codes reflective of common spine surgeries was developed to assess the work RVUs in terms of learning curve, difficulty, psychological intensity, and work effort using a paired Rasch method. RESULTS: The survey was sent to 542 spine specialists. Of 322 respondents, 150 completed the survey for a 43.1% completion rate. Rasch analysis of the submitted responses statistically corroborated common knowledge that the learning curve with lumbar endoscopic spinal surgery is steeper and more complex than with traditional translaminar lumbar decompression surgeries. It also showed that the psychological stress and mental and work effort with the lumbar endoscopic decompression surgery were perceived to be higher by responding spine surgeons compared with posterior comparator decompression and fusion surgeries and even posterior interbody and posterolateral fusion surgeries. The regression analysis of work effort vs procedural difficulty showed the real-world evaluation of the lumbar endoscopic decompression surgery described in CPT code 62380 with a calculated work RVU of 18.2464. CONCLUSION: The Rasch analysis suggested the valuation for the endoscopic lumbar decompression surgery should be higher than for standard lumbar surgeries: 111.1% of the laminectomy with exploration and/or decompression of spinal cord and/or cauda equina (CPT 63005), 118.71% of the laminectomy code (CPT 63047), which includes foraminotomy and facetectomy, 152.1% of the hemilaminectomy code (CPT 63030), and 259.55% of the interlaminar or interspinous process stabilization/distraction without decompression code (CPT 22869). This research methodology was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the Mexican Society of Spinal Surgeons (AMCICO), the International Society For Minimally Invasive Spine Surgery (ISMISS), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Surgery (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS). CLINICAL RELEVANCE: This study provides an updated reimbursement recommendation for endoscopic spine surgery. LEVEL OF EVIDENCE: Level 3.

Disability-adjusted life years from bone and joint infections associated with antimicrobial resistance: an insight from the 2019 Global Burden of Disease Study.

PURPOSE: Bone and joint infections, complicated by the burgeoning challenge of antimicrobial resistance (AMR), pose significant public health threats by amplifying the disease burden globally. We leveraged results from the 2019 Global Burden of Disease Study (GBD) to explore the impact of AMR attributed to bone and joint infections in terms of disability-adjusted life years (DALYs), elucidating the contemporary status and temporal trends. METHODS: Utilizing GBD 2019 data, we summarized the burden of bone and joint infections attributed to AMR across 195 countries and territories in the 30 years from 1990 to 2019. We review the epidemiology of AMR in terms of age-standardized rates, the estimated DALYs, comprising years of life lost (YLLs) and years lived with disability (YLDs), as well as associations between DALYs and socio-demographic indices. RESULTS: The GBD revealed that DALYs attributed to bone and joint infections associated with AMR have risen discernibly between 1990 and 2019 globally. Significant geographical disparities and a positive correlation with socio-demographic indicators were observed. Staphylococcus aureus infections, Group A Streptococcus, Group B Streptococcus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter-related bone and joint infections were associated with the highest DALYs because of a high proportion of antimicrobial resistance. Countries with limited access to healthcare, suboptimal sanitary conditions, and inconsistent antibiotic stewardship were markedly impacted. CONCLUSIONS: The GBD underscores the escalating burden of bone and joint infections exacerbated by AMR, necessitating urgent, multi-faceted interventions. Strategies to mitigate the progression and impact of AMR should emphasize prudent antimicrobial usage and robust infection prevention and control measures, coupled with advancements in diagnostic and therapeutic modalities.

Randomized Clinical Trials and Observational Tribulations: Providing Clinical Evidence for Personalized Surgical Pain Management Care Models.

Proving clinical superiority of personalized care models in interventional and surgical pain management is challenging. The apparent difficulties may arise from the inability to standardize complex surgical procedures that often involve multiple steps. Ensuring the surgery is performed the same way every time is nearly impossible. Confounding factors, such as the variability of the patient population and selection bias regarding comorbidities and anatomical variations are also difficult to control for. Small sample sizes in study groups comparing iterations of a surgical protocol may amplify bias. It is essentially impossible to conceal the surgical treatment from the surgeon and the operating team. Restrictive inclusion and exclusion criteria may distort the study population to no longer reflect patients seen in daily practice. Hindsight bias is introduced by the inability to effectively blind patient group allocation, which affects clinical result interpretation, particularly if the outcome is already known to the investigators when the outcome analysis is performed (often a long time after the intervention). Randomization is equally problematic, as many patients want to avoid being randomly assigned to a study group, particularly if they perceive their surgeon to be unsure of which treatment will likely render the best clinical outcome for them. Ethical concerns may also exist if the study involves additional and unnecessary risks. Lastly, surgical trials are costly, especially if the tested interventions are complex and require long-term follow-up to assess their benefit. Traditional clinical testing of personalized surgical pain management treatments may be more challenging because individualized solutions tailored to each patient's pain generator can vary extensively. However, high-grade evidence is needed to prompt a protocol change and break with traditional image-based criteria for treatment. In this article, the authors review issues in surgical trials and offer practical solutions.

Patient Perceptions of Paramedian Minimally Invasive Spine Skin Incisions.

BACKGROUND: In clinical outcome studies, patient input into the factors that drive higher satisfaction with lumbar minimally invasive spinal surgery (MISS) is rare. The skin incision is often the only visible consequence of surgery that patients can assess. The authors were interested in patients' opinions about the type of lumbar paramedian minimally invasive spinal (MIS) skin incision employed during MISS and how novel skin incisions could impact patients' interpretation of the outcome. The authors wanted to compare traditional lumbar stab incisions to three novel lumbar paramedian (MIS) skin incisions to determine if further study is indicated. The primary objective was to examine patient satisfaction and perceptions regarding lumbar paramedian MIS skin incisions. METHODS: We reviewed the literature and conducted a patient opinion survey. Responses were solicited from back pain patients from a single chiropractic office. Survey questions regarding novel skin incisions for minimally invasive spine surgery (NSIMISS) were conceptualized. The three novel skin incisions were designed using Langer's lines to reduce the total number of incisions; improve patient satisfaction; increase ease of surgical approach/fixation; and reduce operative time/radiation exposure. RESULTS: One hundred and six participants were surveyed. When shown traditional lumbar paramedian MIS skin stab incisions, 76% of respondents indicated negative responses, n = 65. The majority of patients chose traditional stab incisions (n = 41) followed by novel larger intersecting incisions (n = 37). The least popular incisions were the novel horizontal (n = 20) and the novel mini oblique (n = 5) incisions. Female patients worried more than male patients about how their incision looked. However, there was no statistically significant difference (p value of 0.0418 via Mann-Whitney U one-tailed test and p value of 0.0836 via Mann-Whitney U two-tailed test). Patients less than or equal to 50 years of age worried more than patients over 51 years of age, which was statistically significant (p value of 0.0104 via Mann-Whitney U one-tailed test and p value of 0.0208 via Mann-Whitney U two-tailed test). CONCLUSIONS: Patients do have opinions on the type of lumbar paramedian MIS skin incision used. It appears that younger patients and female patients worry most about how the incision on their back looks after surgery. A larger population of patients across many demographics is needed to validate these findings.

Personalized Interventional Surgery of the Lumbar Spine: A Perspective on Minimally Invasive and Neuroendoscopic Decompression for Spinal Stenosis.

Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States.

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Training and Credentialing Standards for Minimally Invasive Spinal Surgery Techniques: Results of a Survey.

BACKGROUND: BACKGROUND: The controversy continues on how to best become proficient in contemporary minimally invasive spinal surgery techniques (MISST). Postgraduate training programs typically lag behind the innovation. Other subspecialty spine care providers often compete with spine surgeons particularly when they do not offer the treatments needed by their patients. The public debate centers around who should be taught and credentialed in providing surgical spine care. OBJECTIVES: The purpose of this study was to conduct an opinion survey amongst spine care providers regarding the learning curve of MISST and which credentialing standards should be established. SETTING: Surgeon online opinion survey sent by email, and chat groups in social media networks, including WeChat, WhatsApp, and LinkedIn. METHODS: Surgeons were asked the following questions: 1) Do you think MISS is harder to learn compared to open surgery? 2) Do you perform MISS? 3) What type of MISS do you perform? 4) If you perform endoscopic surgery, which approach(es)/technique(s) do you employ? 5) In your opinion, where does the innovation take place? 6) Where should MISST be taught? 7) Do you think mastering the MISST learning curve and surgeon skill level affect patient outcomes? 8) Which credentialing criteria do you recommend? Demographic data of responding surgeons, including age, postgraduate training and years from graduation, and practice setting, were also obtained. Descriptive statistics were employed to count the responses and compared to the surgeon's training using statistical package SPSS Version 27.0 (IBM Corporation, Armonk, NY). RESULTS: The online survey was viewed by 806 surgeons, started by 487, and completed by 272, yielding a completion rate of 55.9%. Orthopedic surgeons comprised 52.6% (143/272) of respondents, followed by 46.7% (127/272) neurosurgeons, and 0.7% pain management physicians (2/272). On average, respondents had graduated from a postgraduate training program 15.43 ± 10.13 years. Nearly all respondents employed MISST (252/272; 92.8%) and thought that proficiency in MISST affects patients' outcomes (270/272; 98.2%). Some 54.1% (146/270) opined that MISS is more challenging to learn than traditional open spine surgery. Preferred credentialing criteria were 1) number of MISST cases (87.5%; 238/272), b) skill level (69.9%; 190/272), and c) proficiency assessment (59.9%; 163/272). A case log review (42.3%; 116/272) or an oral examination (26.1%; 71/272) was not favored by surgeons. Surgeons reported academia (43.4%; 116/267) and private practice (41.2%; 110/267) as the centers of innovation. Only 15.4% (41/267) of respondents opined that industry was the main driver over innovation. LIMITATIONS: Geographical and cultural biases may impact the opinions of responding surgeons. CONCLUSIONS: Respondents preferred case volume, skill level, and proficiency assessment as credentialing criteria. Surgeons expect academic university programs and specialty societies to provide the necessary training in novel MISST while working with governing boards to update the certification programs.

A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy.

Background: Endoscopically visualized spine surgery has become an essential tool that aids in identifying and treating anatomical spine pathologies that are not well demonstrated by traditional advanced imaging, including MRI. These pathologies may be visualized during endoscopic lumbar decompression (ELD) and categorized into primary pain generators (PPG). Identifying these PPGs provides crucial information for a successful outcome with ELD and forms the basis for our proposed personalized spine care protocol (SpineScreen). Methods: a prospective study of 412 patients from 7 endoscopic practices consisting of 207 (50.2%) males and 205 (49.8%) females with an average age of 63.67 years and an average follow-up of 69.27 months was performed to compare the durability of targeted ELD based on validated primary pain generators versus image-based open lumbar laminectomy, and minimally invasive lumbar transforaminal interbody fusion (TLIF) using Kaplan-Meier median survival calculations. The serial time was determined as the interval between index surgery and when patients were censored for additional interventional and surgical treatments for low back-related symptoms. A control group was recruited from patients referred for a surgical consultation but declined interventional and surgical treatment and continued on medical care. Control group patients were censored when they crossed over into any surgical or interventional treatment group. Results: of the 412 study patients, 206 underwent ELD (50.0%), 61 laminectomy (14.8%), and 78 (18.9%) TLIF. There were 67 patients in the control group (16.3% of 412 patients). The most common surgical levels were L4/5 (41.3%), L5/S1 (25.0%), and L4-S1 (16.3%). At two-year f/u, excellent and good Macnab outcomes were reported by 346 of the 412 study patients (84.0%). The VAS leg pain score reduction was 4.250 ± 1.691 (p < 0.001). No other treatment during the available follow-up was required in 60.7% (125/206) of the ELD, 39.9% (31/78) of the TLIF, and 19.7% (12/61 of the laminectomy patients. In control patients, only 15 of the 67 (22.4%) control patients continued with conservative care until final follow-up, all of which had fair and poor functional Macnab outcomes. In patients with Excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients (p < 0.001). The overall survival time in control patients was eight months with a standard error of 0.942, a lower boundary of 6.154, and an upper boundary of 9.846 months. In patients with excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients versus control patients at seven months (p < 0.001). The most common new-onset symptom for censoring was dysesthesia ELD (9.4%; 20/206), axial back pain in TLIF (25.6%;20/78), and recurrent pain in laminectomy (65.6%; 40/61) patients (p < 0.001). Transforaminal epidural steroid injections were tried in 11.7% (24/206) of ELD, 23.1% (18/78) of TLIF, and 36.1% (22/61) of the laminectomy patients. The secondary fusion rate among ELD patients was 8.8% (18/206). Among TLIF patients, the most common additional treatments were revision fusion (19.2%; 15/78) and multilevel rhizotomy (10.3%; 8/78). Common follow-up procedures in laminectomy patients included revision laminectomy (16.4%; 10/61), revision ELD (11.5%; 7/61), and multilevel rhizotomy (11.5%; 7/61). Control patients crossed over into ELD (13.4%), TLIF (13.4%), laminectomy (10.4%) and interventional treatment (40.3%) arms at high rates. Most control patients treated with spinal injections (55.5%) had excellent and good functional outcomes versus 40.7% with fair and poor (3.7%), respectively. The control patients (93.3%) who remained in medical management without surgery or interventional care (14/67) had the worst functional outcomes and were rated as fair and poor. Conclusions: clinical outcomes were more favorable with lumbar surgeries than with non-surgical control groups. Of the control patients, the crossover rate into interventional and surgical care was 40.3% and 37.2%, respectively. There are longer symptom-free intervals after targeted ELD than with TLIF or laminectomy. Additional intervention and surgical treatments are more often needed to manage new-onset postoperative symptoms in TLIF- and laminectomy compared to ELD patients. Few ELD patients will require fusion in the future. Considering the rising cost of surgical spine care, we offer SpineScreen as a simplified and less costly alternative to traditional image-based care models by focusing on primary pain generators rather than image-based criteria derived from the preoperative lumbar MRI scan.

Dural Tears During Lumbar Spinal Endoscopy: Surgeon Skill, Training, Incidence, Risk Factors, and Management.

BACKGROUND: Incidental dural tears during lumbar endoscopy can be challenging to manage. There is limited literature on their appropriate management, risk factors, and the clinical consequences of this typically uncommon complication. MATERIALS AND METHODS: To improve the statistical power of studying durotomy with lumbar endoscopy, we performed a retrospective survey study among endoscopic spine surgeons by email and chat groups on social media networks, including WhatsApp and WeChat. Descriptive and correlative statistics were done on the surgeons' recorded responses to multiple-choice questions. Surgeons were asked about their clinical experience with spinal endoscopy, training background, the types of lumbar endoscopic decompression they perform by approach, the decompression instruments they use, and incidental durotomy incidence with routine lumbar endoscopy. RESULTS: There were 689 dural tears in 64 470 lumbar endoscopies, resulting in an incidental durotomy incidence of 1.07%. Seventy percent of the durotomies were reported by 20.4% of the surgeons. Eliminating these 19 outlier surgeons yielded an adjusted durotomy rate of 0.32. Endoscopic stenosis decompression (54.8%; P < .0001), rather than endoscopic discectomy (44.1%; 41/93), was significantly more associated with durotomy. Medium-sized dural tears (1-10 mm) were the most common (52.2%; 48/93). Small pinhole durotomies (less than 1 mm) were the second most common type (46.7%; 43/93). Rootlet herniations were seen by 46.2% (43/93) of responding surgeons. The posterior dural sac injury during the interlaminar approach (57%; 53/93) occurred more frequently than traversing nerve-root injuries (31.2%) or anterior dural sac (23.7%; 22/93). Exiting nerve-root injuries (10.8%;10/93) were less common. Over half of surgeons did not attempt any repair or closure (52.2%; 47/90). Forty percent (36/90) used sealants. Only 7.8% (7/90) of surgeons attempted an endoscopic repair or sutures (11.1%; 10/90). DuralSeal was the most commonly used brand of commercially available sealant used (42.7%; 35/82). However, other sealants such as Tisseal (15.9%; 13/82), Evicel (2.4%2/82), and additional no-brand sealants (38; 32/82) were also used. Nearly half of the patients (48.3%; 43/89) were treated with 24-48 hours of bed rest. The majority of participating surgeons (64%; 57/89) reported that the long-term outcome was unaffected. Only 18% of surgeons reported having seen the development of a postoperative cerebrospinal fluid (CSF)-fistula (18%;16/89). However, the absolute incidence of CSF fistula was only 0.025% (16/64 470). Severe radiculopathy with dysesthesia; sensory loss; and motor weakness in association with an incidental durotomy were reported by 12.4% (11/89), 3.4% (3/89), and 2.2% (2/89) of surgeons, respectively. CONCLUSIONS: The incidence of dural tears with lumbar endoscopy is about 1%. The incidence of durotomy is higher with the use of power drills and the interlaminar approach. Stenosis decompression that typically requires the more aggressive use of these power instruments has a slightly higher incidence of dural tears than does endoscopic decompression for a herniated disc. Most dural tears are small and can be successfully managed with mechanical compression with Gelfoam and sealants. Two-thirds of patients with incidental dural tears had an entirely uneventful postoperative course. The remaining one-third of patients may develop a persistent CSF leak, radiculopathy with dysesthesia, sensory loss, or motor function loss. Patients should be educated preoperatively and reassured. LEVEL OF EVIDENCE: 3.

Indication and Contraindication of Endoscopic Transforaminal Lumbar Decompression.

BACKGROUND: The indications and contraindications to the endoscopic transforaminal approach for lumbar spinal stenosis are not well defined. METHODS: We performed a Kaplan-Meier durability survival analysis of patients with the following types of spinal stenosis: type I, central canal; type II, lateral recess; type III, foraminal; and type IV, extraforaminal. The 304 patients comprised 140 men and 164 women, with an average age of 51.68 ± 15.78 years. The average follow-up was 45.3 years (range, 18-90 years). The primary clinical outcome measures were the Oswestry Disability Index, visual analog scale, and the modified Macnab criteria. RESULTS: Of 304 study patients, 70 had type I (23.0%) stenosis, 42 type II (13.7%), 151 type III (49.7%), and 41 type IV (13.5%). Excellent outcomes were obtained in 114 patients (37.5%), good in 152 (50.0%), fair in 33 (10.9%), and poor in 5 (1.6%). Kaplan-Meier durability analysis of the clinical treatment benefit with the endoscopic transforaminal decompression surgery showed statistically significance differences (P < 0.0001) on log-rank (Mantel-Cox) χ2 testing between the estimated median (50% percentile) survival times of type I (28 months), type II (53 months), type III (32 months), and type IV (66 months). CONCLUSIONS: We recommend stratifying patients based on the underlying compressive disease and the skill level of the endoscopic spine surgeon to decide preoperatively whether more difficult central or complex foraminal stenotic lesions should be considered for alternative endoscopic approaches.

Feasibility of Using Intraoperative Neuromonitoring in the Prophylaxis of Dysesthesia in Transforaminal Endoscopic Discectomies of the Lumbar Spine.

(1) Background: Postoperative nerve root injury with dysesthesia is the most frequent sequela following lumbar endoscopic transforaminal discectomy. At times, it may be accompanied by transient and rarely by permanent motor weakness. The authors hypothesized that direct compression of the exiting nerve root and its dorsal root ganglion (DRG) by manipulating the working cannula or endoscopic instruments may play a role. (2) Objective: To assess whether intraoperative neurophysiological monitoring can help prevent nerve root injury by identifying neurophysiological events during the initial placement of the endoscopic working cannula and the directly visualized video endoscopic procedure. (3) Methods: The authors performed a retrospective chart review of 65 (35 female and 30 male) patients who underwent transforaminal endoscopic decompression for failed non-operative treatment of lumbar disc herniation from 2012 to 2020. The patients' age ranged from 22 to 86 years, with an average of 51.75 years. Patients in the experimental group (32 patients) had intraoperative neurophysiological monitoring recordings using sensory evoked (SSEP), and transcranial motor evoked potentials (TCEP), those in the control group (32 patients) did not. The SSEP and TCMEP data were analyzed and correlated to the postoperative course, including dysesthesia and clinical outcomes using modified Macnab criteria, Oswestry disability index (ODI), visual analog scale (VAS) for leg and back pain. (4) Results: The surgical levels were L4/L5 in 44.6%, L5/S1 in 23.1%, and L3/L4 in 9.2%. Of the 65 patients, 56.9% (37/65) had surgery on the left, 36.9% (24/65) on the right, and the remaining 6.2% (4/65) underwent bilateral decompression. Postoperative dysesthesia occurred in 2 patients in the experimental and six patients in the control group. In the experimental neuromonitoring group, there was electrodiagnostic evidence of compression of the exiting nerve root's DRG in 24 (72.7%) of the 32 patients after initial transforaminal placement of the working cannula. A 5% or more decrease and a 50% or more decrease in amplitude of SSEPs and TCEPs recordings of the exiting nerve root were resolved by repositioning the working cannula or by pausing the root manipulation until recovery to baseline, which typically occurred within an average of 1.15 min. In 15 of the 24 patients with such latency and amplitude changes, a foraminoplasty was performed before advancing the endoscopic working cannula via the transforaminal approach into the neuroforamen to avoid an impeding nerve root injury and postoperative dysesthesia. (5) Conclusion: Neuromonitoring enabled the intraoperative diagnosis of DRG compression during the initial transforaminal placement of the endoscopic working cannula. Future studies with more statistical power will have to investigate whether employing neuromonitoring to avoid intraoperative compression of the exiting nerve root is predictive of lower postoperative dysesthesia rates in patients undergoing videoendoscopic transforaminal discectomy.

Minimal Clinically Important Difference in Patient-Reported Outcome Measures with the Transforaminal Endoscopic Decompression for Lateral Recess and Foraminal Stenosis.

BACKGROUND: Patient-reported outcome measures (PROMs) have become widely used to better measure patients' judgment of treatment benefits from surgical spine care. The concept of determining the minimal clinically important differences (MCIDs) of PROMs is aimed at assessing the benefits of lumbar spine care that are meaningful to the patient. The goal of this study was to validate the utility of MCIDs of the visual analog score (VAS) and Oswestry Disability Index (ODI) in patients with sciatica-type low back and leg pain due to lateral recess and foraminal stenosis who were treated with directly visualized transforaminal outpatient endoscopic decompression. METHODS: The retrospective study population consisted of 406 patients on whom PROMs were obtained preoperatively, and again postoperatively at final follow-up. Employing an anchor-based approach with a patient satisfaction index based on the modified Macnab criteria, a receiver operating characteristics (ROC) and area under the curve (AUC) analysis was performed using IBM SPSS 25.0 to define the optimal MCID in VAS and ODI with the transforaminal endoscopy using the top-left-corner criteria and the Youden index. Improvements in walking endurance were recorded as an additional parameter of patient functioning and correlated with PROMs to test for statistical significance. RESULTS: The patients' average age was 41.08 years, ranging from 30 to 84 years. The mean follow-up was 33.59 months, ranging from 24 to 85 months, with a standard deviation of 12.79. The MCIDs for VAS and ODI were 2.5 to 3.5 and 15 to 16.5, respectively. Patients were dichotomized as improved (377/406; 92.9%) if they reported excellent (224/406; 55.2%), good (112/406; 27.6%), and fair (41/406; 10.1%) Macnab outcomes. Patients were dichotomized as failed if they reported poor (29/406; 7.1%) Macnab outcomes. Preoperatively, only 32.5% (132/406) of patients had unlimited walking endurance compared to 77.6% (315/406) of patients postoperatively. The ROC and AUC analysis showed better accuracy with the single-integer VAS score (0.926) than with the 10-item ODI score (0.751). CONCLUSIONS: Transforaminal outpatient endoscopic decompression for symptomatic foraminal and lateral recess stenosis is an effective surgical treatment to alleviate sciatica-type and back symptoms in 92.9% of patients. Of the PROMs analyzed, the VAS provided a more meaningful and accurate reflection of patients' interpretation of outcome with the transforaminal endoscopic spinal decompression procedure than ODI. Understanding which patient expectations drive these MCIDs may aid in replacing open surgeries for sciatica-type low back and leg pain currently preferred by traditional spine surgeons with a personalized early-staged transforaminal endoscopic hybrid decompressive/ablative procedures favored by the authors. These may prove more cost effective by focusing on significant pain generators validated with a diagnostic interventional workup instead of employing image-based indication criteria for surgery.

Outcomes with transforaminal endoscopic versus percutaneous laser decompression for contained lumbar herniated disc: a survival analysis of treatment benefit.

BACKGROUND: Contained lumbar disc herniations frequently cause back- and leg pain. Clinical outcomes with surgical treatment may be affected by the size and location of the disc herniation. The surgical directly visualized transforaminal endoscopic decompression has gained acceptance and popularity, while the simplified percutaneous laser disc decompression has fallen out of favor in spite of its initial success as a minimally invasive intervention. In an attempt to better understand the durability of both procedures, the authors performed a comparative analysis of clinical outcomes in patients with contained lumbar disc herniations. METHODS: The study population was comprised 248 patients consisting of 162 patients in the endoscopy group (group 1) and 86 patients in the laser group (group 2). Primary outcome measures were Macnab criteria. Herniations were classified as large or small. Additional parameters of advanced degeneration of the lumbar motion segment including posterior disc- and lateral recess height of <3 mm were recorded. IBM SPSS 25.0 was used for Kaplan-Meier survival analysis and cross-tabulation of these variables with statistical testing for significant associations. RESULTS: The mean follow-up was 43.5 months. The serial time recorded for Kaplan-Meier analysis ranged from 1.5 to 84 months. The mean age was 53.37 years (standard deviation =14.65 years). The majority of patients had Excellent and Good Macnab outcomes (212/248; 85.5%) regardless of treatment. Fair and Poor results were achieved in another 36 patients (14.5%). There was a higher percentage of Excellent Macnab outcomes in the endoscopy group (94/162; 58.0%) than in the laser group (38/86; 44.2%) at a statistical significant level (P<0.0001). There was a statistically significantly higher percentage of Excellent and Good Macnab outcomes with endoscopic decompression of small paracentral herniations (97.1%; P<0.0001). Percutaneous laser decompression of large central disc herniations was not statistically better than endoscopic surgical decompression (P=0.125). Endoscopic bony and soft tissue decompression was also better than laser at alleviating symptoms in patients with reduced posterior disc- and lateral recess height with 96.7% in patients with reduced disc height of <3 mm and 94% in patients with reduced lateral recess height of <3 mm (P=0.001). Kaplan-Meier (K-M) Survival time showed longer median survival of the treatment benefit for patients who underwent visualized endoscopic surgical decompression (66.0 months) compared to median K-M survival time for percutaneous laser decompression of 17 months (P<0.0001). CONCLUSIONS: Transforaminal endoscopic decompression for symptomatic herniated disc is an effective and durable surgical treatment to alleviate sciatica-type and back symptoms in the vast majority of patients with good long-term survival of pain relief for up to six years. Interventional percutaneous non-visualized laser decompression for the same condition may provide favorable outcomes in the short-term with soft protrusions. However, the treatment effect deteriorates much faster with a median survival of 17 months.

Lumbar vacuum disc, vertical instability, standalone endoscopic interbody fusion, and other treatments: an opinion based survey among minimally invasive spinal surgeons.

BACKGROUND: A diseased lumbar intervertebral vacuum disc void of any structurally intact tissue may be vertically unstable. A primary standalone endoscopic decompression and interbody fusion surgery in the treatment of vertical instability in patients with a vacuum disc may be a more reliable treatment than decompression alone. METHODS: The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups on social media networks, including Facebook, WeChat, WhatsApp, and Linkedin. Descriptive and correlative statistics were employed to count the responses and compare the surgeon's responses recorded on a Likert scale from 1 (disagree) to 10 (agree) or in multiple-choice questions. Surgeons were asked about their familiarity with the concept of vacuum disc and vertical instability and how they would treat such patients. Kappa statistics and linear regression analysis of agreement of incoming responses were performed. RESULTS: A total of 1,165 surgeons accessed the survey. The completion rate was 22.78. The majority surgeons were very familiar with the concept of a "vacuum disc" as a sign of end-stage lumbar degenerative disc disease and a collapsing lumbar motion segment (182/273; 66.7%; Likert score 6.53). The majority of surgeons also thought that vertical instability precedes anterolateral lumbar instability (187/273; 68.5%; Likert score 6.64) and that a vacuum disc may cause vertical instability with symptomatic dynamic foraminal & lateral recess stenosis (222/273; 81%; Likert score 7.48), mechanical back pain (201/273; 73.1%; Likert score 7.48), and may cause sciatica-type low back and leg pain (179/273; 66.3%; Likert score 6.59). The majority of surgeons indicated that vacuum phenomenon on radiographic studies is associated with vertical instability and collapse resulting in dynamic foraminal and lateral recess stenosis and should be treated surgically (199/266; 73.7%; 7 missing responses; Likert score 6.86). Preferred treatments were decompression alone without fusion (P<0.014). There was consensus in support of fusion by TLIF or PLIF with a Likert score of 6.68 (184/266; 69.2%; 7 missing responses). There was no consensus on standalone fusion. CONCLUSIONS: Vacuum phenomenon on radiographic studies is associated with a vertical instability and collapse, resulting in dynamic foraminal and lateral recess stenosis that should be treated surgically. Preferred surgical treatments were decompression alone, decompression with interbody fusion using just bone graft, and fusion employing TLIF or PLIF. Further research into the clinical significance of lumbar vacuum disc, vertical instability and its most appropriate surgical treatments if any is necessary.

Surgeon motivation, and obstacles to the implementation of minimally invasive spinal surgery techniques.

BACKGROUND: This study aimed to analyze the motivators and obstacles to the implementation of minimally invasive spinal surgery techniques (MISST) by spinal surgeons. Motivators and detractors may impact the availability of MISST to patients and drive spine surgeons' clinical decision-making in the treatment of common degenerative conditions of the lumbar spine. METHODS: The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups in social media networks including Facebook, WeChat, WhatsApp, and Linkedin. Descriptive statistics were employed to count the responses and compared to the surgeon's training. Kappa statistics and linear regression analysis of agreement were performed. RESULTS: A total of 430 surgeons accessed the survey. The completion rate was 67.4%. A total of 292 surveys were submitted by 99 neurosurgeons (33.9%), 170 orthopaedic surgeons (58.2%), and 23 surgeons of other postgraduate training (7.9%). Personal interest (82.5%) and patient demand (48.6%) were the primary motivators for MISST implementation. High equipment (48.3%) and disposables (29.1%) cost were relevant obstacles to MISST implementation. Local workshops (47.6%) and meetings in small groups (31.8%) were listed as the primary knowledge sources. Only 12% of surgeons were fellowship trained, but 46.3% of surgeons employed MISST in over 25% of their cases. CONCLUSIONS: The rate of implementation of MISST reported by spine surgeons was found to be high but impeded by the high cost of equipment and disposables. The primary motivators for spine surgeons' desire to implement were personal interest and patient demand.

Regional variations in acceptance, and utilization of minimally invasive spinal surgery techniques among spine surgeons: results of a global survey.

BACKGROUND: Regional differences in acceptance and utilization of MISST by spine surgeons may have an impact on clinical decision-making and the surgical treatment of common degenerative conditions of the lumbar spine. The purpose of this study was to analyze the acceptance and utilization of various minimally invasive spinal surgery techniques (MISST) by spinal surgeons the world over. METHODS: The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups in social media networks including Facebook, WeChat, WhatsApp, and Linkedin. Surgeons were asked the following questions: (I) Do you think minimally invasive spinal surgery is considered mainstream in your area and practice setting? (II) Do you perform minimally invasive spinal surgery? (III) What type of MIS spinal surgery do you perform? (IV) If you are performing endoscopic spinal decompression surgeries, which approach do you prefer? The responses were cross-tabulated by surgeons' demographic data, and their practice area using the following five global regions: Africa & Middle East, Asia, Europe, North America, and South America. Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using statistical package SPSS Version 25.0. RESULTS: A total of 586 surgeons accessed the survey. Analyzing the responses of 292 submitted surveys regional differences in opinion amongst spine surgeons showed that the highest percentage of surgeons in Asia (72.8%) and South America (70.2%) thought that MISST was accepted into mainstream spinal surgery in their practice area (P=0.04) versus North America (62.8%), Europe (52.8%), and Africa & Middle East region (50%). The percentage of spine surgeons employing MISST was much higher per region than the rate of surgeons who thought it was mainstream: Asia (96.7%), Europe (88.9%), South America (88.9%), and Africa & Middle East (87.5%). Surgeons in North America reported the lowest rate of MISST implementation globally (P<0.000). Spinal endoscopy (59.9%) is currently the most commonly employed MISST globally followed by mini-open approaches (55.1%), and tubular retractor systems (41.8%). The most preferred endoscopic approach to the spine is the transforaminal technique (56.2%) followed by interlaminar (41.8%), full endoscopic (35.3%), and over the top MISST (13.7%). CONCLUSIONS: The rate of implementation of MISST into day-to-day clinical practice reported by spine surgeons was universally higher than the perceived acceptance rates of MISST into the mainstream by their peers in their practice area. The survey suggests that endoscopic spinal surgery is now the most commonly performed MISST.