Endoscopic spine surgery has a significant learning curve to overcome, but it's not out of reach for spine surgeons at any stage of their careers, Dean Perfetti, MD, told Becker's.
Dr. Perfetti, of Carmel, N.Y.-based Somers Orthopaedic Surgery and Sports Medicine Group performed the first endoscopic microdiscectomy at Northern Westchester Hospital in Mount Kisco, N.Y. in August.
He discussed how he tackled the endoscopic spine learning curve, how the practice is supporting his endeavors and the other spine surgery trends he's following closest.
Note: This conversation was lightly edited for clarity.
Question: What is your history with endoscopic spine surgery?
Dr. Dean Perfetti: I trained at Texas Back Institute in Plano and was exposed to endoscopy because one of my fellowship mentors started learning it on his own and made it the centerpiece of his practice. He’s very proficient in it. There are two learning curves: one for visual orientation and one for technical skills. By the end of my fellowship, I was comfortable with the visual aspect, but the hands-on techniques are something you learn at your own pace. When I joined Somers, I had the opportunity to work at several hospitals, but Northern Westchester was particularly eager to grow with me regarding the endoscopic learning curve. Since then, I've performed this procedure on numerous patients who have been very pleased with the endoscopic approach compared to traditional or tubular methods.
Q: Can you elaborate more on the learning curves? What advice do you have for early-career surgeons as well as more seasoned surgeons?
DP: I co-authored a paper on the endoscopic learning curve with Peter Derman, MD, whom I trained with at the Texas Back Institute. We discussed the two learning curves. The first is understanding what you're seeing on the camera in terms of orientation. Even if you're an arthroscopist or have performed cranial endoscopy as a neurosurgeon, this is a unique anatomical location — it's not a true joint. The second learning curve is acquiring the technical skills for uniportal endoscopy, specifically transforaminal and interlaminar techniques. In our paper, we found that after about 20 cases, surgeons generally start to feel comfortable. Operative times also decrease after 20 cases, and that's when surgeons feel ready to move on from basic lumbar procedures to more advanced techniques like posterior cervical surgery.
For younger surgeons versus more experienced ones, the latter can certainly learn endoscopy, potentially even faster. However, experienced surgeons often already have techniques they're proficient with, which can make them hesitant to adopt new ones. They may feel that learning endoscopy isn't worth the time when they’re already achieving good outcomes with their current methods. That said, there's a significant difference between minimally invasive surgery via a tubular retractor and through an endoscope. The endoscope allows for a much smaller incision — about 7 millimeters compared to 18 to 22 millimeters for a tubular retractor — and lets you visualize directly at the level of the pathology. Moreover, the short-term outcomes for endoscopic patients and the ergonomic benefits for the surgeon make it a worthwhile transition.
Q: What’s your outlook for endoscopic spine surgery? What do you think it will take for it to become more widespread?
DP: I think it's only a matter of time before more surgeons adopt it. Endoscopy is already widespread in Eastern cultures, such as Korea and Japan. Patients increasingly want smaller, minimally invasive procedures, and they'll seek out surgeons who offer them. The main barrier in the U.S. is the learning curve, especially since this technique isn’t widely taught during residency or in most fellowships.
Q: Somers is part of Health Plus Management. Can you talk about how that relationship affects your day-to-day work?
DP: From a private practice standpoint, what's great is that Health Plus allows physicians to maintain their autonomy. They’ve certainly facilitated my progress with endoscopy, and there's none of the red tape you might encounter at larger academic centers or hospitals. Health Plus has been very open to trying new technologies and incorporating them, provided they make sense both clinically and financially. In terms of advancing care and giving patients the best opportunities from a technological perspective, Health Plus has been fantastic.
Q: When it comes to arguing the validity of new technology or a procedure, and securing the financials, how do you approach that?
DP: You can incorporate new technology by reviewing literature on short-term outcomes and financial considerations, including both immediate costs and postoperative expenses. Endoscopic procedures, for example, help people return to work more quickly and are associated with fewer complications, like lower postoperative infection rates. To mitigate costs, you might use different technologies or companies to reduce disposable expenses. Additionally, offering cutting-edge technology like spinal endoscopy can attract patients, who will return for other orthopedic or spine-related procedures. As demand for these technologies grows, costs should come down, making them more accessible.
Q: What other technologies are exciting to you? What do you think will come to the forefront in the next few years?
Dr. Perfetti: Two exciting technologies we've started utilizing are mixed reality and robotics. With mixed reality, the surgeon and co-surgeon wear helmets that allow us to see three-dimensional slices of the spine while actively navigating and instrumenting it. This has helped ergonomically by eliminating the need to twist or contort to view navigation screens. Robotics is also an exciting development, as it enhances a surgeon’s precision and accuracy during instrumentation. Robotics is beginning to play a role in other parts of procedures as well, such as decompression.
Q: What are some other trends you’ve been keeping an eye on lately?
Dr. Perfetti: Outpatient surgery is another significant trend. Not just 23-hour stays, but same-day discharge, similar to how you would discharge a knee or hip arthroscopy patient. That's one of the real advantages of endoscopy. In Texas and with my own patients, I've seen that they can leave the hospital two to three hours after surgery, often with significant relief. They might experience some flank pain for a day or two, but after a week, they're generally very happy with the results. Minimally invasive spine surgery isn’t the solution for every condition, but for single-level degenerative problems, it’s an excellent way to address the issue without distorting anatomy or causing adjacent segment problems that require instrumentation later on.