While endoscopic spine surgery is gaining more attention, a steep learning curve for the minimally invasive technique is holding back its adoption.
Here is how four spine surgeons got past the challenges of learning endoscopic spine surgery techniques.
Ashish Patel, MD. DuPage Medical Group (Downers Grove, Ill.): The learning curve is real; it's a different skill set. Orthopedic spine surgeons have this comfort with arthroscopy. Being able to use a camera through a small incision has been part of my training in orthopedic surgery. My learning curve will consist of doing the more straightforward cases first. Once I've mastered those, I will push myself to do the more complex cases. The straightforward, most accessible cases would be disc herniation cases at L2-3, L3-4, L4-5.
Once you've mastered those, you proceed to L5-S1 and perform disc herniation cases that have gone into the foramen or the far lateral region to do more central disc herniations. After you master these and feel comfortable with all disc herniations in the lower back, you then move onto lumbar stenosis cases, which would be more of a midline approach using slightly different equipment. Then, you can move on to cervical cases, such as laminoforaminotomies or thoracic cases. Once you have a comfort in that, you then proceed to what surgeons are now working toward, which is lumbar fusions through the endoscope.
Saqib Hasan, MD. Golden State Orthopedics and Spine (Walnut Creek, Calif.): The biggest learning curve was conceptually understanding how to leverage the value of these technologies in an efficient manner. Currently, there is no robotic system which allows easy integration of robotic and endoscopic technologies. I had to essentially create a workflow and then I went to the lab to try it out. The lab was successful, so I decided to utilize this workflow in a one-level fusion case. The case turned out well; she was discharged the next day and continues to do excellent at about six months postoperatively.
Corey Walker, MD. Cedars-Sinai (Los Angeles): At the end of the day the learning curve really comes to figuring out how to use the different tools through a single port. It's not about whether you can see what you're doing better. But it's figuring out how to use the tools to accomplish the same end goal. Especially with uniportal surgery, it's one handed, and that's what took a little bit of time for me.
The one piece of advice I got that gave me a lot of confidence was from Peter Derman, MD. He said, "When I started doing endoscopic surgery, it never felt unsafe. It just felt like I was [working] slower." I think that that's a testament to the fact that your visualization allows you to still be really safe through the process, to still see the anatomy that you're trying to preserve and decompress. It just might take you a little longer when you first start, and I think when you're picking up a new technology, you never want to do something that's going to expose your patient to more risk.
There's a lot of resources available from different companies to help you train and learn. Doing cadaver labs is incredibly helpful, and there is a significant amount of training material through the form of videos, which is unique to endoscopic surgery. One of the things I would advocate for a new spine surgeon trying to learn the technique is to record every case and go back and watch their case video and see where they could have spent less time, [what] made them inefficient, and then try to improve on that next time.
Daniel Park, MD. Michigan Orthopedic Surgeons (Royal Oak): As I transitioned to adoption in real clinical life, the biggest hurdle was figuring out the basic things. I did not know if I should use a water pump or gravity or if I used gravity, how high should the bag of fluid be. I did not know what setting to put in the radiofrequency device, I did not know if I should put epinephrine in the irrigation solution. The surgical skills needed and orientation was not that much different but the support on how to set up the case and perform the actual case was the biggest hurdle. Because there are a handful of U.S. surgeons who perform this surgery unlike when I started, talking to other surgeons and asking these questions will make one's learning curve much faster.