Becker's Spine Review

34 Thought Leadership Challenges of adopting endoscopic spine surgery & advice for overcoming the learning curve: Q&A with Dr. Saqib Hasan By Alan Condon S aqib Hasan, MD, a complex spine surgeon with expertise in minimally invasive techniques, spoke to Becker's Spine Review about how endoscopic spine surgery has benefited his practice and why he anticipates more surgeons adopting endoscop- ic approaches in the future. Note: Responses are lightly edited for style and clarity. Question: Do you see more surgeons adopting endoscopic techniques as spine procedures continue to migrate to the outpatient setting? Dr. Saqib Hasan: I think the migration to en- doscopic procedures is just one component of the larger shi to the outpatient setting. is move is largely facilitated by more surgeons utilizing minimally invasive techniques and leveraging technologies to provide reliable outcomes and faster postoperative recovery. However, most simple decompression surger- ies are typically already done as outpatient pro- cedures. e move toward endoscopic spine surgery is more intuitive — if you can utilize a 7mm camera to achieve equivalent or superior outcomes compared to current standard tech- niques, the question becomes, "Why wouldn't I use endoscopic techniques?" Many surgeons themselves would likely pre- fer receiving an endoscopic discectomy over a standard microdiscectomy — I know I would. Numerous randomized-controlled trials have shown the significant benefits of endoscopic techniques in the context of less postoperative pain and faster recovery, which lends to the wid- er trend toward the ambulatory care setting. Q: What do you attribute the lack of en- doscopic spine surgery programs to? SH: Endoscopic spine surgery is already very popular in Asia and Europe, and more U.S. surgeons continue to adopt these techniques. Training always lags behind new technology. Only aer a critical mass of spine surgeons begin utilizing endoscopic techniques will you start to see it as part of a normal spine surgical curriculum in the U.S. Many of my attendings in residency learned arthroscopic techniques aer they had completed their training. Ar- throscopic surgery really revolutionized or- thopedic surgery because of the paradigm shi from open surgery. Unfortunately, I believe early iterations of endo- scopic spine surgery were not ready for prime time. e technology and techniques were not there, hence, the clinical data didn't stack well against what was tried and true. With the cur- rent picture quality and instrument improve- ments, endoscopic spine surgery today allows for an elegant and versatile method of treating both simple and complex spinal pathology. Q: Do you see more institutions adopt- ing endoscopic-based fellowships in the coming years? SH: Endoscopic-based techniques are not cur- rently a part of the normal landscape of spine surgical training. I had an interest in arthroscopic techniques in residency, which carried over into my spine surgical training. I did a significant amount of research on endoscopic spine surgery, and I truly believed it would be a standard tool spine surgeons would use in the future. is led me to seek an advanced endoscopic spine surgery fellowship aer completing my spine fellowship. e problem was, there were no fellowships ded- icated to teaching endoscopic spine surgery in an academic setting. I found my way to a discussion with Christoph Hofstetter, MD, at the University of Washington in Seattle. Dr. Hofstetter was utilizing endoscopic tech- niques for the cervical, thoracic and lumbar spine — techniques I had never seen in my training. e combination of the breadth and volume of endoscopic cases performed in an academic training environment allowed for the creation of the first U.S.-based full-endoscopic spine fellowship. ere are currently no other U.S.-based advanced fellowship programs that provide comprehensive training in the full gamut of endoscopic spine techniques of the cervical, thoracic and lumbar spine. However, I do not think advanced endoscop- ic-based fellowship programs will become the norm. I do think endoscopic spine techniques will find their way into the armamentarium of more and more surgeons, broadening the ex- posure to trainees. ere may be a time when certain training programs may be considered more "endoscopic-heavy," akin to the "defor- mity-heavy" programs of today. Q: What is the most difficult aspect of endoscopic spine surgery training? SH: ere are certainly some initial difficulties. e magnified anatomy from an unfamiliar perspective combined with the mechanical pe- culiarities of handling a uniportal endoscope can be daunting for novice surgeons. Howev- er, the mechanics and relative anatomy can be learned fairly easily. Like most things in sur- gery, the wisdom is in knowing when not to use a particular technique. I believe the most difficult aspect is understanding which scenar- ios endoscopic techniques provide a benefit for both the surgeon and the patient. I think when you understand what the endoscope can and cannot do, you prepare yourself for success. Q: What advice do you have for those looking to learn endoscopic spine sur- gery? SH: For the average surgeon (not in training) who wants to learn these techniques, I'd recom- mend going to some of the industry-sponsored endoscopic courses to get your hands familiar with the technology. I encourage anyone inter- ested in learning to really do a deep dive into transforaminal anatomy — something that is not stressed traditionally. I also think a men- torship model is critical in providing guidance and feedback as you begin your endoscopic journey. Understanding some of the finer nu- ances will come with experience. Q: What are the optimal cases for en- doscopic spine surgery? SH: We recently published a paper that fo- cused on "e Benefit Zone of Endoscopic Spine Surgery." e gist of that article was that the benefits of endoscopic techniques are really realized when the alternative options become increasingly invasive and complex. e best ex- ample of that would be a calcified thoracic disc herniation — the treatment options include a large transthoracic surgery, [video-assisted thoracoscopic spinal surgery], trans-pedicular approach, etc., all of which have varying levels of morbidity. ese are not small procedures. en you take an endoscopic thoracic discectomy, and you've turned that very complicated surgery into a rel- atively easy procedure with great outcomes. I

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