Don Young Park

Lumbar fusion has evolved from open transforaminal lumbar interbody fusion (TLIF) to minimally invasive TLIF (MIS-TLIF), the current minimally invasive benchmark. Endoscopic techniques, proven in discectomy and decompression, have been extended to fusion (uniportal endoscopic TLIF and biportal endoscopic TLIF), offering an alternative to MIS-TLIF. This structured debate-style review critically compares both techniques across 7 domains to clarify their respective roles in lumbar degenerative disease. It combined independent advocacy drafts with an international survey of 106 respondents across 35 countries, capturing procedural preferences and case-based reasoning. Using a prespecified 70% agreement threshold, domains were classified as domains with ≥70% panel agreement, whereas domains falling below this threshold were categorized as domains below the prespecified agreement threshold. This represents structured international survey agreement, not a formal Delphi process. Endoscopic fusion offers advantages in decreased blood loss, soft-tissue preservation, early postoperative back pain, and early recovery, with comparable mid-term clinical outcomes (long-term insufficiently established) to MIS-TLIF, which remains more reproducible and familiar. Complication rates are similar but technique-sensitive for endoscopic fusion. Panel responses favored endoscopic approaches for morbidity-related domains (soft-tissue preservation 89.6%, visualization 81.1%, recovery 74.5%), while fusion stability, short- to mid-term clinical outcomes, complications, and revision remained context-dependent without clear agreement. Endoscopic fusion is a credible option for selected single-level lumbar degenerative disease, offering perioperative advantages with comparable mid-term outcomes to MIS-TLIF; core endpoints, including fusion rate and revision rate, did not reach 70% panel agreement, even among endoscopy-favorable panelists. MIS-TLIF retains reproducibility advantages. The debate has shifted from feasibility to implementation, training standardization, cost-effectiveness, and long-term durability.

Introduction of Korean American Spine Society Special Issue

BACKGROUND: Posterior migration of a mobile-bearing cervical disc replacement (CDR) can be catastrophic. The authors report a single-patient case of catastrophic failure after recent trauma and implant loosening. OBSERVATIONS: A 48-year-old woman had received C5–6 and C6–7 Mobi-C CDRs at an outside institution 3 weeks before presentation and had sustained a ground-level fall 8 days before presentation. Outside imaging from after the fall showed implant loosening. After subsequently lifting a laundry basket, the patient developed acute quadriparesis with complete motor and sensory loss below C7. CT demonstrated catastrophic C5–6 and C6–7 hardware failure with posterior migration of the C6–7 polyethylene insert into the canal. Emergency revision C5–7 anterior cervical discectomy and fusion was performed, but she remained American Spinal Injury Association Impairment Scale grade A at the 1-year follow-up. LESSONS: Patients with recent trauma and radiographic evidence of loosening, posterior endplate translation, loss of endplate parallelism, or polyethylene core malposition should prompt urgent surgical evaluation and likely revision. https://thejns.org/doi/10.3171/CASE26740

➢ As has been shown by higher-level evidence, endoscopic spine surgery (ESS) provides clinical outcomes comparable with those of microscopic and tubular techniques for lumbar disc herniation and spinal stenosis. ➢ The cervical and thoracic ESS evidence base has been limited, with a lack of contemporary multicenter randomized trials and overreliance on single-center retrospective data. ➢ U.S. adoption has been constrained by a steep learning curve, limited training pathways, and reimbursement challenges, despite increasing interest and fellowship exposure. ➢ The economic viability of ESS is facility-dependent, with higher disposable costs possibly offset by reduced hospital resource utilization. Migration of spine surgery into ambulatory surgery centers may also create additional opportunities for ESS adoption. ➢ Broader U.S. integration will require standardized training, multi-institutional outcome registries, and alignment with value-based payment models, such as the 2026 Medicare Transforming Episode Accountability Model (TEAM) program.

BACKGROUND: Distraction fractures are unstable spinal injuries characterized by a horizontal fracture line through the vertebra, often occurring following deceleration mechanisms. Surgical management typically involves fixation and fusion to restore sagittal alignment. Minimally invasive approaches, including percutaneous pedicle screw fixation, have demonstrated reduced operative morbidity while achieving deformity correction comparable to that of open techniques. However, accurate rod contouring in percutaneous procedures remains technically challenging. OBSERVATIONS: A 61-year-old male presented with a three-column unstable T7 distraction fracture in the setting of diffuse idiopathic skeletal hyperostosis following a rear-end motor vehicle accident at low to moderate speeds. A T4–10 percutaneous pedicle screw fixation for fracture reduction and stabilization was performed. Preoperative CT images were formatted and printed at a 1:1 scale on a sheet of paper; cut along the fracture line, taped together to reduce the fracture, and photocopied; sterilely bagged; and used intraoperatively to guide rod bending prior to placement. LESSONS: Using a 1:1 ratio paper printout of the patient’s preoperative CT scan as an anatomical template, the authors appropriately performed intraoperative rod bending without additional adjustment of rod contour. This method offers a practical, cost-effective solution to improve the precision and efficiency of rod bending in percutaneous spinal fusion. https://thejns.org/doi/10.3171/CASE26257

Systematic review and meta-analysis. Endoscopic lumbar discectomy is a minimally invasive technique used to treat herniations while reducing tissue trauma, incision length, blood loss, and infection. However, such procedures may damage the annulus fibrosus, which increases the risk of reherniation and revision. The current study aimed to compare the outcomes of endoscopic lumbar discectomy with and without simultaneous repair of the annulus fibrosus through suturing. From project initiation on June 2025 to the present, three reviewers conducted a systematic review of studies published in PubMed, Embase, and Cochrane Library databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All meta-analyses were conducted using STATA ver. 18.0. A total of nine studies, with 1,192 patients who underwent endoscopic lumbar discectomy for lumbar herniation, were included for analysis. Among the included patients, 514 (43.1%) underwent annulus fibrosus suturing, whereas 678 (56.9%) received only discectomy. The most commonly involved disc segment was L4/L5 with 267 patients (44.5%). Patients who underwent endoscopic lumbar discectomy with annulus fibrosus suturing showed a significant increase in operative time by 8.89 minutes (weighted mean difference [WMD], 8.89 minutes; 95% confidence intervals [CI], 1.01-16.77; p=0.03), had 0.31 times the odds of developing reherniation (odds ratio [OR], 0.31; 95% CI, 0.17-0.55; p=0.00), and had 0.26 times the odds of needing revision surgery (OR, 0.26; 95% CI, 0.10-0.68; p=0.01). No significant difference in intraoperative blood loss and hospital length of stay were observed between the groups. Postoperative and 3-month follow-up Visual Analog Scale (VAS)/Oswestry Disability Index (ODI) scores did not significantly differ between the groups at correlation coefficients r=0.3, 0.5, and 0.7, although the suture group demonstrated a favorable trend in ODI scores (p=0.0681-0.0782). Among the patients who underwent lumbar endoscopic discectomy, those who received annulus fibrosus suturing demonstrated significantly increased operative time but decreased reherniation and reoperation rates compared to those who did not received annulus fibrosus suturing. No significant difference in length of stay or blood loss were observed between the two groups. Conflicting results were noted for VAS and ODI scores, with patients receiving annulus fibrosus suturing generally showing better ODI outcomes but worse VAS scores.

Purpose Clear intraoperative visualization is essential for safe and effective endoscopic spine surgery, yet existing assessments remain subjective and lack standardization. The Visualization in Endoscopic Workspace (VIEW) Score was developed to provide an objective, reproducible grading system for evaluating intraoperative visualization quality. This study aimed to validate the VIEW Score as a standardized and reliable tool for assessing visualization during endoscopic spine surgery. Methods The VIEW Score is a 4-point ordinal scale (0 = Excellent, defined as no bleeding observed, to 3 = Poor) developed through expert consensus to evaluate bleeding, clarity of anatomical structures, and impact on surgical progress. Five experienced endoscopic spine surgeons independently rated 40 de-identified, 5-second video clips of interlaminar endoscopic lumbar spine surgery. After a 4-week washout period, the raters re-evaluated the same clips in a randomized order. Inter- and intra-rater reliability were analyzed using the Intraclass Correlation Coefficient (ICC) with a two-way random effects model for absolute agreement. Results The VIEW Score demonstrated excellent inter-rater reliability for mean ratings (ICC(2,5) = 0.963; 95% CI 0.940–0.979) and good single-rater reliability (ICC(2,1) = 0.839; 95% CI 0.758–0.902). Intra-rater reliability was also high (mean ICC 0.889 ± 0.04; range 0.840–0.943). Reliability remained consistently strong across approach (ICC(2,5) = 0.965) and decompression phases (ICC(2,5) = 0.945). Conclusions The VIEW Score is a reliable and objective grading system for assessing intraoperative visualization during endoscopic lumbar decompression. Its strong reproducibility supports its use for standardized communication, surgical training evaluation, quality assessment, and future research examining visualization, hemostasis, and surgical workflow.

» Virtual and hybrid mentorship models have transitioned from temporary coronavirus disease 2019 pandemic responses to durable, scalable components of the orthopaedic training curriculum. » Despite high trainee satisfaction, most orthopaedic virtual mentorship programs rely on short-term, self-reported metrics and lack the objective, longitudinal tracking of research productivity or career advancement seen in other specialties. » While virtual pipelines demonstrate the potential to broaden access for underrepresented groups, inconsistent collection of detailed demographic and socioeconomic data limits the assessment of their true impact on diversity. » Neurosurgery and plastic surgery provide instructive models for virtual collaboratives that successfully use standardized expectations and longitudinal outcome tracking to measure success. » To ensure these programs drive equitable change rather than just broader participation, future orthopaedic virtual mentorship programs should incorporate standardized outcome frameworks, mentor perspectives, and longitudinal, multi-institutional follow-up.