Gabriel Oswaldo Alonso Cuéllar

Purpose: To characterize baseline spinal multimorbidity, we investigated sex-associated differences in disability, and the temporal distribution of patients aged 80 years or older presenting to a tertiary spine center over three decades. Methods: We performed a retrospective single-center study (1994–2024). Of 3199 screened unique patient medical records evaluated for low back pain, 193 unique patients were age-eligible; 71 were excluded for prespecified record-quality criteria, leaving 122 patients in the analytical cohort. Baseline Visual Analog Scale (VAS) scores were available for all 122 patients and Oswestry Disability Index (ODI) scores for 99. Diagnoses required clinical-imaging concordance. A Lumbar Pathology Count (LPC) summarized seven coexisting degenerative diagnosis categories. Temporal distributions across study periods (D1: 1994–2004, D2: 2005–2014, D3: 2015–2024) were examined descriptively. Multivariable robust linear regression evaluated the association between sex and ODI. Results: Mean age was 84.2 years, and median VAS was 8/10. Among 99 patients with ODI data, mean ODI was 47.6%. Women with complete sex and ODI data had higher disability than men (51.5% vs. 39.8%; p = 0.002; Cohen d = 0.66). In the adjusted model (n = 98), female sex remained associated with a 12.3-point higher ODI (95% CI 4.5–20.2; p = 0.002). Most patients (76.2%) had more than one lumbar diagnosis (mean LPC, 1.99), but LPC was not significantly correlated with VAS or ODI. From D2 to D3, facet arthrosis increased from 31.3% to 65.3% and central disc herniation decreased from 37.5% to 9.9%; both remained significant after Benjamini–Hochberg correction (q = 0.039). The analytical cohort comprised five patients in D1, 16 in D2, and 101 in D3. Conclusions: In this selected referral-center cohort, advanced-age patients presented with severe baseline pain, disability, and frequent coexisting lumbar degeneration. Female sex was independently associated with higher baseline disability. Temporal patient distributions reflect complete-record inclusion criteria rather than population epidemiology. These findings emphasize the necessity of explicit functional phenotyping in late-life spine care.

Introducción: Colombia enfrenta una acelerada transición epidemiológica hacia una población envejecida; esto plantea importantes retos sobre el sistema de salud. El dolor lumbar crónico es una de las enfermedades de mayor impacto en la funcionalidad y en la pérdida de autonomía en pacientes de vejez avanzada. La cirugía mínimamente invasiva de columna (CMIC) es una alternativa que permite recuperar la capacidad funcional en esta población frágil. El propósito de este trabajo es evaluar los resultados del tratamiento mínimamente invasivo, el impacto funcional y su seguridad en pacientes por encima de los 80 años de edad.Materiales y métodos: Estudio observacional descriptivo de 122 pacientes entre 80 y 99 años tratados en un centro de referencia con técnicas quirúrgicas mínimamente invasivas de columna. Se analizaron variables demográficas, comorbilidades y escalas de dolor y discapacidad.Resultados: La mediana de la edad fue de 84 años (RIC: 81-86,25). Un 91,8% de los pacientes geriátricos reportó alguna comorbilidad; la HTA fue la más frecuente con un 72%. Se realizaron un total de 223 procedimientos. Uno de los más comunes fue la rizólisis facetaria percutánea (31%). La CMIC redujo la EVA significativamente de 8 a 2 puntos (p<0,001) y la mediana del índice de funcionalidad ODI se redujo de 46% a 14% (p<0,001). La tasa de complicaciones fue de 5% con una satisfacción global al cuestionario Macnab del 60,7%.Conclusión: La CMIC usando anestesia regional es una alternativa segura y efectiva que permite la restauración funcional en pacientes de longevidad extrema en los que el mantenimiento de la autonomía es un factor importante en la calidad de vida.

Minimally invasive spine surgery has achieved remarkable advances in recent years. Despite the numerous benefits associated with this approach, some complications may still occur. Among them, the use of continuous irrigation in the epidural space stands out, as it can cause changes in intracranial pressure (ICP). The present study aims to conduct a systematic review of the literature on ICP variations during endoscopic lumbar spine surgery. To this end, a search was carried out in the PubMed, Embase, Scielo, Lilacs, and Google Scholar databases, selecting studies that evaluated ICP intraoperatively during endoscopic spine procedures. Five comparative studies were included: three measured epidural pressure as an indirect surrogate of intracranial pressure (ICP), whereas two performed direct ICP measurements. Three of these studies identified significant changes in ICP during the procedure, whereas two did not observe relevant fluctuations. The analysis of the literature therefore confirms the possibility of ICP variations occurring intraoperatively in endoscopic lumbar spine surgeries. Level of Evidence III; Systematic Review.

Objective: To report the clinical outcomes obtained using AECF for cervical spondylarthrosis treatment. Methods: A retrospective study evaluated the patient-reported outcome measures (PROM) and complications of patients with radiating cervical pain and imaging findings of spondylarthrosis and foraminal stenosis treated with awake outpatient AECF. Results: AECF was performed in 18 patients. A satisfaction rate between excellent and good was obtained in 82.4% of the patients. Neck Disability Index significantly decreased 37.4% ± 14.3 (95% CI 29.8 – 45.0) to 11.5% ± 9.7 (95% CI 5.54 17.4) (P<0.001). VAS scores showed a statistically significant variation from a preoperative pain of 7.83 ±1.38 (95% CI 7.15 – 8.52) and then, at the 24-month follow-up, a score of 2.20 ± 1.79 (95% CI 1.31 – 3.09). There were two complications and two reoperations. Conclusion: This case series demonstrated favorable clinical outcomes using the anterior endoscopic technique for radiculopathy due to cervical spondylosis, supporting AECF as a feasible surgical alternative. Although current evidence suggests endoscopic treatment as an alternative for lateral stenosis, further high-quality studies are needed to strengthen the level of evidence. Level of Evidence IV; Case Series.

Objective: To evaluate the clinical outcomes achieved with the combined surgical management of Transforaminal Endoscopic Lumbar Foraminoplasty (TELF) with an Interspinous Spacer Device (ISD) in patients with DS grades I and II and LSS. Methods: A retrospective observational study was conducted using clinical records of patients who underwent a TELF procedure plus the placement of an ISD for LSS and DS. Demographic variables and Patient-Reported Outcome Measures (PROMs), including the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI), were analyzed to evaluate the clinical outcomes of the combined procedures. A total of 37 patients (54.05% women, 45.95% men) were evaluated. The mean age was 59.59 ± 15.89 years (95% CI 55.29 – 64.89); 43.24% (n=16) of the sample were women aged 60 or older and 32.43% of the patients were “pensioner-retired.” The most common presenting symptom was radicular pain: 30.30% on the right side and 48.48% on the left side. A total of 49 TELF procedures were performed, and 45 ISD were placed in the 37 patients. The average procedure duration was 85.77 ± 28.54 minutes, and the average blood loss was 23.28 ± 21.96 ml. The most frequently operated level was L4-L5. Results: The VAS and ODI scores improved significantly differences (p <0.001) before and after the procedure. Two complications were observed (5.4%). The overall reoperation rate was 10.81% (n=4). Conclusion: Transforaminal endoscopic decompression with ISD represents a feasible and safe outpatient alternative for patients with low-grade spondylolisthesis and stenosis. This combined minimally invasive technique provides significant clinical improvement with a low reoperation rate and offers a compelling alternative to more invasive surgery. Level of Evidence IV; Case Series.

Background: There is no consensus on treating symptomatic adjacent segment disease (ASD). The best choice depends on several factors. Spinal fusion is associated with complications that may be more relevant in adult patients. The study aimed to report the feasibility and clinical results obtained in patients over 60 years of age with ASD treated with a uniportal interlaminar endoscopic approach. Materials and Methods: We retrospectively reviewed patients> 60 years old admitted with radicular symptoms secondary to ASD history between May 2020 and January 2023 who underwent endoscopic surgery using a uniportal interlaminar approach. We collected information on patient-reported outcome measures (PROMs), including pre-and postoperative visual analog scale index (VAS), Oswestry ODI criteria, and patient satisfaction score using the MacNab criteria. Results: Eight patients, five women and three men, with an average age of 72.8 ± 7.89 years, were included in the study. The average follow-up time was 23.0 ± 16.7 months. The difference between the preoperative and postoperative VAS and ODI was statistically significant. Satisfaction with the procedure was above 80%, and the results were excellent. There were no intraoperative complications; only one case had to be reoperated with a conventional technique. No patient had a hospital stay. Conclusion: Ambulatory uniportal interlaminar endoscopic surgery is a technique that may become an alternative for the treatment of symptomatic ASD in patients over 65 years of age.

Background The authors conducted a comprehensive review and integration of insights from 4 webinars hosted by the International Society for the Advancement of Spine Surgery (ISASS) to arrive at recommendations for best clinical practices for guideline development for endoscopic spine surgery. This perspective article discusses the limitations of traditional surgical trials and amalgamates surgeons’ experience and research on various cutting-edge techniques. Methods Data were extracted from surveys conducted during each webinar session involving 3639 surgeons globally. The polytomous Rasch model was employed to analyze responses, ensuring a robust statistical assessment of surgeon endorsements and educational impacts and focusing on operative nuances and experience-based outcomes. Bias detection was performed using the differential item functioning test. Results The ISASS webinars provided a dynamic platform for discussing advances in endoscopic spine surgery, identifying a range of high-value procedures from basic discectomies to complex lumbar interbody fusions. Each high-value endoscopic spine surgery was highlighted in separate peer-reviewed publications, which form the basis for this summary document that synthesizes key takeaways from these webinars. High-value clinical applications of endoscopic spine surgery, primarily defined as higher-intensity endorsement transformation from the pre- to postwebinar survey with a shift to higher mean logit locations of test items both with unbiased and orderly threshold progression, were: (a) Percutaneous interlaminar endoscopic decompression for lateral canal stenosis, (b) transforaminal debridement of low-grade degenerative spondylolisthesis, (c) transforaminal full-endoscopic interbody fusion for hard disc herniation, (d) endoscopic standalone lumbar interbody fusion, (e) endoscopic debridement of spondylolytic spondylolisthesis, and (f) posterior cervical foraminotomy for herniated disc and bony stenosis. Conclusions The ISASS webinar series has significantly impacted surgeons’ education and contributed to the identification of high-value endoscopic spine surgery practices that may serve as a cornerstone for surgeon training standards, policy, and guidelines development. Ongoing research on technological advancements and expansions of clinical indications combined with systematic review is expected to refine the recommendations on high-value endoscopic spinal surgeries recommended for enhanced reimbursement. Clinical Relevance Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level of Evidence Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.

Background The International Society for the Advancement of Spine Surgery hosted the second of a series of 4 webinars on endoscopic spine surgery techniques. The second webinar focused on the application of unilateral biportal endoscopy for discectomy and laminectomy in combination with interbody fusion and interspinous process spacers. This series was intended to identify current trends with contemporary modern endoscopic spine surgery techniques. Objective To analyze the level of surgeon endorsement for the presented endoscopic spine surgery techniques before and after the webinar utilizing polytomous Rasch analysis, as well as to evaluate the potential for these insights to inform clinical guideline recommendations. Methods A survey was available to 667 potential respondents during the Zoom webinar, collecting data on surgeon endorsements using a Likert scale. The polytomous Rasch model was employed to analyze responses while considering the complexity of decisions against surgeon expertise, developing a logarithmic measurement scale, allowing objective statistical analysis of categorical variables, highlighting incongruent or out of order items vs congruent and in order items, and driving improvement in clinical guidelines. Results Of the 667 surgeons who participated in the webinar, 224 accessed, 122 started, and 61 completed the prewebinar survey, achieving a 50.0% completion rate. Respondents comprised primarily orthopedic surgeons (70.5%) and neurosurgeons (24.6%), with fellows and medical students each making up 1.6%. These surgeons estimated that mastering the learning curve of endoscopic spine surgery required an average of 18.08 cases corroborated by postwebinar responses averaging 15.78 cases. Descriptive statistics revealed an acknowledgment of a learning curve in mastering endoscopic spine surgery, with a slight increase in recognition postwebinar (81.8% up from 80.3%). The data underscored the importance of cadaver courses and high-volume surgical practice before the webinar and highlighted the value of mentorship afterward, indicating a preference shift toward more interactive learning. The confidence in various endoscopic techniques saw notable changes, particularly for procedures involving interlaminar lateral canal decompression and the combined use of transforaminal endoscopic decompression with interspinous process spacers, which saw an increase in high-level endorsements postwebinar. Polytomous Rasch analysis provided insights into training methods and procedural techniques, with mentorship and cadaver courses emerging as key elements for mastering the learning curve. The analysis also highlighted a general consensus on the effectiveness of percutaneous endoscopic interlaminar decompression for lateral canal stenosis, reflecting evolving surgeon preferences and consensus on best practices. Infit and outfit statistics from the Rasch analysis suggested a good fit between the survey responses and the Rasch model both before and after the webinar, indicating minimal data distortion due to bias. Differential item functioning analysis showed no significant bias in item responses between orthopedic surgeons and neurosurgeons in the prewebinar survey, but it identified potential bias for one item postwebinar—unilateral biportal endoscopic laminectomy for central stenosis. Conclusion This webinar highlighted the importance of hands-on training methods such as cadaver courses and mentorship in mastering the complex spinal endoscopy procedures. The application of polytomous Rasch analysis provided a detailed understanding of surgeons’ current preferences and perceptions, as well as the evolving consensus on best practices in endoscopic spine surgery, displaying wide acceptance of the percutaneous interlaminar endoscopic decompression for lateral canal stenosis decompression and a growing interest in integrating endoscopic techniques for more comprehensive spinal care, including wide decompression and spinal stabilization. Clinical Relevance Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level of Evidence Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.