Gun Choi

Background Endoscopic spine surgery (ESS) is increasingly recognized for its clinical efficacy and patient-centered advantages, including reduced morbidity and faster recovery. However, despite growing global interest, its adoption remains highly variable, shaped more by systemic, economic, and institutional forces than by technical limitations. Objective To evaluate global adoption barriers to ESS using psychometrically validated tools and identify region-specific structural disparities through Rasch analysis and differential item functioning (DIF). Methods A cross-sectional global survey was conducted among 1834 spine surgeons. Of the 1040 individuals who began the survey, 438 (42.6%) from 46 countries completed the survey. A 27-item instrument assessed access, reimbursement, training infrastructure, and institutional support for ESS. Rasch rating scale modeling was used to test internal validity, unidimensionality, and item fit. DIF analysis and 1-way analysis of variance were performed to detect region-specific biases in item responses. Respondents were stratified by country and region, including China, India, Brazil, the United States, Latin America, and Europe. Results Collectively, the responding surgeons reported an extrapolated cumulative experience of 1,286,496 endoscopic spine procedures, suggesting that responses were anchored in substantial clinical experience. Rasch analysis confirmed acceptable model fit. DIF analysis revealed strong regional disparities. Surgeons in China and India reported high institutional support, better training access, and fewer reimbursement obstacles, suggesting high system adaptability. Conversely, respondents from the United States and Latin America cited limited training integration, poor reimbursement, and institutional inertia. Europe exhibited a structural stalemate driven by low surgeon compensation and excessive bureaucratic gatekeeping. Despite these differences, surgeon and patient interest in ESS remained uniformly high across regions, identifying shared global momentum for minimally invasive innovation. Conclusions The global diffusion of ESS is hindered less by clinical limitations than by systemic inertia and fragmented policy frameworks. Countries with flexible, market-responsive systems (eg, China and India) are emerging as innovation leaders, while historically dominant regions (eg, United States and Europe) risk stagnation without structural reform. ESS serves as a diagnostic lens for broader health system adaptability, highlighting the urgent need for investment in training, reimbursement reform, and institutional endorsement. This study provides level II evidence that endoscopic lumbar decompression is a surgical work comparable to open techniques and should be valued accordingly. Grounded in more than 1.2 million cases and expert consensus, this study supports policy recommendations to retire Current Procedural Terminology 62380 and to adopt reimbursement frameworks based on surgical work rather than visualization method. Level of Evidence While this study cannot be reclassified in the strict Oxford Centre for Evidence-Based Medicine hierarchy, the authors employ the following analogy: Rasch/DIF methods filter bias in the same way randomization filters bias in clinical trials. While it relies on self-reported surgeon data rather than direct clinical outcomes, the application of Rasch modeling and DIF analysis strengthens internal validity and minimizes measurement bias. Importantly, surgeon responses were anchored in an extrapolated cumulative experience of more than 1.28 million endoscopic spine procedures, reflecting deeply internalized clinical judgment rather than anecdotal opinion. These methodological features distinguish the study from unvalidated descriptive surveys and support its classification as higher-level clinical evidence—offering a filtered and reliable lens into global surgical practice patterns and systemic barriers to ESS adoption. Based on its cross-sectional observational design enhanced by validated psychometric methodology, the authors consider this survey study a psychometrically validated, high-quality observational survey study. Clinical Relevance This study identifies structural and systemic barriers that limit global adoption of ESS and highlights key targets—such as training, reimbursement, and institutional support—for improving access and accelerating safe implementation.

Background/Objectives: Most brain magnetic resonance imaging (MRI) is performed in supine position, although posture may influence cerebrovascular signal characteristics through gravity-related physiological changes. However, posture-dependent vascular signal alterations on low-field MRI have not been sufficiently quantified. This study aimed to quantify posture-related internal carotid artery (ICA) signal alterations using low-field MRI by comparing seated and supine images with intensity-, noise-, and texture-based metrics. Methods: Nine healthy adults (20–69 years old; one female) underwent 0.25 T tilting MRI in supine and seated postures. 3D gradient echo T1-weighted images were obtained. The bilateral ICA regions of interest (ROI) and adjacent reference ROI were manually delineated. The signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), signal intensity ratio (SIR), gray-level co-occurrence matrix (GLCM) texture features (contrast, correlation, energy, and homogeneity) were extracted and compared between postures using Wilcoxon signed-rank tests. Results: Seated posture produced significantly higher ICA signal intensity metrics than the supine posture, with increased SNR (median 17.11 vs. 13.48), CNR (median 21.94 vs. 18.36), and SIR (median 10.84 vs. 9.54) (p = 0.004). GLCM texture analysis demonstrated a significant decrease in contrast in the seated position (median 62.01 vs. 145.92; p = 0.004), whereas correlation, energy, and homogeneity showed no significant between-posture differences. Conclusions: Low-field MRI was sensitive to posture-dependent ICA signal alterations. ICA-based metrics may provide quantitative markers of gravity-related cerebrovascular adaptation.

Objective The study aims to assess the current development status of transforaminal full-endoscopic spine surgery (TFES) by exploring and analyzing the published literature to obtain an overview of this field and discover the evolution and emerging topics that are underrepresented. Methods Using Bibliometrix, CiteSpace, and VOSviewer, we analyzed the bibliometric data selected from the Web of Science Core Collection between January 2002 and November 2022. The descriptive and evaluative analyses of authors, institutes, countries, journals, keywords, and references are compiled. The quantity of research productivity was measured by the number of publications that were published. A quality indicator was thought to be the number of citations. In the bibliometric analysis of authors, areas, institutes, and references, we calculated and ranked the research impact by various metrics, such as the h-index and m-index. Results A total of 628 articles were identified in the field of TFES by the 18.73% annual growth rate of research on the subject from 2002 to 2022, constituting the documents are by 1961 authors affiliated with 661 institutions in 42 countries or regions and published in 117 journals. The USA (n = 0.20) has the highest international collaboration rate, South Korea has the highest H-index value (h = 33), and China is ranked as the most productive country (n = 348). Brown univ., Tongji univ., and Wooridul Spine represented the most productive institutes ranked by the number of publications. Wooridul Spine Hospital demonstrated the highest quality of paper publication. The Pain Physician had the highest h-index (n = 18), and the most cited journal with the earliest publication year in the area of FEDS is Spine (t = 1855). Conclusion The bibliometric study showed a growing trend of research on transforaminal full-endoscopic spine surgery over the past 20 years. It has shown a significant increase in the number of authors, institutions, and international collaborating countries. South Korea, the United States, and China dominate the related areas. A growing body of evidence has revealed that TFES has leapfrogged from its infancy stage and gradually entered a mature development stage.

Study Design: A retrospective review. Objectives: To evaluate the therapeutic efficacy of the triple layer closure technique to establish watertight sealing without diversion of lumbar drainage, in preventing persistent incidental subarachnoid-pleural fistula and other neurological complications related to excessive drainage of cerebrospinal fluid (CSF) after dural defect in transthoracic ossified posterior longitudinal ligament (OPLL) surgery. Summary of Background Data: CSF leakage into the pleural cavity leads to unfavorable conditions for natural healing of incidental durotomy due to the negative pressure environment of the pleural space and lack of wound healing around the bony cavity near the decompressed spinal cord. This often leads to a persistent incidental subarachnoid-pleural fistula. In addition, diversion of lumbar drainage may lead to excessive CSF drainage resulting in intracranial hypotension. To avoid this, we studied the efficacy of a modified sealing method to establish a more watertight covering at the ventral dural defect without lumbar CSF drainage. Methods: Fifty-three patients who had CSF leakage from the ventral aspect of the spinal cord during transthoracic spine surgery for thoracic OPLL between 2004 and 2013 were retrospectively reviewed. Patients were divided into 2 groups: a conventional group (group A) and a triple layer closure group (group B). In group A (n=33 patients), the dural defect was covered with fibrin glue (Beriplast P) mixed with gelfoam (Spongostan Standard) with subsequent subarachnoid lumbar drainage. In group B (n=20 patients), the dural defect was sealed using the triple layer technique with 2 layers of fibrin glue and gelatin sponge plus a third layer of synthetic hydrogel (Duraseal, Dural Sealant System) without subsequent subarachnoid lumbar drainage. Both groups had chest tubes that drained through an underwater seal. Clinical data including duration and total amount of drainage (chest tube and lumbar drainage), related complications, and duration of hospital stay were compared between the 2 groups. Results: Compared with the patients in group A, group B had a significantly smaller total volume of drainage and shorter chest tube drainage time (P<0.05) during their hospital stay. In group A, complications occurred in 6 cases (18.2%), including 3 cases of intracranial hypotension combined with transient mental status alteration, postural headache, and dizziness, 1 case of regional atelectasis with pneumonia, and 2 cases of revision thoracotomy. Revision thoracotomy was performed to treat persistent subarachnoid-pleural fistula due to significant and prolonged CSF leakage. In group B, there were no complications and no revision thoracotomy was needed. The mean duration of hospital stay was shorter in group B (15.6 d) compared with group A (22.4 d). Conclusions: The established watertight closure of the dural defect using the triple layer sealing method without lumbar drainage was more effective and safe.

Thoracic disc surgeries make up only a small number of all spine surgeries performed, but they can have a considerable number of postoperative complications. Numerous approaches have been developed and studied in an attempt to reduce the morbidity associated with the procedure; however, we still encounter cases that develop serious and unexpected outcomes. This case report presents a patient with abducens nerve palsy after minimally invasive surgery for thoracic disc herniation with an intraoperative spinal fluid fistula. A literature review of all cases related to this complication after spine surgery is included. Despite the uncommon nature of this type of complication, understanding the procedure itself, the principle occurrences and outcomes following the procedure, the physiopathogical features of abducens nerve palsy, and the possible adverse effects of spinal surgery, including minimally invasive procedures, can enable an early diagnosis of complications and facilitate the procedure. In spite of being very rare and multifactorial, uni- or bilateral abducens nerve paralysis carries significant morbidity and can occur as a postoperative complication after conventional or minimally invasive spine surgery. This condition requires an accurate diagnosis and adequate multidisciplinary follow up.

Background: Although percutaneous endoscopic lumbar discectomy (PELD) has shown favorable outcomes in the majority of lumbar discectomy cases, there were also some failures. The most common cause of failure is the incomplete removal of disc fragments. The skin entry point for the guide-needle trajectory and the optimal placement of the working sleeve are largely blind, which might lead to the inadequate removal of disc fragments. The objective of this study was to present our early experiences with image-guided PELD using a specially designed fluoroscope with magnetic resonance imaging-equipped operative suite (XMR) for the treatment of lumbar disc herniation.Methods: This prospective study included 89 patients who had undergone PELD via the transforaminal approach using an XMR protocol. Pre- and postoperative examinations (at 12 weeks) included a detailed clinical history, visual analogue scale (VAS), Oswestry disability index (ODI), and radiological workups. The results were categorized as excellent, good, fair, and poor according to MacNab's criteria. At the final follow-up, the minimum follow-up time for the subjects was 2 years. The need for revision surgeries and postoperative complications were noted on follow-up.Results: Postoperative mean ODI decreased from 67.4% to 5.61%. Mean VAS score for back and leg pain improved significantly from 4 to 2.3 and from 7.99 to 1.04, respectively. Four (4.49%) patients underwent a second-stage PELD after intraoperative XMR had shown remnant fragments after the first stage. As per MacNab's criteria, 76 patients (85.4%) showed excellent, 8 (8.89%) good, 3 (3.37%) fair, and 2 (2.25) poor results. Four (4.49%) patients had remnant disc fragments on XMR, which were removed during the same procedure. All of these patients had either highly migrated or sequestrated disc fragments preoperatively. Four (4.49%) other patients needed a second, open surgery due to symptomatic postoperative hematoma (n= 2) and recurrent disc herniation (n= 2).Conclusions: This prospective analysis indicates that XMR-assisted PELD provides a precise skin entry point. It also confirms that decompression occurs intraoperatively, which negates the need for a separate surgery and thus increases the success rate of PELD, particularly in highly migrated or sequestrated discs. However, further extensive experience is required to confirm the advantages and feasibility of PELD in terms of cost effectiveness.

Background: The long-term complications of traditional discectomy and fusion surgery have led to the need for minimally invasive procedures that do not require a complete discectomy and fusion. Jho developed an anterior unco-foraminotomy that we have modified, with the approach being more medial than that of Jho, into an anterior transcorporeal tunnel approach which we use for cervical spondylotic unilateral radiculopathy. Methods: A retrospective analysis was carried out in 30 patients who underwent a transcorporeal “tunnel” anterior micro-foraminotomy for unilateral radicular symptoms with a follow-up more than 2 years. All were operated by a single surgeon using the same technique from the vertebral body proximal to the lesion and proceeding downwards to the herniation. At final follow-up we reviewed the clinical and radiological results. Results: All patients in the immediate post-operative period showed relief of their symptoms, and there were major complications. 3 patients complained about the numbness in the immediate postoperative period which resolved within 3 months. There was a significant improvement in NDI from pre-operative 55.16% to postoperative 5.82% (P P Conclusion: The transcorporeal tunnel approach can be used as an alternative treatment for cervical spondylotic radiculopathy.