Jorge Felipe Ramírez León

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.

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 Transforaminal endoscopic lumbar decompression (TELD) has emerged as a minimally invasive alternative for managing lumbar stenosis and disc herniations. While the literature consistently reports favorable outcomes, real-world adoption remains variable, with discrepancies often linked to surgeon experience and case complexity. Objective To evaluate surgeon perspectives on the clinical applicability of TELD across different pathologies and compare these findings with published evidence. Methods An international cross-sectional survey was conducted among spine surgeons. Responses were analyzed using Rasch modeling to assess consensus levels, with agreement categorized as strong, moderate, weak, or disagreement. Differential Item Functioning (DIF) and correlation analyses were applied to identify potential bias between neurosurgeons and orthopedic surgeons and to explore associations between pathologies. Results Analysis of 128 surgeon responses demonstrated clear stratification of consensus across pathologies. Strong agreement was observed for posterolateral herniated nucleus pulposus (HNP), far-migrated HNP, and lateral canal stenosis, reflecting consistent confidence in the applicability of TELD for these conditions. Moderate consensus was found for central HNP and central canal stenosis, where responses were stable but showed slightly greater variability. In contrast, low agreement was reported for lumbar facet cysts and low-grade spondylolisthesis, underscoring areas of ongoing controversy and divergent practice patterns. The Q3 correlation matrix revealed both overlapping and divergent domains of surgical confidence. Positive correlations linked lateral canal and central canal stenosis (r = 0.116), suggesting that surgeons proficient in transforaminal approaches for lateral pathology may also extend these skills to central disease. Similarly, lumbar facet cysts and low-grade spondylolisthesis showed a modest positive relationship (r = 0.073), consistent with their frequent clinical copresentation. Conversely, negative correlations highlighted distinct areas of expertise. For example, central canal stenosis and posterolateral HNP demonstrated a strong negative association (r = –0.475), while far-migrated HNP correlated negatively with both facet cysts (r = –0.348) and low-grade spondylolisthesis (r = –0.317). Conclusion These findings suggest that technical proficiency in 1 domain does not necessarily translate to others, emphasizing the need for specialized training in complex or atypical scenarios. Refinement in training and technique positions transforaminal endoscopic surgery to redefine spinal stenosis care, moving past the entrenched notion that its use is confined to foraminal and lateral canal disease while central canal pathology belongs exclusively to interlaminar methods. Clinical Relevance This study signals a shift away from the rigid notion that transforaminal endoscopy is limited to compressive painful pathology in the lateral canal while interlaminar approaches are preferable for central stenosis. In expert hands, modern endoscopic techniques demonstrate that low-risk transforaminal decompression can be successfully applied to more complex conditions, including central stenosis with or without low-grade spondylolisthesis. These findings emphasize the importance of advanced training programs to enable practicing spine surgeons to achieve outcomes comparable to those reported by key opinion leaders. Level of Evidence Psychometrically validated, high-quality observational survey study (see also Authors’ Note).

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.