Yi-Hao Liang

Endoscopic spine surgery has advanced from a percutaneous niche technique to a mainstream platform for lumbar decompression. This original study examines the relationship between endoscopic and microscopic platforms across 7 contested domains, using an embedded cross-sectional single-round international survey to map patterns of expert agreement and divergence. Seven contested domains—learning curve, technical feasibility, patient selection, clinical and radiological outcomes, complications, cost-effectiveness, and reoperation—were each argued by a Pro-Microscopic and a Pro-Endoscopic advocate before reconciliation, then complemented by a structured single-round international survey of 105 spine surgeons from 5 world regions. The survey was designed to describe practice patterns and map the distribution of expert opinion, not to determine whether endoscopy can replace microscopy. Statements meeting a prespecified conjunctive threshold of at least 70% agreement overall and within each of 3 practice-profile strata were classified as meeting the consensus standard, with the 70% level adopted on the precedent of the CORE (Convergence of Opinion on Recommendations and Evidence) methodology. Seven statements met this standard: reduced approach-related trauma, lower surgical site infection, primacy of surgeon experience over platform, the training burden of endoscopy, standardized outcome reporting, comparable 1- to 2-year outcomes in selected stenosis, and health-system dependence of cost-effectiveness. Endoscopy-favoring distributions were modal in all 7 domains, reaching a majority for complications, outcomes, and patient selection; learning curve and cost-effectiveness remained areas of mixed opinion, and reoperation showed the widest divergence of views. Although 75.2% judged that endoscopy is ready to replace the microscope as the default platform, this fell to 38.5% (95% confidence interval, 13.9%–68.4%) among microscopically oriented surgeons and failed stratification. Endoscopy has demonstrated comparable outcomes for selected pathology and perioperative advantages in specific domains, but not durable long-term superiority. The evidence supports coexistence rather than replacement, with platform selection matched to pathology, patient phenotype, endoscopic platform, and surgeon expertise. The survey illustrates where expert practice patterns align with, diverge from, or run ahead of published comparative evidence.

Our research examines the learning curves of various minimally invasive lumbar surgeries to determine the benefits and challenges they pose to both surgeons and patients. The advent of microsurgical techniques since the 1960s, including advances in fluoroscopic navigation and intraoperative computed tomography, has significantly shifted spinal surgery from open to minimally invasive methods. This study critically evaluates surgical duration, intraoperative conversions to open surgery, and complications as primary parameters to gauge these learning curves. Through a comprehensive literature search up to March 2024, involving databases PubMed, Cochrane Library, and Web of Science, this paper identifies a steep learning curve associated with these surgeries. Despite their proven advantages in reducing recovery time and surgical trauma, these procedures require surgeons to master advanced technology and equipment, which can directly impact patient outcomes. The study underscores the need for well-defined learning curves to facilitate efficient training and enhance surgical proficiency, especially for novice surgeons. Moreover, it addresses the implications of technology on surgical accuracy and the subsequent effects on complication rates, providing insights into the complex dynamics of adopting new surgical innovations in spinal health care.

The main aim of this video article is to demonstrate the combined use of O-arm navigation and unilateral biportal endoscopy (UBE) to manage far-out syndrome (FOS). In FOS there is entrapment and compression of the fifth lumbar nerve beyond the foramen and between L5 transverse process and the sacral ala at the lumbosacral junction. Conventional microscopic decompression using a paraspinal approach had been the gold standard for its management. However, the surgery is technically challenging due to the deep location of the pathology and intricate anatomy of extraforaminal space. There have been some published reports of unsatisfactory outcomes with microscopic decompression for FOS. We decided to integrate navigation with UBE to increase precision for the management of FOS. A 70-year-old female presented to us with chief complaint of left lower limb radiculopathy since 1 year. She also complained of numbness and paresthesias in her left leg and foot. She was unable to walk for more than 10 minutes due to pain. Her magnetic resonance imaging scan revealed compression of left L5 nerve root in the extraforaminal region. UBE decompression via paraspinal approach was performed for her under O-arm navigation. She experienced immediate relief of her symptoms in the postoperative period. O-arm-navigation-guided UBE is an effective and safer alternative to microsurgical decompression for the management of FOS. This video demonstrates the step-by-step implementation of O-arm navigation with endoscopy and its precise execution.

This video provides a step-by-step guide for performing the hybrid endoscopic thoracic discectomy using navigation and robotic arm for addressing high migrated calcified disc herniation. With the development of techniques, endoscopic spine surgery has emerged as a reliable treatment for thoracic myelopathy. This approach offers high-resolution, off-axis visualization of the surgical field. The field is poised to advance further as endoscopic instruments are refined, becoming less invasive and more precise through the integration of navigation and robot-assisted systems. A 62-year-old woman presented to us with chief complaints of both legs weakness. She had difficulty standing and walking after squatted due to weakness in her legs and her Oswestry Disability Index score was 66. On examination her both side knee extension and ankle dorsiflexion were grade 4 without dysesthesia. The imaging examination confirmed the diagnosis of thoracic myelopathy caused by a highly migrated calcified disc herniation at T5–6 level. The patient underwent an endoscopic thoracic discectomy using robotic arm and navigation for addressing highly migrated calcified disc herniation, resulting in an excellent outcome. The continuous development of navigation and robotic systems in endoscopic thoracic surgery enhanced accuracy in surgical incisions and instrument placement, as well as improved efficiency in locating pathology and achieving precise decompression. Endoscopic thoracic discectomy combines full-endoscopy and unilateral biportal endoscopic (UBE) techniques to leverage the benefits of both approaches, including the cross-viewing of full-endoscopy cannula and the use of larger Kerrison rongeurs under UBE.