Endoscopic Spine Surgery: A French National Survey on Practices, Motivations, and Challenges

Discussion

The results of this survey provide valuable insight into the current state of endoscopic spine surgery in routine practice among spine surgeons in France. While a substantial number of surgeons have incorporated it into their practice, challenges, such as learning curves and financial barriers, have limited its widespread adoption. The fact that most of the surgeons are in the early phase of their experience (1–3 years), endoscopy will become more prevalent as these surgeons gain experience and influence the field.

Although the history of endoscopic spine surgery is approximately 30 years old,3,4,8 it has gained popularity among spine surgeons over the past few years. Surgeons have shown a willingness to learn, which can be appreciated in the survey responses. Most of the surgeons are in an early phase of experience, and there are surgeons who have been doing 100% of their cases using endoscopy. These findings suggest a rising trend of adoption and align with the advantages of endoscopy over open technique.9

Most of the usage of endoscopy and related research work originated in China and South Korea.10 Native surgeons would be inclined more toward this technique due to easier availability of training, and this, in turn, is responsible for higher usage of endoscopy in these countries. Thus, there is a geographical disadvantage to France, leading to insufficient training as a major barrier, as also seen in our survey. The second most common limitation was that the surgeons were not convinced of the benefits associated with endoscopic spine surgery. However, according to the available current literature, the advantages strongly supported are less tissue destruction and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent epidural fibrosis and scarring, reduced hospital stay, early functional recovery, improvement in the quality of life, and better cosmesis.11,12 Apart from these aspects, the surgery can be performed on a day-care basis, and the complication rates are low, which, in turn, reduces the financial burden.13 Although we expect a contradictory response from surgeons not using endoscopy, we noticed 3 respondents from the user group mentioning no added benefit of endoscopy over open technique. These surgeons did notice an increase in surgical time and no difference in patient recovery. Due to the anonymity of the responses, we could not find the other responses of these surgeons, but we assume these surgeons must be the ones who have less experience and perform fewer cases per month. Fleiderman et al14 looked at the learning curve in 41 cases of transforaminal endoscopic lumbar discectomy. For the initial 20 cases, the mean operating time was 114 minutes, and it reduced to 80 minutes in the next 21 cases. They had a 17% incidence of recurrent disc herniation; however, the interesting finding to note here is that the last recurrence was observed in the 23rd case. Thereafter, for the next 18 cases, no recurrence was observed. Therefore, they concluded that at least 20 cases were to be operated initially to observe a significant reduction in operating time and complications.

It is interesting to note that only 67.6% of endoscopic users in France perform the transforaminal approach, compared with 92.5% of users in Australia.15 This is likely related to the overrepresentation of biportal endoscopy compared with the uniportal technique among endoscopic spine surgery users in France. We find this particularly surprising, as we consider the transforaminal approach to be a game changer in the latest endoscopic spine surgery techniques.

Another major barrier that needs separate mention is high equipment cost. We observed that more than 80% of the respondents are practicing in a private setup, where there is no financial support available by the government. Therefore, the cost becomes the major deciding factor in the treatment of patients. Manabe et al16 looked at the cost of endoscopic surgery in Japan in association with the amount reimbursed to the hospital. They observed that the hospital is not adequately reimbursed for the surgery, and the major burden is due to equipment costs. Similarly, Wu17 mentioned equipment cost as 1 of the major challenges, even if the surgeon is a well-trained endoscopic spine surgeon. This scenario is similar for every minimally invasive spine surgery. The surgery can only be cost-effective if the improvement in patients is durable, thereby reducing the overall financial burden.18 The rest of the constraints observed in our respondents were lack of time for training due to ongoing busy practices, and few surgeons are near retirement, which makes them less motivated to acquire new skills.

The indications of endoscopic spine surgery are still expanding. The procedure started with lumbar discectomy and is now also being used for lumbar interbody fusion, cervical disc herniation, and thoracic disc herniation.19 A similar trend was observed in our survey, where few surgeons are performing thoracic discectomy and lumbar fusion procedures regularly. The implications of the wider adoption of endoscopic techniques in spine surgery are significant. As more surgeons become proficient in these methods, the potential for improved patient outcomes and reduced healthcare costs increases. However, addressing the barriers to adoption, particularly in regions where reimbursement and equipment costs pose challenges, will be critical to ensuring that more patients can benefit from these minimally invasive approaches.

It is important to acknowledge the limitations of the study. First, the number of surgeons who responded is small. Therefore, the findings cannot be generalized to the whole population. Second, there is potential response bias, as the surgeons trained and performing endoscopy regularly are more like to respond in favor compared with surgeons not trained. Even with these limitations, the findings of the survey highlight the current status of endoscopic spine surgery in France and are worth mentioning.