BACKGROUND AND OBJECTIVES:Transforaminal endoscopic diskectomy is an effective approach for treatment of thoracic and lumbar disk pathologies. Classically, intraoperative neuromonitoring is used in these approaches given the risk to the exiting nerve root during transforaminal targeting. The trans-superior articular process (trans-SAP) approach is a targeting technique that docks on the ventrolateral SAP, allowing access to lateral recess pathology. This approach theoretically minimizes risk to the exiting nerve root which could occur with targeting or aberrant reaming. We investigate the safety of the trans-SAP approach by analyzing intraoperative neuromonitoring events in transforaminal endoscopic cases. METHODS:A retrospective analysis of 180 transforaminal endoscopic cases using the trans-SAP approach and free-running electromyography (EMG) neuromonitoring was performed. Cases were performed at 4 institutions; Houston Methodist Hospital, University Of Michigan, University of Washington, and Texas Back Institute, from 2021 to 2024. Neuromonitoring data using free-running EMG were carefully reviewed for each case and adverse monitoring events or EMG triggers were recorded. RESULTS:Free-running EMG neuromonitoring was used in 180 of the 212 reviewed cases (84.91%). No adverse monitoring events or EMG triggers were recorded in 179 of the 180 monitored trans-SAP approach cases (99.44%). Three were performed awake with conscious sedation and no recorded events during targeting. One case was deemed safe without neuromonitoring based on thoracic foraminal pathology without cord compression. In the single case with a neuromonitoring event, multiple episodes of spontaneous neurotonic EMG activity were recorded during the dissection and diskectomy portion of the case, ultimately subsiding. CONCLUSION:The trans-SAP approach for endoscopic diskectomy allows for safe access in transforaminal surgery. There was only one neuromonitoring event during the initial targeting in the 180 monitored or 3 awake trans-SAP cases included in this study that resolved without intraoperative or postoperative symptoms. These results could obviate the need for intraoperative neuromonitoring in these cases.
INTRODUCTION:Posterior lumbar fusion is a widely used technique for stabilizing the lumbar spine, yet complications such as cranial facet violations, increased blood loss, and soft tissue trauma have prompted interest in minimally invasive alternatives. Transfacet screw fixation has emerged as a promising technique, offering advantages such as reduced surgical morbidity, lower risk of adjacent segment degeneration, and greater biomechanical stability in specific patient populations. This study investigates the clinical outcomes of patients undergoing one- or two-level lumbar fusion using transfacet screws. METHODS:A retrospective cohort study was conducted on a consecutive series of 31 patients who underwent posterior lumbar fusion using transfacet screws between 2010 and 2022. Patients were included if they received transfacet or translaminar screw fixation at one or two spinal levels and had a minimum of one-year follow-up. Clinical outcomes were evaluated using Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores for back and leg pain, and clinical data on reoperation rates and indications were evaluated. RESULTS:The mean age of the study population was 53.3 years (range 26-83), and 54.8% were male. Most patients (71%) involved a combined interbody and posterior fusion. A total of 82 screws were implanted across 41 levels, with 48 being translaminar facet screws and 34 being transfacet screws. Patients experienced significant improvements in ODI (40.1 vs. 23.1; p<0.001), back pain (6.4 vs. 2.7; p<0.001), and leg pain (4.7 vs. 2.3; p=0.003) scores. The overall reoperation rate was 19.4% (n=6), with half of these reoperations addressing preexisting pathology rather than surgical failure. Five of the six reoperations (83.3%) involved the use of transfacet screws at additional levels. Time from index to reoperation was shorter on average for continued symptomatic patients (19.7 months) than those who developed symptoms due to new pathologies (49.7 months). CONCLUSION:This study found that the use of transfacet screw fixation provides a viable alternative to traditional pedicle screws, offering significant pain relief and functional improvement.
BACKGROUND CONTEXT Cervical total disc replacement (TDR) has demonstrated outcomes comparable or superior to anterior cervical discectomy and fusion, including reoperation rates. However, a complication unique to TDR is osteolysis, characterized by significant bone loss in the vertebral bodies at the implanted level, which may necessitate revision surgery. PURPOSE To evaluate the occurrence of cervical TDR removal due to osteolysis and identify associated risk factors. STUDY DESIGN/SETTING Retrospective study of a consecutive series from a multisite spine specialty center. PATIENT SAMPLE A total of 2476 patients undergoing cervical TDR beginning in 2003, with a minimum of 12 months postoperative follow-up. OUTCOME MEASURES Incidence of TDR removal or revision due to osteolysis. METHODS Patient records were reviewed to identify cases requiring TDR removal for osteolysis. Variables including age, sex, body mass index (BMI), device type, and number of operated levels were analyzed using stepwise logistic regression to identify factors associated with revision. RESULTS TDR removal due to osteolysis occurred in 23 of 2476 cases (0.9%; 95% CI 0.61%–1.40%). Device type was the only factor significantly associated with revision. Age, sex, BMI, and number of operated levels were not significant predictors. Among 11 device types used, two designs—M6-C and Simplify—demonstrated higher revision rates (8.1% and 4.2%, respectively). The mean time to removal was 36.6 months (range, 9–80 months). In most cases, the TDR was removed and converted to anterior cervical discectomy and fusion (ACDF). In select cases with less severe but progressive osteolysis, the TDR was replaced with a different device. CONCLUSIONS Osteolysis is an uncommon but important complication of cervical TDR, with an overall low incidence. The risk appears to be associated with specific device designs. These findings are consistent with existing literature, though limited sample sizes for certain devices may affect interpretation. FDA Device/Drug Status M6-C, Secure-C, and PCM (approved for single-level use); Simplify, Mobi-C, ProDisc-C, and Prestige (approved for one- and two-level use). No devices are approved for hybrid or multi-level (>2) applications; remaining devices were investigational.
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 CONTEXT Cervical disc replacement has emerged as an alternative to fusion for 1- and 2-level disease. Periprosthetic bone loss is a recognized radiographic finding, though its clinical significance remains unclear. PURPOSE To evaluate the association between periprosthetic bone changes and clinical outcomes, including patient-reported outcomes and index level revision. STUDY DESIGN/SETTING Subanalysis of FDA IDE trials with mid- and long-term follow-up. PATIENT SAMPLE Patients treated with PEEK-on-ceramic cervical disc replacement at 1 level (n=146) or 2 levels (n=178). OUTCOME MEASURES NDI, neck pain, arm pain, SF-12, and index level revision. METHODS Radiographs were evaluated for anterior bone loss and cystic changes. Patient-reported outcomes were compared with preoperative values through 5 years. Associations were analyzed using general linear mixed models. RESULTS No significant association was found between bone changes and clinical outcomes, including NDI, pain scores, or SF-12 measures. Index level revision rates were similar regardless of bone changes. CONCLUSIONS Periprosthetic bone changes were not associated with clinical outcomes for 5 years. These findings suggest limited aggregate clinical impact, though long-term follow-up is ongoing. FDA Device/Drug Status Simplify Cervical Disc (Approved for this indication)
