Neurology & Neurosurgery

Endoscopic Spine Surgery 101: How to Build a Successful Practice

Sep. 27, 2021 - Eden McCleskey

Endoscopic spine surgery may still be in its nascency in America, but if the interest and buzz it generates at national spine surgery conventions is any indication, that's about to change.

One early adopter and true believer in the "ultra minimally invasive" surgical technique is Dr. Meng Huang, a Houston Methodist neurosurgeon who has performed more than 60 endoscopic spine surgeries just a year out of fellowship training. As a participating faculty member of the hospital's neurosurgical spine fellowship program, he is also tasked with training fellows and residents in the endoscopic technique.

Dr. Huang will be presenting his insights on how to start a career in endoscopic spine surgery at the North American Spine Society annual meeting on Sept. 30. He spoke with Leading Medicine about the challenges and opportunities endoscopy presents for surgeons and trainees interested in getting in on the ground level of a field that's clearly about to take off.

Q: Why are you so passionate about endoscopic spine surgery?

This is the type of surgery I would want to have, or want my loved one to have, if needed. I really believe it's the wave of the future, certainly for any kind of disk herniation and relief from nerve impingement caused by a multitude of pathologies.

There are several well-established benefits to it, in addition to being an outpatient procedure. The reduced risk of surgical complications (infection, surgical site blood clots, spinal fluid leakage), speedier recovery time, dramatically reduced postoperative pain and need for opioids (many patients report needing no narcotic pain medications after surgery) and much faster return to work and normal activity. In some cases, it can even be done without general anesthesia and the attendant cardiopulmonary risks.

But I also believe that it has long-term benefits that haven't been proven yet in clinical studies. There's minimal collateral soft tissue damage, meaning reduced disruption to normal muscle, ligament and bone around the spinal canal when accessing and removing the disk herniation. I think, over time, this will prove to be an important benefit, in terms of decreasing the risk of long-term accelerated degeneration of that area of the spine.

Q: Why do you think it's a good career move to learn how to do endoscopic surgery?

Right now, we're still in this period where there's a bit of a stunted growth curve because of factors like the cost of the equipment and the learning curve required to move from traditional spine surgery or minimally invasive spine surgery to this new and different endoscopic surgery technique. But I believe we've reached critical mass and this new era of endoscopic spine surgery is coming, whether you're ready or not. I am basing this off of the interest of medical students, residents, colleagues and patients.

So, if it's happening anyway, why not get in at the ground level, so to speak, rather than scramble to catch up? It may be a bit of a cliché, but think of tech disruptors like Uber and Airbnb. Better to be on the early side of adoption than late, right? Right now, there are only a handful of well-established fellowship programs. We are trying to create our own simply to get more well-trained endoscopic spine surgeons out there. But that's a tiny fraction of overall training programs and spine surgeons. That means there's still plenty of space to establish yourself.

Furthermore, if you are at a large academic medical center, you have an advantage. I did my residency here at Houston Methodist and then left for my fellowship with the express understanding that I would go off and learn this technique and then bring it back here to start a program of our own — both a surgical program and a training program. With the generous support of Dr. Gavin Britz, chair of the Department of Neurosurgery, we were able to buy the necessary endoscopic equipment and console tower, which would be cost-prohibitive for smaller hospitals and centers.

Bottom line, it's still early, and that means it's still a really great time to get in the field — that is my message.

Q: What are the main challenges you have to overcome in order to perform this type of surgery?

Besides the cost of equipment, it's a whole different way of doing surgery. I'm not going to lie, it can be awkward to learn when you're well versed at either traditional spine surgery or minimally invasive spine surgery. With minimally invasive surgery, you're working within a tube the same as with endoscopy, but it is a much larger tube and you can use instruments in both hands simultaneously. One hand is using a suction device, which can also double as a retractor to retract the nerves. The other hand is using an instrument to probe, look for disk herniation and grab it when you see it.

With the interlaminar endoscopic technique, everything is similar, except you're using one scope with one working channel. All the instruments are passing through one hand. You're using the other hand to control the scope, which is very different from doing static surgery through a tube using two hands.

The transforaminal endoscopic technique uses an even smaller endoscope that can pass through the natural nerve exit corridor. It changes the entire orientation of surgery. In traditional surgery, you're trained to make a window through the bone, and the first thing you see is the nerves. Then you can retract the nerves and get the disk material out. With this transforaminal approach, the first thing you see is the disk herniation. The last thing you see is the nerve as you are decompressing it. That can be scary to surgeons because you would prefer to see and control the nerve before you work on removing the pathology. You have to be really precise with the herniated disk removal and be very conscious of where the nerves could potentially be.

But, again, the benefits to the patient are manifold. And with that transforaminal approach, you don't even necessarily have to use general anesthesia. So your patient can even provide real-time feedback on the improvement of their symptoms or proximity of your instruments to their nerves.

Q: Any other words of advice for people interested in starting out?

When you're in your board certification period, I know the general wisdom is you should stick to the basic, easy and well-established techniques that nobody can criticize you on. But my argument is, endoscopic spine surgery is the wave of the future. The complication profile in experienced hands is actually significantly lower than traditional surgery. So don't be afraid to start working towards it right off the bat. If you're going to do it, there's no better time than right after training, when you've had some exposure to it. You have some familiarity, and you've just begun building your practice, so you have the luxury of spending some time investing in yourself.

If you're not part of a formal training or mentorship program, there are textbooks you can start with, courses and videos. There are many ways to get yourself the exposure you need to get started.

A final piece of advice is collaborating with your partners who may share your interest. I have performed many complex cases together with one of my mentors, Dr. Paul Holman, director of the Houston Methodist Spine Center, who shares my enthusiasm for endoscopic spine surgery. We have been able to support each other in tough cases and learn and hone our skills together.

I know I'm still early in my career, but I've flourished in this niche because I decided a while back that this was what I wanted to pursue. And I advise those who are interested in the same thing, and who have the aptitude, to go for it. I certainly have not regretted it, as you can see from my advocacy.


Neurology Neurosurgery Spine Endoscopy Surgical Case