Regional variations in acceptance, and utilization of minimally invasive spinal surgery techniques among spine surgeons: results of a global survey

Abstract

Background: Regional differences in acceptance and utilization of MISST by spine surgeons may have an impact on clinical decision-making and the surgical treatment of common degenerative conditions of the lumbar spine. The purpose of this study was to analyze the acceptance and utilization of various minimally invasive spinal surgery techniques (MISST) by spinal surgeons the world over.

Methods: The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups in social media networks including Facebook, WeChat, WhatsApp, and Linkedin. Surgeons were asked the following questions: (I) Do you think minimally invasive spinal surgery is considered mainstream in your area and practice setting? (II) Do you perform minimally invasive spinal surgery? (III) What type of MIS spinal surgery do you perform? (IV) If you are performing endoscopic spinal decompression surgeries, which approach do you prefer? The responses were cross-tabulated by surgeons' demographic data, and their practice area using the following five global regions: Africa & Middle East, Asia, Europe, North America, and South America. Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using statistical package SPSS Version 25.0.

Results: A total of 586 surgeons accessed the survey. Analyzing the responses of 292 submitted surveys regional differences in opinion amongst spine surgeons showed that the highest percentage of surgeons in Asia (72.8%) and South America (70.2%) thought that MISST was accepted into mainstream spinal surgery in their practice area (P=0.04) versus North America (62.8%), Europe (52.8%), and Africa & Middle East region (50%). The percentage of spine surgeons employing MISST was much higher per region than the rate of surgeons who thought it was mainstream: Asia (96.7%), Europe (88.9%), South America (88.9%), and Africa & Middle East (87.5%). Surgeons in North America reported the lowest rate of MISST implementation globally (P<0.000). Spinal endoscopy (59.9%) is currently the most commonly employed MISST globally followed by mini-open approaches (55.1%), and tubular retractor systems (41.8%). The most preferred endoscopic approach to the spine is the transforaminal technique (56.2%) followed by interlaminar (41.8%), full endoscopic (35.3%), and over the top MISST (13.7%).

Conclusions: The rate of implementation of MISST into day-to-day clinical practice reported by spine surgeons was universally higher than the perceived acceptance rates of MISST into the mainstream by their peers in their practice area. The survey suggests that endoscopic spinal surgery is now the most commonly performed MISST.

Keywords: Lumbar minimally invasive spinal surgery; regional variations.

Figure 1

Responses to questions one through five of the regional variations questionnaire on acceptance, and utilization of minimally invasive spinal surgery techniques among spine surgeons.

Figure 2

Frequency distribution of responses by region of residence, and the number of peers of responding spine surgeons.

Figure 3

Do you think minimally invasive spinal surgery is considered mainstream in your area and practice setting? ^a, 4 cells (26.7%) have expected count less than 5. The minimum expected count is 1.10.

Figure 4

Pie charts on map distribution of regional variations on MISST acceptance showing statistically significant differences (P=0.04) with surgeons in Asia (72.8%) and South America (70.2%) showing the highest percentage, followed by surgeons from North America (62.8%), and nearly equal for numbers of surgeons from Europe (52.8%) and Africa & the Middle East region (50%). MISST, minimally invasive spinal surgery techniques.

Figure 5

Do you perform minimally invasive spinal surgery? ^a, 2 cells (20.0%) have expected count less than 5. The minimum expected count is 2.19.

Figure 6

Pie charts on map distribution of regional variations on the percentage of surgeons performing MISST (top left panel). The percentage of MISST spine surgeons employing it was much higher per region at a statistically significant level (P<0.000) than the rate of surgeons who thought it was mainstream in their area: Asia (96.7%), Europe (88.9%), South America (88.9%), and Africa & Middle East (87.5%; P<0.000). Usage of the tubular retractor (top right panel) was the least commonly employed MISST (41.8%). Mini-open approaches (left bottom panel) were the second most widely applied MISST (55.1%), and endoscopic surgery (right bottom panel) is currently reported as the most commonly employed MISST globally. MISST, minimally invasive spinal surgery techniques.

Figure 7

Pie charts on map distribution of regional variations on percentage of surgeons performing various endoscopic approaches: top left panel—transforaminal approach (56.2%), top right panel—interlaminar approach (41.8%), left bottom panel—full endoscopic (35.3%), and bottom right panel—over the top endoscope (13.7%). Regional variations analysis showed transforaminal over interlaminar approach being preferred in North America. In contracts, the interlaminar approach being preferred in Asia, and equally being utilized in South America with the transforaminal approach.