{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T16:53:55Z","timestamp":1774630435112,"version":"3.50.1"},"reference-count":31,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T00:00:00Z","timestamp":1774569600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: The endoscopic approach to the spine has a steep learning curve, primarily due to challenges in learning how to access Kambin\u2019s triangle, leading to significant radiation exposure. Real-time live instrument tracking using two-dimensional fluoroscopic navigation has been shown to significantly reduce the time and radiation exposure needed to perform a trans-Kambin approach; however, the impact on the learning curve for those in training has not been studied. Methods: Physicians in training (PITs) in a single program were evaluated while accessing Kambin\u2019s triangle using a gel sawbone model. The PITs were randomized in terms of spinal level, the technology used first, and the approach side. Time to access Kambin\u2019s triangle and radiation were recorded for each cohort. A linear regression model was used to assess associations between procedure time and radiation exposure and endoscopic experience and PGY level. Results: Seven PITs were studied with a range of prior experience, consisting of three PITs with high exposure (HE) (\u226530 cases) and four with low exposure (LE) (0\u201320 cases, averaging 7.5). Unassisted by instrument tracking, the SE group was 63% faster and was exposed to 63% less radiation. Further, there was a moderate correlation with experience and time (R = \u22120.52) and radiation (R = \u22120.60). Using instrument tracking allowed all the PITs to be 40% faster, taking 6.6 min (range 2.9\u201312.4) without instrument tracking and 4.0 min (1.9\u20136.3) with it. Radiation also decreased by 91% (2.52 vs. 0.23 mGy with instrument tracking). Conclusions: Experience significantly enhanced the accessibility of Kambin\u2019s triangle, reducing time and radiation exposure by about two-thirds. Regardless of experience, instrument tracking reduced radiation exposure by 90%. Additionally, familiarizing PITs with instrument location can eliminate 70% of the learning curve for those inexperienced with accessing Kambin\u2019s triangle.<\/jats:p>","DOI":"10.3390\/jcm15072579","type":"journal-article","created":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T15:45:42Z","timestamp":1774626342000},"page":"2579","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Physicians in Training Learning Endoscopy: Reduction in Radiation Exposure with Optical Navigation Technology"],"prefix":"10.3390","volume":"15","author":[{"given":"Audrey","family":"Demand","sequence":"first","affiliation":[{"name":"Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX 77030, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Samuel B.","family":"Kankam","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX 77030, USA"},{"name":"T.H. Chan School of Public Health, Harvard University, Cambridge, MA 02115, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chris","family":"Oake","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX 77030, USA"},{"name":"Texas A&M School of Engineering Medicine, Houston, TX 77030, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paul","family":"Holman","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX 77030, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Meng","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX 77030, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"84","DOI":"10.21037\/atm-20-1052","article-title":"Intraoperative risks of radiation exposure for the surgeon and patient","volume":"9","author":"Jenkins","year":"2021","journal-title":"Ann. Transl. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1032","DOI":"10.1001\/jamasurg.2025.2482","article-title":"Mortality Among Surgeons in the United States","volume":"160","author":"Patel","year":"2025","journal-title":"JAMA Surg."},{"key":"ref_3","first-page":"113","article-title":"Occupational Exposure to Ionizing Radiation in Female Physicians and Breast Cancer Risk: A Systematic Review and Meta-analysis","volume":"26","author":"Reis","year":"2025","journal-title":"Clin. Breast Cancer"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"524","DOI":"10.5312\/wjo.v8.i7.524","article-title":"Radiation exposure and reduction in the operating room: Perspectives and future directions in spine surgery","volume":"8","author":"Narain","year":"2017","journal-title":"World J. Orthop."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"8419739","DOI":"10.1155\/2022\/8419739","article-title":"Navigation Techniques in Endoscopic Spine Surgery","volume":"2022","author":"Hagan","year":"2022","journal-title":"BioMed Res. Int."},{"key":"ref_6","first-page":"e25202","article-title":"Evaluation of Endoscopic Versus Open Lumbar Discectomy: A Multi-Center Retrospective Review Utilizing the American College of Surgeons\u2019 National Surgical Quality Improvement Program (ACS-NSQIP) Database","volume":"14","author":"Page","year":"2022","journal-title":"Cureus"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.ijsu.2016.05.061","article-title":"Comparison of percutaneous endoscopic lumbar discectomy versus open lumbar microdiscectomy for lumbar disc herniation: A meta-analysis","volume":"31","author":"Ruan","year":"2016","journal-title":"Int. J. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1016\/j.wneu.2015.09.047","article-title":"Comparison of Outcomes of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Young Adults: A Retrospective Matched Cohort Study","volume":"86","author":"Ahn","year":"2016","journal-title":"World Neurosurg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1016\/j.spinee.2023.01.009","article-title":"Full-endoscopic spine surgery diminishes surgical site infections\u2014A propensity score-matched analysis","volume":"23","author":"Mahan","year":"2023","journal-title":"Spine J."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1022","DOI":"10.1016\/j.spinee.2023.12.009","article-title":"Full-endoscopic versus microscopic spinal decompression for lumbar spinal stenosis: A systematic review & meta-analysis","volume":"24","author":"Chin","year":"2024","journal-title":"Spine J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"549","DOI":"10.3171\/2021.8.SPINE21890","article-title":"Endoscopic decompression for the treatment of lumbar spinal stenosis: An updated systematic review and meta-analysis","volume":"36","author":"Gaztanaga","year":"2022","journal-title":"J. Neurosurg. Spine"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e15647","DOI":"10.1097\/MD.0000000000015647","article-title":"Three-dimensional navigation (O-arm) versus fluoroscopy in the treatment of thoracic spinal stenosis with ultrasonic bone curette: A retrospective comparative study","volume":"98","author":"Wen","year":"2019","journal-title":"Medicine"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1007\/s00701-019-04104-y","article-title":"How I do it? Interlaminar contralateral endoscopic lumbar foraminotomy assisted with the O-arm navigation","volume":"162","author":"Chen","year":"2019","journal-title":"Acta Neurochir."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"5716235","DOI":"10.1155\/2016\/5048659","article-title":"Minimally Invasive Spinal Surgery with Intraoperative Image-Guided Navigation","volume":"2016","author":"Kim","year":"2016","journal-title":"BioMed Res. Int."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"E306","DOI":"10.1097\/BRS.0b013e318281d70b","article-title":"Estimating the effective radiation dose imparted to patients by intraoperative cone-beam computed tomography in thoracolumbar spinal surgery","volume":"38","author":"Lange","year":"2013","journal-title":"Spine (Phila Pa 1976)"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"E7","DOI":"10.3171\/2015.11.FOCUS15485","article-title":"Patient radiation exposure during transforaminal lumbar endoscopic spine surgery: A prospective study","volume":"40","author":"Iprenburg","year":"2016","journal-title":"Neurosurg. Focus"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"375","DOI":"10.14444\/7049","article-title":"Effect of instrument navigation on C-arm radiation and time during spinal procedures: A clinical evaluation","volume":"14","author":"Wang","year":"2020","journal-title":"Int. J. Spine Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e389","DOI":"10.1016\/j.wneu.2023.01.037","article-title":"A Comparison of Percutaneous Pedicle Screw Accuracy Between Robotic Navigation and Novel Fluoroscopy-Based Instrument Tracking for Patients Undergoing Instrumented Thoracolumbar Surgery","volume":"172","author":"Wang","year":"2023","journal-title":"World Neurosurg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2597","DOI":"10.1007\/s00586-022-07280-1","article-title":"Application of electromagnetic navigation in endoscopic transforaminal lumbar interbody fusion: A cohort study","volume":"31","author":"Zhang","year":"2022","journal-title":"Eur. Spine J."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e101","DOI":"10.1016\/j.wneu.2021.05.058","article-title":"A prospective comparison of the effects of instrument tracking on time and radiation during minimally invasive lumbar interbody fusion","volume":"152","author":"Hamouda","year":"2021","journal-title":"World Neurosurg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"651","DOI":"10.2214\/AJR.18.20788","article-title":"Computer-Assisted Instrument Navigation Versus Conventional C-Arm Fluoroscopy for Surgical Instrumentation: Accuracy, Radiation Time, and Radiation Exposure","volume":"213","author":"Wang","year":"2019","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1016\/j.wneu.2023.01.031","article-title":"Combined L5-S1 anterior lumbar interbody fusion and multilevel lateral lumbar interbody fusion in a single-stage lateral decubitus position using fluoroscopy-based instrument tracking system","volume":"172","author":"McCloskey","year":"2023","journal-title":"World Neurosurg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"106698","DOI":"10.1016\/j.clineuro.2021.106698","article-title":"Operative time and learning curve between fluoroscopy-based instrument tracking and robot-assisted instrumentation for patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF)","volume":"206","author":"Wang","year":"2021","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Drossopoulos, P.N., Sharma, A., Ononogbu-Uche, F.C., Tabarestani, T.Q., Bartlett, A.M., Wang, T.Y., Huie, D., Gottfried, O., Blitz, J., and Erickson, M. (2024). Pushing the Limits of Minimally Invasive Spine Surgery\u2014From Preoperative to Intraoperative to Postoperative Management. J. Clin. Med., 13.","DOI":"10.3390\/jcm13082410"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Huang, C.-C., Fitts, J., Huie, D., Bhowmick, D.A., and Abd-El-Barr, M.M. (2024). Evolution of Cervical Endoscopic Spine Surgery: Current Progress and Future Directions\u2014A Narrative Review. J. Clin. Med., 13.","DOI":"10.3390\/jcm13072122"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1016\/j.whi.2015.05.005","article-title":"Cancer Prevalence among a Cross-sectional Survey of Female Orthopedic, Urology, and Plastic Surgeons in the United States","volume":"25","author":"Chou","year":"2015","journal-title":"Women\u2019s Health Issues"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2637","DOI":"10.1097\/00007632-200010150-00016","article-title":"Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion","volume":"25","author":"Rampersaud","year":"2000","journal-title":"Spine"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1097\/BRS.0b013e3181ceb976","article-title":"Radiation exposure to the surgeon during open lumbar microdiscectomy and minimally invasive microdiscectomy: A prospective, controlled trial","volume":"36","author":"Mariscalco","year":"2011","journal-title":"Spine"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1397","DOI":"10.1016\/j.spinee.2019.04.003","article-title":"Evaluation of surgeon and patient radiation exposure by imaging technology in patients undergoing thoracolumbar fusion: Systematic review of the literature","volume":"19","author":"Pennington","year":"2019","journal-title":"Spine J."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"226","DOI":"10.3171\/2013.4.SPINE12719","article-title":"Operating room radiation exposure in cone beam computed tomography\u2013based, image-guided spinal surgery","volume":"19","author":"Nottmeier","year":"2013","journal-title":"J. Neurosurg. Spine"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"S20","DOI":"10.14245\/ns.2040116.058","article-title":"A Narrative Review of Development of Full-Endoscopic Lumbar Spine Surgery","volume":"17","author":"Wu","year":"2020","journal-title":"Neurospine"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/7\/2579\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T16:02:47Z","timestamp":1774627367000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/7\/2579"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,27]]},"references-count":31,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["jcm15072579"],"URL":"https:\/\/doi.org\/10.3390\/jcm15072579","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,27]]}}}