Endoscopic spine surgery is an emerging technique offering a minimally-invasive alternative to traditional open exposures [1]. The purported benefits include preservation of ligamentous and muscular structures, decreased blood loss, and shorter hospital stays [2,3]. Although endoscopic techniques are growing in familiarity among spine surgeons, it remains unclear whether prospective patients are aware of the potential benefits and risks of this surgical technique. Social media platforms are frequently used by patients to obtain information about potential procedures and to gain complementary patient perspectives [4]. However, no previous study has evaluated the information available to patients on the commonly used social media platform Twitter/X regarding endoscopic spine surgery.

X (formerly known as “Twitter,” rebranded as “X” in July 23, 2023, and hereinafter referred to as Twitter/X) is a popular, US-based social media platform where users share information in real-time in the form of “tweets.” These tweets can garner reactions and replies from other users on the platform. Tweets are restricted by characters (140 characters at launch in 2006, expanded to 280 characters in 2017), which limits the background context for the content presented. The “hashtag” functionality, first introduced by Twitter/X, allows key words preceded by the character “#” (e.g., “#spinalendoscopy”) to serve as a searchable index for a given topic. Given the ease of identifying relevant content and algorithms promoting conversation among users, social media has become a repository of patient perspectives and discussion regarding many orthopedic conditions/procedures, such as adolescent idiopathic scoliosis [4,5] and anterior cruciate ligament reconstruction [6]. Twitter/X also serves as a platform for medical professionals to broadcast research activities, interact with colleagues, and disseminate patient-facing educational materials [7].

The primary objective of this study was to analyze publicly-available content related to endoscopic spine surgery on Twitter/X. Secondary objectives included determining content authorship and location, use of multimedia features, contextual nature (educational versus promotional), and relative popularity of available content. We hypothesized that most content would be produced by medical professionals, focusing on raising awareness about endoscopic techniques.

The public-facing Twitter/X website was used to compile tweets related to endoscopic spine surgery. Due to Twitter/X application programming interface (API) restrictions limiting third-party compilation software functionality, tweets were manually extracted and cataloged using a spreadsheet. The Twitter/X website’s advanced search feature was used to identify publicly-available posts containing the following “hashtags”: #spinalendoscopy, #spineendoscopy, #spineendoscopic, #spinalendoscopic, #endoscopicspinesurgery, #endoscopicspinalsurgery, #endospine, and #endospinal. Two reviewers independently screened the tweet content, excluding tweets unrelated to endoscopic spine surgery. View counts for the most recent 6 months of tweets were tabulated.

The content of all tweets was analyzed, focusing on geographic origin (United States or outside United States), type of author (healthcare professional, vendor, healthcare organization, patient, and others), and key themes related to endoscopic spine surgery (“minimally invasive,” small incisions, “high tech” claims). Attributes of tweets suggesting use as an advertisement were also reviewed, including inclusion of phone numbers and other contact information. Patient perspectives and content highlighting patient outcomes were also categorized. Non-English tweets were translated using Twitter/X’s embedded translation functionality. Descriptive statistics were generated using Microsoft Excel Software (Microsoft Corp., Redmond, WA, USA). As the study utilized publicly-available data, it was exempt from local Institutional Review Board regulation.

A total of 890 tweets from 199 unique accounts were available on the platform at the time of manuscript preparation and were included in the analysis. Tweet content spanned from January 1, 2011, to December 31, 2024. View counts were collected for tweets from January 1, 2024 to June 30, 2024 (tweets available for at least 6 months), yielding a total of 39,046 views among the included hashtags during this period. Fig. 1 shows a gradual increase in tweet content over time, with substantial year-to-year increases from 2021–2024 (138.3%, 71.3%, and 3.2%, respectively). Fig. 2 illustrates tweet authorship, revealing that approximately 76.0% of content originated from outside the United States. Authorship breakdown was as follows: MD/DOs (medical doctor/doctor of osteopathy) or other healthcare professionals (44.4%), vendors (7.7%), and organizations (such as hospitals, healthcare practices, and professional groups) (45.0%). Only two tweets were directly attributable to patients.

Table 1 categorizes the cataloged tweets. Content intended as an advertisement to potential patients was seen in 24.5% of tweets. Contact information (address, telephone number, or links to appointment scheduling) was seen in 18.9% of tweets. Approximately 22.1% of tweets appeared to be intended for other healthcare providers or an audience already familiar with endoscopic spine surgery, while 12.5% of tweets highlighted conference or other professional activities related to endoscopic spine surgery (such as upcoming presentations, regional or national meetings, or industry-sponsored seminars). A smaller proportion of tweets highlighted research findings or contained an external link to a research paper (3%), resident or trainee involvement in endoscopic spine surgery (4.7%), or references to interesting cases or noteworthy applications of endoscopic techniques (5.2%).

Multimedia content, such as images, videos, or links to other platforms, appeared in 81.1% of tweets. An example of a multimedia tweet featuring an embedded patient outcome video is shown in Fig. 3. Among the 25.7% of tweets containing videos, 59.8% were related to patient outcomes. Images were present in 45.8% of tweets. An example of a tweet that includes an embedded intraoperative image is shown in Fig. 4. Links to external websites or other social media platforms, such as LinkedIn or Instagram pages, were present in 15.1% of tweets.

Examples of thematic content are presented in Table 2. References to “less-invasive” or “minimally invasive” techniques appeared in 12.1% of tweets. The relatively small size of the incisions (e.g., “stitchless”) was directly mentioned in 4.1% of tweets. Content that included the term “pain” was seen in 15.8% of tweets. Tweets related to patient-facing educational content about the procedures or conditions treated (such as lumbar spinal stenosis, lumbar radiculopathy, etc.) accounted for 12.9% of the content. Several illustrative examples of potentially misleading content are included for reference. Notably, none of the tweets highlighted complications related to endoscopic spine surgery or revision surgeries due to the use of endoscopic techniques.

The Twitter/X content analyzed in this study appears to fall into two categories: patient-facing advertisements by surgeons/healthcare organizations and content shared by healthcare professionals to promote endoscopic spine surgery. Patient-directed advertisements accounted for approximately 24.5% of tweets, with 18.9% containing direct contact information for scheduling an appointment. Content intended for other healthcare professionals accounted for 22.1% of tweets, largely focusing on conference activity and interesting endoscopic cases. An unexpected finding of this study was the relative lack of patient perspectives, with surgeons and healthcare professionals dominating the information landscape. Furthermore, the absence of content related to complications or revision surgery related to the use of endoscopic techniques suggests a potential bias in the outcome information presented to patients.

A key consideration while evaluating written consumer health information is the objectivity of the author and the possibility of inaccurate information. Given the short format of information presented on Twitter/X, the content is unsuitable for many established quality assessment tools originally intended for other online media, such as full-length websites or videos. The DISCERN score, a commonly used tool for evaluating online health information, was originally developed as a fifteen-question instrument [8]. Recent social media studies have utilized the modified DISCERN score for online media such as videos [9]. This score encompasses five questions (Are the aims clear and achieved? Are reliable sources of information used? Is the information both balanced and unbiased? Are additional sources of information listed for patient reference? Are areas of uncertainty mentioned?). Even for high-quality tweets authored by established opinion leaders, the inherent brevity of Twitter/X leads to a low score on this evaluation tool. Similarly, the Health on the Net Code of Conduct (HONcode), a credibility assessment tool designed for websites, addresses concerns related to online health resources, such as protecting patient confidentiality, presenting balanced evidence when comparing treatments, and disclosing funding sources and advertisement revenue for a website [10]. However, due to the character limits of a tweet, authors cannot meet many of the original HONcode benchmarks within a single tweet, making it necessary to extend analysis to a user’s profile or other tweets. This highlights the need for developing evaluation tools specifically designed for short-format social media platforms like Twitter/X, TikTok, and Instagram, which could be valuable for future social media research.

Social media utilization continues to expand, with a 2024 survey indicating that 53% of American adults aged 30–49 use more than five social media platforms (such as YouTube, Facebook, Twitter/X, LinkedIn, Instagram, and others) [11]. A study by Shenker et al. [12] analyzed endoscopic spine surgery content on Instagram, finding that medical professionals and industry accounts comprised 62.9% and 12.9% of accounts posting content. Notably, no patient-authored content was captured by the study’s search terms. Social media engagement with healthcare providers is a nascent area of development, particularly in the wake of expanding telehealth services in the post-COVID-19 (coronavirus disease 2019) era. A 2010 study found that among 742 anonymous surveys sent to hand and upper extremity outpatients, 139/148 respondents indicated interest in using social networking sites to engage with healthcare providers [13]. Despite this potential interest in online discourse, our study did not capture any conversation shared between patients and providers. This is likely attributable to the relatively small number of spine surgeons offering endoscopic spine surgery and the correspondingly smaller number of patients willing to present their experiences on social media. Similarly, it is unclear if patients undergoing endoscopic spinal procedures would clearly indicate this technical distinction in the body of a tweet, rather than referring to the operation using more broad/generic terms (such as “minimally invasive” or simply “back surgery”).

The low level of patient participation in social media discourse on endoscopic spine surgery is unusual compared to other operations [14,15]. In a study of patients undergoing anterior cervical discectomy and fusion, Swiatek et al. [14] found that social media posts from patients and nonmedical professionals outnumbered those from medical professionals by nearly 9:1. Among the 1,136 posts categorized, the majority of posts characterized the postoperative recovery and return to daily activity from the patient perspective, with 79.2% of posts exhibiting a positive tone. The authors noted that these patient perspectives offered an opportunity to address postoperative concerns and expectations, enhancing healthcare delivery and providing transparency in patient expectations. For a relatively less-common procedure like endoscopic spine surgery, access to patient perspectives and postoperative concerns could be invaluable to both surgeons considering adding this procedure to their practice and patients seeking insights from others who have undergone the procedure. For patients seeking information about a specific condition or treatment, the content presented by surgeons on social media websites can supplement the information received during a traditional office visit [16]. Given the searchability of social media, patients can quickly identify providers offering specific techniques for a surgical procedure [17].

However, the reliability and validity of information presented on social media websites presents a challenge to both spine surgeons and patients [18]. In a study of discectomy-related content available through major search engines, content posted on social media and discussion websites was found to have the lowest DISCERN scores compared to all other available resources [19]. On the contrary, a study evaluating the quality of endoscopic spine surgery content on YouTube found average modified DISCERN scores of 4.3±0.8 (out of a maximum of 5), suggesting high quality and reliability [20]. Given the diversity of public perceptions and patient experiences with spine surgery, there is a high risk of spreading negative and inaccurate information in the non-peer-reviewed setting of social media and video hosting websites, particularly for emerging procedures. Here, high-visibility accounts may dominate online content and influence public opinion. Endoscopic spine surgery is particularly vulnerable due to the paucity of high-quality prospective randomized trials supporting its efficacy. In this context, the patient outcome videos shared in tweets should be viewed as anecdotal evidence until peer-reviewed, prospective studies validate these findings.

Though social media participation by spine surgeons appears to be growing, their participation remains relatively low compared to the general public. According to a recent study by Samtani et al. [21], among a sample of 325 spine surgeons, only 17.8% held a professional Facebook page, with 13.8% and 7.1% having professional Twitter/X and Instagram accounts, respectively. Social media has the potential to attract and educate patients, generate patient referrals from colleagues, and highlight individual areas of expertise [17]. Twitter/X platform’s appeal lies in its candid, short-format content, presented in a contemporaneous sequence. This format often builds traction around popular opinions, which are reproduced on the site without regard to validity. Twitter/X represents an unfiltered source of public opinion, searchable by keywords and hashtags [22]. However, the credentials of users are self-reported and the current user verification system on Twitter/X is based on subscription status. Given the inherent lack of peer review and quality control, the nature of the platform underscores the challenges physicians face when utilizing Twitter/X for patient outreach. A study of Pediatric Orthopedic Society of North America members revealed that 21.0% of respondents held an unfavorable or very unfavorable impression of Twitter/X [23]. The authors attributed this negative perception to the platform’s lack of regulations and information authentication to prevent the spread of misinformation.

One common use of social media observed in this study is the sharing of noteworthy or interesting cases. This has also been noted in other social media studies, including a study on hand fellowship social media presence, where case examples received the most “likes” among all program content [24]. These posts often feature intraoperative images and radiographic studies, which can attract high view counts. However, this type of content also raises concerns about patient privacy [25,26] and the potential liability due to informal documentation during procedures. Physicians must be mindful of institutional policies related to the sharing of such content, even if it is deemed non-identifiable [27].

Twitter/X presents a potentially under-utilized opportunity for disseminating research related to endoscopic spine surgery. The Altmetric Attention Score is an objective measure of an article’s impact that incorporates social media mentions and traditional citations. This is a complementary measure to the use of journal citations for determining impact factor [28]. A recent study of cervical spine literature identified Twitter/X as the most frequent source of article mentions on social media [29]. However, it can be challenging to ascertain the true audience for a tweet when content is made public. While individual followers are more likely to see the information, retweets and conversations increase the visibility of tweets and expand their reach to broader audiences. A study of ophthalmology articles published between 2016 and 2021 revealed that 34.4% of articles in the top quartile for citation count were included in at least one tweet; by comparison, 27.8% of articles in the top quartile were not referenced in any tweets [30].

Some limitations of this study should be acknowledged. A major limitation is that the analysis was restricted to one social media platform, Twitter/X. Expanding the analysis to other platforms like LinkedIn, Instagram, Facebook, and other emerging social media sites may provide a more comprehensive understanding of the online footprint of endoscopic spine surgery. Another limitation is the use of English-language hashtags, which may introduce a bias toward English-speaking countries. Using broader key words (such as endoscopic) could be an alternative, but this approach is limited by the prevalence of nonspine applications for endoscopy. To overcome this challenge, natural language processing or other software could be employed to facilitate data collection and improve the accuracy of results.

Endoscopic spine surgery is an emerging field. While key opinion leaders are typically identified through highly-cited research, this limits online outreach to those familiar with navigating scientific literature. In the social media setting, endoscopic spine surgery has a modest but identifiable presence, featuring a combination of content centered on practice advertisements, educational endeavors, and patient outcome videos. Given the propensity of non-peer-reviewed and crowd-sourced content to propagate misinformation, continued research into topics like endoscopic spine surgery on Twitter/X is crucial. This would allow healthcare providers to understand the scope of online information accessible to patients and better anticipate questions and concerns raised by these forums. Notably, current online content related to endoscopic spine surgery appears to be mainly driven by medical professionals, lacking patient perspectives.