When Andrew Zhang, MD, an orthopedic spine surgeon, arrived at the Philadelphia-based University of Pennsylvania, endoscopic spine surgery was not part of the orthopedic spine program’s routine practice.
That changed Feb. 27. Dr. Zhang performed the department’s first endoscopic spine surgery, treating a large disc herniation through an interlaminar approach. Since then, he has continued using endoscopic techniques for disc herniations when the anatomy allows.
The milestone matters less for the novelty of the procedure than for what it represents. For years, Dr. Zhang said, endoscopic spine surgery occupied an uncertain place in the field: promising enough to attract early adopters, but unfamiliar enough to be dismissed by others as another technology that might eventually fade.
Dr. Zhang believes that question is becoming easier to answer.
“I think this is actually no longer a fad,” he told Becker’s. “It’s withstood the test of time.”
The harder question now is what it takes to move the technique from a specialized capability into broader practice. The obstacle is not simply whether endoscopic surgery can work. It is whether surgeons are willing to relearn familiar operations, whether hospitals will invest in the equipment and whether health systems can measure value beyond the cost of the procedure itself, Dr. Zhang said.
The same operation, with a smaller footprint
Dr. Zhang’s interest in endoscopic spine surgery began with a straightforward premise. Could surgeons accomplish the same decompression with less disruption on the way in?
Traditional open and tubular approaches can effectively relieve nerve compression, but reaching the pathology may require more muscle dissection, larger working corridors and greater soft tissue disruption. Endoscopy offers another route, according to Dr. Zhang.
“Being able to accomplish the same goals with less repercussions just made a lot of sense to me,” Dr. Zhang said.
The incisions are smaller, but he argues the more important difference is what happens underneath them. Less soft tissue trauma can mean less bleeding and less postoperative incisional pain. For selected patients, it can also make outpatient recovery easier.
Dr. Zhang said many of his patients are surprised by how little pain they feel from the surgical site immediately after the procedure, particularly when they arrived with severe leg or back pain from a disc herniation.
Some experience immediate relief of their preoperative symptoms. “They’re really surprised at how well they feel immediately after surgery, just in the recovery room,” he said.
That recovery profile has changed the logistics of care as well. Patients who might once have remained in the hospital because of postoperative pain can often leave within an hour or two, Dr. Zhang said, while requiring less pain medication.
The potential value therefore extends beyond incision size. It includes what the patient needs after the incision is closed.
The fad question is fading
Spine surgery has never lacked new technology. Some innovations fundamentally change practice. Others enjoy a burst of enthusiasm and disappear.
Dr. Zhang has been asking where endoscopy belongs on that spectrum. At a recent Philadelphia spine meeting, he presented on whether endoscopic spine surgery had been overhyped or whether it had developed enough evidence and clinical momentum to become durable.
His conclusion: the field has moved beyond the experimental phase. Endoscopic techniques have existed in some form for decades, but adoption and research have accelerated substantially in recent years. Publications have increased, surgeons have applied the technology to a broader range of procedures and reported outcomes have continued to mature.
Dr. Zhang sees decompressions and discectomies as the clearest territory. For those procedures, he said, endoscopic outcomes are increasingly comparable with traditional approaches.
That does not mean every spine operation is about to become endoscopic. Fusion is a different problem. Alignment, reconstruction and the mechanical demands of fusion require surgeons to do more than remove a focal source of compression. Endoscopic fusion techniques are developing, but Dr. Zhang believes it is too early to assume they will replace established approaches.
That distinction is important. Endoscopy does not need to replace every spine operation to become consequential. Its more immediate opportunity may be in procedures such as decompressions, discectomies and laminectomies, where Dr. Zhang said outcomes are becoming comparable with traditional approaches.
A smaller operation can expand the patient pool
The shift may also change how surgeons think about candidacy. Patient selection remains important, particularly because anatomy determines whether a surgeon can safely reach a disc herniation endoscopically. But some factors that complicate traditional surgery may matter less when the working corridor is dramatically smaller. Dr. Zhang pointed to obesity and larger soft tissue envelopes as examples.
In a traditional exposure, additional tissue can make access more difficult and increase concern about wound complications. A very small endoscopic incision can reduce some of those constraints.
“We’re able to overcome those barriers that were previously there before,” he said. The technique can also give some patients a smaller option before moving to a more consequential operation. A patient considering fusion or disc replacement may be more willing to first undergo a focused endoscopic decompression if the pathology can be addressed without reconstruction.
For some patients, endoscopy may offer a smaller intervention before moving to a more extensive procedure such as disc replacement or fusion. Dr. Zhang said patients may be more willing to try an endoscopic procedure first because they view it as a less significant operation.
Why adoption is still slow
If the recovery can be easier and outcomes can be comparable, why has endoscopic spine surgery not spread faster? Dr. Zhang sees two major barriers.
The first is the surgeon. Endoscopic surgery has a significant learning curve. A physician who has spent years becoming highly efficient with open or tubular techniques may have little incentive to become slower again.
“It’s not for everyone,” Dr. Zhang said. Early cases can take longer. Surgeons must learn a different visual orientation and become comfortable working through a smaller corridor. The first cases may also carry greater complication risk while that proficiency develops.
For an established surgeon, the question is rational: If the existing technique already works well, why take on the disruption of learning another one?
The second barrier is the hospital. Endoscopic equipment costs money. Hospitals may already own the instruments required for conventional procedures. Endoscopy can require new capital equipment, specialized tools and additional vendor support.
From a narrow accounting perspective, the newer approach can therefore look more expensive. Dr. Zhang thinks that comparison misses part of the equation.
His research has examined the difference between what a hospital spends on the procedure and the broader cost of the episode of care. A more complete calculation could include length of stay, postoperative medication use, emergency department visits, returns to the operating room and other downstream healthcare utilization.
“The true overall cost,” he said, has to account for more than the number attached to the operation itself. That is the economic argument endoscopic spine surgery will increasingly have to make. A technology does not become valuable simply because it is less invasive. It becomes valuable if the smaller intervention produces enough downstream benefit to justify the investment required to deliver it.
Adoption is an investment decision
Dr. Zhang sees endoscopic spine surgery as an investment: surgeons spend time learning it, hospitals buy new equipment and operating rooms absorb some inefficiency during the learning curve. “People who are willing to make that investment will jump towards endoscopic spine surgery,” he said. “People who aren’t willing to make that investment will stay in their lane.”
The next phase of adoption will depend on whether health systems can make that investment sustainable. Hospitals will want stronger data on total episode costs, surgeons will need clearer training pathways and researchers will have to define which procedures benefit most.
Dr. Zhang also expects endoscopy to increasingly intersect with navigation, robotics and other advanced tools, though he is cautious about how far those applications will go.
“The doors are pretty much wide open to where we can use it,” he said.
For now, the case is simpler: For certain procedures, surgeons may be able to achieve the same goal with less surgical trauma. The question is whether the healthcare system is willing to invest in doing it differently.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
