Endoscopic spine surgery has been billed as the next leap forward in minimally invasive care for over a decade, promising smaller incisions and faster recovery for patients with herniated discs and spinal stenosis. Yet outside a handful of high-volume adopters, many U.S. spine surgeons still aren’t using it.
Becker’s connected with 18 surgeons, who overwhelmingly pointed to reimbursement and the economics of the learning curve — not patient outcomes — as the real barrier to wider endoscopic adoption.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Is the slow adoption of endoscopic spine surgery more about patient outcomes, or more about surgeons being cautious with their own learning curve and referral base?
Paul Arnold, MD. Professor of Neurosurgery at Carle Illinois College of Medicine (Urbana, Ill.): It might be more about making a large investment in equipment and training for a procedure that otherwise has pretty good outcomes without all that.
Adam Bruggeman, MD. CEO and surgeon at Texas Spine Care Center (San Antonio): As with many new technologies, endoscopic spine surgery suffers significantly from lack of dedicated payment and coding. The learning curve is steep, but without a guaranteed and dedicated payment model, I don’t think many will venture down that road.
Tan (Dan) Chen, MD. Orthopedic spine surgeon at Inova Orthopaedics & Sports Medicine (Alexandria, Va.): It’s probably a combination, but the real question is whether endoscopy offers a meaningful advantage over modern MIS. Much of endoscopic spine surgery today is focused on subtractive procedures like decompressions and discectomies. The promise is significant: less tissue disruption, potentially faster recovery and the possibility of expanding minimally invasive treatment to more patients. But the technology and techniques still need to evolve for more complex reconstructive procedures, particularly fusion and instrumentation.
It’s an exciting technology, but we need better long-term comparative data to determine whether those proposed benefits truly translate into better outcomes. There are also practical hurdles such as higher disposable costs, radiation exposure, OR time and reimbursement.
At the end of the day, endoscopy needs to prove it offers more than a smaller incision. The benefits have to justify the added cost and complexity.
Saqib Hasan, MD. Spine surgeon at Golden State Orthopedics and Spine (Oakland, Calif.): I think the slow adoption of endoscopic spine surgery in the U.S. could be a case study for how the U.S. healthcare system is missing the mark — due to a combination of conflicting interests and an archaic infrastructure. High-ticket items like large reconstructive spine surgeries generate better reimbursement for all the parties involved in the healthcare equation. The barriers to adoption will continue to exist until our healthcare system financially rewards value.
The common misunderstanding is the supposition that endoscopic spine surgery is a monolithic procedure. In reality, it is a set of tools and techniques that allow us to treat spinal conditions in innovative ways. The value it creates is in the surgery the patient did NOT get — the surgery that carried higher morbidity or required implants and the lifelong surveillance and potential issues that are part and parcel of these larger, more complex surgeries. I am not saying patients do not benefit from these larger procedures, but certainly they should not be the starting point.
While there is a question of durability or degree of effectiveness for certain spinal pathologies (spondylolisthesis, severe foraminal stenosis), I have been employing endoscopic techniques in my practice for almost 10 years and I have been pleasantly surprised. I have grown an extremely busy practice by simply trying smaller, more targeted solutions for very complex pathology.
Patients who have been told by five surgeons that they need some permutation of a hardware-intensive procedure often seek me out because I treated their friend or neighbor. The value I create is in giving the patient options and discussing the positives and negatives of the treatments that exist for them. Sometimes endoscopic is the right answer, sometimes it’s not. My practice has shifted to over 50% endoscopic because I know what it can help and what it can’t.
The conversation about endoscopic spine often revolves around marketing, reducing it to a simple procedure — a simple discectomy with a smaller scar — the barrage of all these great buzzwords and tactics. It lumps surgeons who actually use these tools to create true value in with surgeons who just want a marketing edge in the healthcare marketplace.
This pattern of misaligned incentives is unique to our healthcare system. I developed a hypothesis on the current worldwide state of endoscopic spine surgery and tested it with a survey-based study I collaborated with Dr. Kai Lewandrowski on, which was recently published in the International Journal of Spine Surgery.
We asked 438 surgeons in 46 countries, who between them have done over a million of these cases. What came back was not subtle. Interest in endoscopic surgery is high everywhere — there is no meaningful difference between a surgeon in Shanghai and a surgeon in San Francisco on that. What differs is everything around the surgeon. The U.S. stood out for poor reimbursement, weak institutional backing and essentially no formal training pathway. Over 40% of surgeons worldwide never touched an endoscope in residency or fellowship.
The mechanism isn’t mysterious. CPT 62380 is a flat code with no assigned RVUs. We get paid based on how we look at the anatomy rather than the work we actually do. Oftentimes, endoscopic procedures on complex spine pathology can require far more work than an open equivalent. This is structural malalignment built into our system that discards potential value gains for the patient.
So to answer the question — it’s neither. The learning curve is real, but surgeons climb steep learning curves all the time when the incentives point that way. Here they don’t. Or as we put it in the paper: “The West is falling behind not technically, but structurally.”
Justin Iorio, MD. Orthopedic spine surgeon at Joseph’s Physicians Orthopedics (Syracuse, N.Y.): The slow adoption may be from No. 1, surgeon experience because endoscopy is relatively new, No. 2, comfort level because of the learning curve involved, No. 3, cost — the endoscopic equipment requires disposables, so there is an additive cost to the surgery center or hospital — and No. 4, lack of RVU reimbursement. There is no assigned wRVU for endoscopy.
Nick Jain, MD. Orthopedic spine surgeon at DISC Sports and Spine Center (Newport Beach, Calif.): Reimbursement is the primary issue — no added reimbursement from payers for the additional equipment cost per case, so facilities have no incentive to allow these types of cases.
Second is surgeons being cautious about their own learning curves. Third may be related to outcomes and presence of symptomatic hematoma.
Wade Jensen, MD. Spine surgeon at Mountain West Orthopedics (Afton, Wyo.): The adoption of endoscopic spine surgery is not about patient outcomes. The data is more and more clear as studies are published. Adoption is limited by surgeons developing the skills to be able to competently offer ultra-minimally invasive surgery to their patients. Fortunately, companies like Arthrex are committed to teaching these skills to surgeons wanting to adopt this technology.
Khalid Odeh, MD. Spine surgeon at Michigan Orthopaedic Specialist (Troy, Mich.): I believe much of the hesitation comes from the literature showing similar outcomes to established minimally invasive techniques. Endoscopy may offer early recovery advantages, but without a clear, clinically meaningful improvement in longer-term outcomes, surgeons have less incentive to take on the learning curve and added costs. An established surgeon may reasonably worry when adapting any new technique about longer cases, early complications and losing referring physicians’ confidence, but endoscopy has yet to provide clinically meaningful improvement in longer-term outcomes.
Robert Masson, MD. Founder and medical director at Masson Spine Institute (Orlando, Fla.): I come at this as a microneurosurgeon who spent a career under the microscope and then built one of the first exoscopes, so I have lived every step of the visualization arc in spine surgery: loupes, microscope, exoscope and now the endoscope. I see endoscopy as the next chapter of advanced digitalization for least disruptive spine surgery. Putting the camera at the tip of the instrument is the logical end point of that arc, and I am an advocate.
But the question sets up a false choice. A surgeon’s caution about the learning curve is not separate from patient outcomes. It is about patient outcomes.
The learning curve in endoscopic spine surgery is steep, and it gets steeper fast once you move past the straightforward disc herniation into advanced degenerative disease, multilevel stenosis, instability and revision. Safety is the risk everyone talks about during that curve, and it is one lens. The lens that gets far less attention is the objective. A surgery can be perfectly safe and still fail because it did not accomplish what the patient needed: an incomplete decompression, an unaddressed foraminal component, an instability problem left behind.
A surgeon who has spent decades reliably hitting the objective through a small open or microscopic corridor is right to be careful about trading that certainty for a smaller incision. That is not timidity. That is judgment, and a referral base is built on exactly that judgment.
The third factor is the one nobody wants to say out loud: the economics do not work for many surgeons. In both the U.S. and the U.K., reimbursement for endoscopic procedures has not kept pace with the capital cost, the disposables or the longer operative times during the ramp. Unless you are a cash-pay practice or an employed surgeon whose institution absorbs the cost, the return on investment is very hard to find. An independent surgeon is being asked to invest capital and time, accept slower cases for a year or more and take on objective risk with the referral base, all for the same or lower payment. That is a rational reason to wait, and it has nothing to do with whether the technology is good. Advanced magnified atraumatic vision is of course valuable!
I say this as an advocate, but also as someone who has practiced independently for decades and done outpatient spine reconstruction in my own surgery centers for over 15 years, and who wants independence-minded surgeons to stay both independent and stable. My advice to them is to adopt endoscopy the way you would adopt any advanced capability: deliberately, with indications you can own, with the case objective defined before you pick up the scope and with the numbers worked out so the technology is not paid for out of your practice’s margin. Get the objective right first. The incision follows.
The reason this matters is bigger than the spine. Chronic disability from degenerative spine disease steals healthy, productive years from an enormous number of people. Effective, least destructive surgery that reliably restores function is massive fuel for purposeful longevity, in the short term for the patient in front of you and over decades for the population. That is the case for endoscopy done right. It is also the argument against endoscopy adopted for its own sake.
Joshua Prickett, DO. Neurosurgeon at LewisGale Physicians Neurosurgery (Salem, Va.): I haven’t been able to explore endoscopic spine as of yet mainly because our hospital doesn’t have anything currently approved and available, and with HCA this is a very lengthy process. It sometimes takes six or even 12 months from the first time we say we want to try something to getting it actually approved through all of the channels.
Vincent Rossi, MD. Neurosurgeon at Carolina Neurosurgery and Spine Associates (Charlotte, N.C.): The slow adoption of endoscopic spine surgery has less to do with patient outcomes and more to do with the learning curve and the economics surgeons face while climbing it. Most practicing spine surgeons weren’t trained on these techniques, and the curve is steep — often 50-plus cases before efficiency approaches that of traditional MIS, during which operative times can run multiples of standard techniques for equivalent reimbursement. Few established surgeons want to absorb that cost in their practice.
That’s changing from the bottom up. As more residents and fellows train on endoscopic techniques, the next generation will enter practice having already cleared much of the learning curve. Biportal endoscopic techniques are accelerating this shift too — the curve is gentler, the instrumentation more familiar and the indications broader, making it a natural bridge to full-endoscopic adoption.
Kevin Sharif, MD. Orthopedic surgeon at Nevada Orthopedic & Spine Center (Las Vegas): In my experience, the slow adoption has much more to do with surgeon comfort and training than with patient outcomes. I’ve been performing endoscopic spine surgery for about four years now, and when I first started looking into it, what drew me in was how well it fit my practice style. I’ve always leaned toward minimally invasive techniques, and endoscopic surgery took that a step further.
What holds most surgeons back isn’t a question of outcomes, it’s exposure. Very few residency or fellowship programs actually train surgeons in endoscopic technique. That’s starting to change, but the number of programs offering real hands-on experience is still small. On top of that, microdiscectomy, the procedure endoscopic surgery is often compared to, is already a highly predictable operation with patients who tend to do well. So surgeons are being asked to take on a real learning curve without an obvious, easily quantified benefit over something they’re already doing successfully.
Getting there also takes more than a weekend course. Courses matter, but what really makes the difference is having a mentor you can talk through cases with before you ever get to the OR. Add the capital equipment hurdle on top of that, and it’s easy to see why adoption has been slow. Most microdiscectomies are already done in an outpatient surgery center, or the patient goes home the same day even when it’s done in a hospital. So there isn’t much of a cost-saving argument for a hospital to invest in new equipment for a procedure that’s already efficient the way it’s currently done.
That said, I don’t think of endoscopic surgery as just a smaller incision. To me, it’s an anatomy-preserving procedure. Patients tend to have less pain, a quicker recovery and get back to work sooner than they would with traditional open surgery. In a meaningful number of cases, it’s also allowed me to avoid a fusion in patients who would ordinarily have needed one. That’s really what I want to offer patients in my community. I’m proud to be among the first surgeons to bring this technique to the Las Vegas metro area.
Mohammad Shukairy, MD. Neurosurgeon and minimally invasive spine surgeon at Bone and Joint Specialist (Merrillville, Ind.): As a neurosurgeon who has been practicing in the Chicagoland and Northwest Indiana area for the last 16 years, I have adopted endoscopic spine procedures as a significant part of my practice. I perform over 100 endoscopic procedures a year. In my opinion, the slow adoption of the procedure is due to the significant capital cost and ongoing operating expenditures of endoscopic spine procedures as they currently stand. It’s a significant capital expenditure, usually over $600,000, whether for an ASC or a hospital. Furthermore, there is a higher rate of disposable costs, raising the operating expenses for a procedure that pays no differently than the standard procedure with the same CPT code. Hopefully, companies can reduce their costs and find ways of making the procedures more cost-friendly to providers, thereby widening the scope of endoscopic spine surgeries for more patients.
Vladimir Sinkov, MD. Founder and CEO of Sinkov Spine Center (Las Vegas): Endoscopic surgery has been developing rapidly in the past several years with more studies showing efficacy and safety, better instrumentation and better and more abundant training opportunities. In my opinion, the slow adoption is mostly due to surgeons being cautious about the steep learning curve, time needed to train properly, reimbursement concerns and lack of equipment at their facilities.
Michael Venezia, DO. Orthopedic spine surgeon at Florida Orthopedic Institute (Tampa, Fla.): It’s genuinely both, and the two are the same thing viewed from different sides. I remember my first 25 or so cases and the specific spots where patients struggled, so the outcome concern inside that curve is real, not theoretical. And in a community practice, your referral base is just the accumulated record of how your patients did, so protecting it isn’t self-interest, it’s the same obligation. That’s exactly why patient selection inside the curve matters so much.
AJ Yates Jr., MD. Professor and chief of orthopedic surgery at UPMC-Shadyside Hospital (Pittsburgh): In my opinion, the risk of malpractice suits is already high for spine surgeons, and the risk of the plaintiff’s expert claiming that the defendant is too early in the learning curve of a highly technical procedure leading to a complication might be a cause for hesitancy to adopt the techniques.
Christian Zimmerman, MD. Spinal neurosurgeon at the SAHS Neuroscience Institute (Boise, Idaho): To my mind, the “cautious approach” to endoscopic spine surgery is dually fueled by the outcomes effect from the learning curve cause. The ubiquitous awareness of protracted time investment coupled with a paltry training consensus hampers the widespread acceptance of these techniques compared to the acknowledged tried-and-true microscopic approach. Potential neurological injury, poorer visualization, comorbid variables and measurably longer anesthetic use impede this technology from its wanton convention.
Richard Hynes, MD. Spine surgeon at Health First Medical Group (Melbourne, Fla.): In my last 20 years of international travel, including four visits this year to South America, endoscopic surgery has been commonplace, especially in Asia, with fairly evolved techniques and experience in many countries in South America. Every spine conference now has an entire section dedicated to endoscopic surgery, and this will help promote the conversation needed for us to keep moving to adoption.
The U.S. has been slowly adopting. Limitations on one hand are likely the result of financial aberrations in fair reimbursement for hospitals, ASCs and surgeons. On the other hand, infrastructure for teaching the techniques is not yet available in many major centers.
I remember visiting Dr. Parviz Kambin as he demonstrated early percutaneous disk removal techniques back in the 1980s in Philadelphia. Dr. Anthony Yeung has been one of the strongest advocates for this technique in the past several decades. Dr. Hijikata in Japan, Drs. Forst and Hausmann in Europe and Dr. Kambin evolved techniques and contributions throughout the 1980s. Kambin’s triangle anatomically is the foundational anatomic corridor for the early endoscopic technique development. Seems like the U.S. started early but is adopting late.
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