From patient demand and outpatient growth to steep learning curves and questions about cost and clinical fit, spine surgeons remain divided on where endoscopic surgery belongs in a health system’s priorities. Six spine surgeons discussed how aggressively programs should invest in endoscopy and what health systems risk getting wrong.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker’s invites all spine surgeon and specialist responses.
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Editor’s note: Responses were lightly edited for clarity and length.
Bryce Basques, MD. Spine Surgeon and Director of Minimally Invasive and Endoscopic Spine Surgery at Brown University (Providence, R.I.): Endoscopic spine surgery is an important part of a mature spine program and provides significant benefits, but the mistake is assuming that buying the system creates the program. Because of the long learning curve and specialized equipment, you need a surgeon champion who is willing and able to get through the learning curve safely.
That said, the marketing effects are real and endoscopic spine surgery is in high demand from patients. It is also important to understand the economics of endoscopic spine surgery. These cases can often be more expensive than traditional approaches and are usually decompressions without fusion; however, having an endoscopic spine surgery program will get patients in the door who may not otherwise get surgery or go elsewhere.
Marco Burkhard, MD. Attending Spine Surgeon at Hospital for Special Surgery (New York City): Endoscopic spine surgery is an important addition to our toolbox, but it is not a replacement for established minimally invasive techniques. New technologies should be adopted only when they demonstrably improve patient outcomes and safety, not because they are fashionable or marketable.
The future belongs to surgeons who master multiple techniques and select the approach that most reliably addresses the patient’s pathology with the lowest perioperative risk and the greatest long-term durability, rather than trying to fit every pathology into a single technique.
Peter Derman, MD. Endoscopic & Minimally Invasive Spine Surgeon and Founder of Peter B. Derman, MD. (Dallas): Endoscopic spine surgery belongs at the top of a health system’s priority list. It isn’t a niche luxury; it is the future of the discipline. We are currently witnessing the birth of an entirely new sub-field of “sports spine,” mirroring how arthroscopy revolutionized orthopedics decades ago by turning major open reconstructions into outpatient procedures. If surgeons and healthcare systems don’t adopt this technology soon, they will continue to fall behind as patients actively seek out centers that can treat them through a 7 mm portal rather than an open incision.
Many programs fear that endoscopy will shrink traditional, higher-revenue spine volume, cannibalizing their best “business.” The reality is that doing the right thing for patients can never be the wrong answer, and endoscopy drives immense patient demand that elevates volume across the board. It acts as a huge front door for the hospital, capturing an untapped market of patients who previously suffered in silence out of fear or who are now willing to travel distances for specialized treatment. It ultimately grows the entire spine program, from the ultra-minimally invasive to the complex.
Jeremy Smith, MD, Division Chief of Spine Surgery at Hoag Orthopedic Institute ( Irvine, Calif.): I think the adoption of endoscopic spine surgery is moving faster than the evidence and infrastructure supporting it. The learning curve is significant, outcomes for many indications are still being defined and reimbursement has not caught up with the time, training and resources required to build a high-quality program. Health systems should be cautious about treating endoscopy as an arms race or feeling that every spine program needs to rapidly adopt it simply to remain competitive.
That said, I believe endoscopic spine surgery will be an important part of the future of spine care. The key is to view it as another tool in the surgical tool belt rather than a replacement for established techniques. Programs should introduce it with appropriate training, initially focusing on specific pathologies where the approach offers a meaningful advantage. As the evidence, surgeon experience and reimbursement mature, its role will likely continue to expand.
Issada Thongtrangan, MD. Endoscopic and Minimally Invasive Spine Surgeon at MicroSpine (Scottsdale, Ariz.): Endoscopic spine should be viewed less as an “arms race” and more as a strategic capability. It belongs on a program’s priority list when it aligns with patient population, surgeon expertise, outpatient strategy and a commitment to building a durable minimally invasive spine pathway, not simply because a neighboring hospital has purchased the technology.
Acquiring the equipment is not the same as establishing an endoscopic program. Success also requires appropriate patient selection; surgeon training and repetition; coordinated anesthesia and operating room teams; postoperative protocols; and transparent outcome tracking. Without that infrastructure, the technology can become an expensive marketing tool rather than a meaningful clinical advance.
For the right indications, endoscopic techniques can offer less tissue disruption, reduced postoperative pain, faster recovery and the potential to perform selected procedures in an ambulatory setting. But they are not a replacement for every open or minimally invasive procedure. Programs should prioritize endoscopy based on clinical fit and measurable outcomes, not competition alone.
Jacky Yeung, MD. Neurosurgeon at Yale Medicine (New Haven, Conn.): I think many spine practices underestimate the financial value of expanding minimally invasive spine surgery. For appropriately selected patients, less invasive techniques can shorten hospital stays, reduce complications and accelerate recovery while lowering the overall cost of care.
From a hospital perspective, improving efficiency within a fixed diagnosis-related group can create meaningful financial value without compromising outcomes. The biggest barrier is the investment in surgeon training and the willingness to move beyond established techniques, which is why many practices are slower to adopt these approaches than the evidence and economics would support.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Speaking only for our region, endoscopic spine has settled in the lower quartile of the priority list for both expansion and use. The tried-and-true gold standard of microscopic decompression and neurolysis remains the preferred approach for the majority of spinal cases. For recurrent pathology and salvage operations, endoscopy is rarely the chosen option.
The potential doubling of OR time, need for general anesthesia and risk of mishaps related to intraoperative anatomic localization or inadequate visualization warrant scrutiny. Circumferential dissection and probing of encased neural structures, especially adherent ventral pathology, are much more difficult with limited visibility. Restrictive use and temerity elsewhere have consequences.
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