Saqib Hasan, MD, has been practicing endoscopic spine surgery for nearly a decade, and he’s grown tired of a particular conversation. It’s the one where someone points to a study showing no significant long-term outcome difference between two surgical approaches, and treats that as the end of the discussion. Dr. Hasan, a spine surgeon at Golden State Orthopedics and Spine in Walnut Creek, Calif.,, doesn’t think it works that way.
He spoke with Becker’s about that precedent, and why he believes patient preference is what ultimately decides which surgical techniques survive.
The arthroscopy precedent
Dr. Hasan’s central argument rests on a comparison to a shift orthopedics already lived through: the near-total replacement of open ACL reconstruction and rotator cuff repair with arthroscopic technique.
“If you look at the literature, the best randomized control studies comparing arthroscopic versus open ACL reconstruction, rotator cuff repair — there’s no difference in long-term outcomes,” he said. And yet, he pointed out, virtually no surgeon performs those procedures open anymore.
The reason, in his view, has little to do with the data.
“It’s because patients won’t go to that doctor” once a less invasive alternative exists, he said. “How do you convince a patient — oh well, there’s no difference? It’s like, don’t believe your lying eyes.” A smaller incision and a camera are intuitive to a patient in a way that a study’s confidence interval is not, he argued, and that intuition drives where patients seek care regardless of what the outcomes literature ultimately shows.
He expects endoscopic spine surgery to follow the same arc. “More and more patients are going to learn more about what options exist, and then the surgeons who do these procedures will continue to get the lion’s share of the volume,” he said.
A conversation he thinks isn’t happening enough
Dr. Hasan said the decision-making process patients go through deserves more attention than it typically gets. Many patients, he said, are drawn to less invasive options for an intuitive reason that has nothing to do with outcomes data: they simply don’t want hardware placed in their body if it can be avoided. “Most patients generally, you know, they don’t love the idea of putting hardware in their body,” he said. “It’s more like, ‘I just want to be out of pain.'”
He believes that as patients become more informed due to a wider access to medical information, including AI tools that help patients understand their own treatment options, more of them will actively seek out surgeons who can offer a less invasive path before jumping to a larger reconstructive procedure.
“I think spine surgery is going to be a spectrum,” he said. “As you progress in your pathology, there’s limits to what we can do with minimally invasive procedures, and then we need large reconstructive surgeries, and they provide value too. I just don’t think that’s the starting point.”
That starting-point question, what can be done without hardware, before deciding hardware is necessary, is the conversation Dr. Hasan believes needs to happen more often between surgeons and patients.
“Someone has to have that conversation,” he said. “I don’t think that conversation’s had enough.”
Why he keeps doing it
Ultimately, Dr. Hasan said his own continued use of the technique comes down to results, not ideology. “I’ve had very good success with my endoscopic surgeries, and that’s why I keep doing it,” he said. He believes that as more surgeons see similar results in their own patients, adoption will keep expanding on its own. “We’re going to do what helps our patients, and when more surgeons learn these techniques and see how much it’s helping their patients, they’re naturally going to want to do more.”
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