Research is key to the future of endoscopic spine surgery, 1 surgeon says

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Endoscopic spine surgery continues to gain traction, but that could bring challenges with payers, according to Saqib Hasan, MD, of Walnut Creek, Calif.-based Golden State Orthopedics and Spine.

Dr. Hasan spoke with Becker's to discuss the latest with endoscopic spine surgery at his practice and his outlook for the technique in the coming years.

Question: Can you give me an update on endoscopic spine at your practice?

Dr. Saqib Hasan: Endoscopic spine surgery has always been a focus of my practice. From my early days in orthopedic residency, I always wondered why arthroscopic techniques were not employed for the spine. I completed a second fellowship in endoscopic spine surgery with Christoph Hofstetter, MD, PhD, at the University of Washington back in 2018 with the goal of being an early adopter of these techniques. Currently, I use endoscopic techniques for cervical, thoracic and lumbar decompressions, lumbar fusions, and even SI joint pathology. 

I think the real utility of endoscopic spine is the paradigm shift that occurs when formulating treatment options. When you have this tool that can provide targeted access to pathology with minimal collateral damage — you start to think, is there a way I can address 90% of this patient's concerns with a sub-centimeter incision and no real downtime? It seems so intuitive that even patients ask, "Why doesn't everyone do this?"

We published a paper entitled "The Benefit Zone of Endoscopic Spine Surgery," where we proposed the true benefit of endoscopic techniques were when alternative surgical options were comparatively more invasive and complex. The best example of this is a thoracic disc herniation — standard options include numerous highly invasive techniques that most patients would turn down if they were offered a thoracic endoscopic discectomy. My colleague, Sanjay Konakondla, MD, gets referred to all thoracic disc herniations within a 100-mile radius because even most spine surgeons understand that endoscopy is the better option.

In my practice, I utilize endoscopic techniques anytime I think that's what I would want if I was on that operating room table.

Q: Can you talk a little bit about your experiences when it comes to dealing with payers and endoscopic spine procedures?

SH: The coding of spinal endoscopy is premature and inconsistent. The early use of endoscopic procedure codes were conflated with percutaneous procedures performed by non-spine surgeons. The lumping of apples and oranges resulted in an inaccurate reflection of the true value of the work inherent to full-endoscopic spine surgery. The key distinction between percutaneous spine procedures is that endoscopy utilizes direct-light based visualization of anatomy, akin to using a microscope and a tube — just on a miniature scale. Hence, coding should reflect that. Payers still sometimes deny these procedures as "experimental," despite some of the best randomized controlled studies in spine surgery affirming their benefits and at minimum, equivalence in outcomes.

Q: So minimally invasive endoscopic spine surgery is being coded like an open surgery?

SH: I don't think there is a hard rule on coding. I think each surgeon should have a discussion with their coders/billers/payers to differentiate between percutaneous procedures and true full-endoscopic spine surgery. The goal should be to elucidate payer guidelines and understand similarities/differences between tubular and open surgery and where endoscopic surgery fits in the spectrum.

I think when payers deny endoscopic procedures as experimental, they are missing the big picture. Endoscopic procedures cut down on costs for the insurance carriers in terms of infection, return to the operating room, length of stay, overall complication rate, faster return to work, less opioid requirements, etc. This does not even include the savings they would see when a patient gets an endoscopic decompression instead of a decompression/fusion because of the concerns of iatrogenic instability.

Q: With an increased patient demand and increased surgeon adoption, do you think that could eventually change the coding situation?

SH: The biggest impetus for change in the U.S. will be through endoscopic spine surgery research. That is the only way. Data is the language that healthcare systems, insurance carriers, hospitals, surgeons and patients all speak. Dr. Christoph Hofstetter helped found the Endoscopic Spine Research Group, which is a consortium of spine surgeons across the U.S. whose practices have a special focus on utilizing endoscopic techniques. Via the use of a mobile data collection application, SpineHealthie, we can collect large amounts of data to analyze and elucidate important information about the value of endoscopic spine surgery and be in a better position to have conversations about coding.

Q: What are the current endoscopic spine education programs in the U.S. doing right, and where can they improve?

SH: Learning endoscopic techniques in the United States is typically very self-directed. Surgeons typically get their interest piqued via social media applications such as LinkedIn. This usually results in some surgeons enrolling in a hodgepodge of cadaver courses at annual meetings and industry-sponsored courses. I think these workshops are critical to the development and expansion of the field, as they were when arthroscopic surgery really took off in the 1970 to 1990s.

While there is a small minority of academic surgeons across the U.S. who are training residents and fellows in endoscopic techniques, more and more surgeons who are already in practice are seeking out endoscopic techniques. Some of my mentors have gone to South Korea and Germany to get more exposure.

In an effort to fill the void of a central educational space where surgeons can be exposed to an industry-agnostic environment, we created the Annual Endoscopic Spine Symposium with the help of the Seattle Science Foundation. This was a heavily attended didactic event where we had a program of national and international experts discussing all things endoscopic spine surgery. 

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