For decades, the U.S. defined the future of spine surgery. Today, too often, we are watching that future unfold elsewhere.
Many American spine surgeons recognize the experience. We return from international meetings having watched innovative procedures performed routinely abroad, only to discover that bringing those same advances home means navigating years of reimbursement uncertainty, coding ambiguity, coverage denials, institutional resistance and limited training opportunities.
The result is not merely professional frustration. It is a gradual migration of surgical innovation away from the country that once led it.
Innovation cannot survive when the surgeon who pioneers it is punished for being early.
The problem is not a lack of American ingenuity. It is a system that has become progressively less capable of evaluating, reimbursing and implementing innovation. America is losing more than innovation. It is losing the surgeons, companies and institutions that have historically driven it.
While the U.S. debates whether promising technologies deserve coverage, much of the world continues to refine them, study them and improve them through everyday clinical practice.
Our recently published international analysis of more than 1.2 million endoscopic spine surgery cases demonstrates that scientific progress is shaped not only by clinical evidence, but also by reimbursement policy, coding structures, educational opportunities, hospital economics and regulatory implementation. Together these forces create what we described as innovation friction — the structural resistance that slows or prevents the adoption of valuable surgical advances.
A procedure cannot build an American evidence base when American patients cannot access it.
This is the paradox. Coverage is often withheld because additional American evidence is requested, yet the very policies restricting patient access also prevent American surgeons from generating that evidence. The consequence is predictable: the evidence accumulates elsewhere.
When reimbursement refuses to recognize innovation, innovation moves elsewhere.
Companies conduct research where adoption is possible. Surgeons refine techniques where they are permitted to use them. Fellowship training follows case volume. Investment follows opportunity. Patients ultimately benefit where innovation is welcomed rather than deferred.
America is not running out of innovation. It is exporting it.
This is not an argument against evidence-based medicine. Quite the opposite. Evidence-based medicine remains one of the greatest advances in modern healthcare. But surgery is not pharmacology. Operations evolve through iterative improvements in technique, technology, patient selection and surgeon experience. High-quality, real-world evidence should therefore complement — not replace — traditional clinical trials. Together they provide a more complete understanding of innovation in clinical practice.
Evidence-based medicine should remain our foundation. But when it is interpreted in a manner that excludes robust real-world evidence, it can inadvertently delay the very innovations that ultimately become tomorrow’s standard of care.
If we continue insisting upon evidence that our own policies prevent us from generating, we should not be surprised when the next generation of surgical advances is developed, validated, and adopted elsewhere.
The question is no longer whether surgical innovation will continue. It will.
The question is whether America intends to lead it, or import it after someone else has.
The world is not waiting. Why are we?
Morgan P. Lorio, MD, a spine surgeon based in Florida, is a past president of the International Society for the Advancement of Spine Surgery and has served as chair of its coding and reimbursement task force.
Reference
Lewandrowski KU, Lorio MP, Alfaro H, Bae J, Basil GW, et al. The Orphaned Innovation: Cost, Structural Barriers, and Global System Shifts Prompting Reimbursement Reform in Endoscopic Spine Surgery—Insights From 1.2 Million Cases. International Journal of Spine Surgery. 2026. doi:10.14444/8908.
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