Why endoscopic spine surgery in the US lags behind Europe, Asia


Endoscopic spine surgery is growing in popularity among surgeons in the U.S., but lags growth in Asia and Europe. Reimbursement shackles and a lack of training are two big hurdles affecting its adoption.

Three spine surgeons discuss how endoscopy has benefited their practice and expand on the challenges affecting its widespread adoption in the U.S.  

Note: Responses are lightly edited for style and clarity.

Saqib Hasan, MD. Webster Orthopedics (Oakland, Calif.): Endoscopic spine surgery is already very popular in Asia and Europe, and more U.S. surgeons continue to adopt these techniques. Training always lags behind new technology. Only after a critical mass of spine surgeons begin utilizing endoscopic techniques will you start to see it as part of a normal spine surgical curriculum in the U.S. Many of my attendings in residency learned arthroscopic techniques after they had completed their training. Arthroscopic surgery really revolutionized orthopedic surgery because of the paradigm shift from open surgery. 

Unfortunately, I believe early iterations of endoscopic spine surgery were not ready for prime time. The technology and techniques were not there, hence, the clinical data didn't stack well against what was tried and true. With the current picture quality and instrument improvements, endoscopic spine surgery today allows for an elegant and versatile method of treating both simple and complex spinal pathology.

Tony Mork, MD. Endoscopic Spine Academy (Newport Beach, Calif.): There's little to no comprehensive training readily available. The endoscopic approach uses a totally different skill set than open surgery and requires a relearning of the anatomy. When you start to look at the spine through a scope, it's very different at first. Any problems encountered, for example a dural tear or bleeding, must be taken care of through the scope. This takes a little patience and a lot of practice to feel comfortable. 

The second reason is that the reimbursement is not very good. The equipment is expensive: A diamond burr, used for bone work, can cost up to $1,900 per burr. So, if the facility isn't being reimbursed adequately, then it becomes a financial issue. Endoscopic spine surgeries are mostly outpatient procedures, so hospitals are concerned because they're not getting adequately reimbursed. Also, it's the physicians that decide between an endoscopic procedure and a fusion for a given condition. So, if the outcomes may be similar, some physicians might do a fusion because the reimbursements are so much better. 

Raymond Gardocki, MD. Vanderbilt Health (Nashville, Tenn.): Endoscopy has been around for a while, but in the early days the optics were poor. I think there were some people pushing endoscopic spine surgery who promised it could do more than it actually can. That left a bad taste in peoples' mouths, especially in the spine community. There's a greater risk of liability in the U.S. than other countries, so people don't want to be the first person to do something. I started doing outpatient lumbar fusions in 2008, and it weighed heavily on my mind because I was basically outside the standard of care. If I had any complications, it would have been very hard to defend. But it's slowly becoming accepted now. 

Having had that experience, I felt I could tackle the endoscopic aspect. Fundamentally, I think it's better. It's less invasive, not only intuitively, but there are studies that show inflammatory mediators are lower after an endoscopic approach than even a tubular approach. It's objectively less invasive; it allows us to do surgery on patients that are awake so you can avoid the risk of general anesthesia, which can be significant in the elderly population. You also get instant feedback — you can sometimes tell while the patient is on the table if they're better because you can ask them how their leg feels.

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