What must change for more widespread endoscopic spine surgery adoption


More surgeons are expected to take a deeper look at endoscopic spine surgery as the technology continues to advance and spine procedures rapidly migrate to the outpatient setting.

From increased training programs to addressing reimbursement shackles and improving patient awareness, five spine surgeons discuss changes that would lead to widespread adoption of endoscopic spine surgery.

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. We invite all spine surgeon and specialist responses.

Next week's question: How will surgeons in 2030 look back at how spine care is performed today?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, Aug. 4. 

Note: The following responses were lightly edited for style and clarity.

Question: What needs to change for endoscopic spine surgery to become more widely adopted in the U.S.?

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): I have been consistently performing endoscopic spine surgery for three to four years now. Here is my opinion:

1. Surgeon education and training: Most companies invested in weekend cadaveric courses before the COVID-19 pandemic, but the format was changed to virtual meetings when the pandemic hit. But live courses are now coming back again. I participated in several workshop courses during the weekend, having a mentor for the first three to four cases. My surgical time significantly increased in the first five to ten cases, and then got faster when I felt more comfortable and familiar with the anatomy, equipment, etc. The surgeon must commit and dedicate their time for training and accept that it will take time to build the new skills.

There are short-term and long-term fellowships available in Korea, India and Japan. Unfortunately, they were shut down because of the pandemic. I was planning to go to Korea for further training before the pandemic hit. I hope they will resume their fellowship programs when it is safe to do so.

2. Hospitals and ASCs: They have to work with surgeons and vendors to bring this technology to the hospital. The data is undeniable. The patients' outcomes are superior in many level 1 studies. It will be a great investment in the long run.

3. Insurances: I would love it if the insurance carriers accept the new data and change their guidelines to accept this technique. Most commercial payers are still confused that the endoscopic technique is similar to percutaneous discectomy even though they have separate CPT codes. They need to be educated as they still deny the coverage due to their stubbornness. The other aspect is reimbursement: It has to be adjusted to reflect the skills of the surgeons who can perform this technique as well as the incurred expenses (disposable tools).

4. Device companies/vendors: They must continue to support surgeon training and educate the patients and staff.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The reporting of same or better patient outcomes in side-by-side comparisons with traditional or "vanilla" minimally invasive techniques will lead to wider adoption. Buzz creation is key in getting patients to demand this technology. On the company side, creating a more affordable, modular system that is adaptable to existing in-house camera solutions with high-quality components and great service will pay dividends. Marrying it to newer augmented reality visualization solutions will create a much more dynamic and truly watershed moment in terms of widespread adoption and practice of endoscopic spine surgery.

James Mok, MD. Northshore Orthopaedic & Spine Institute (Skokie and Des Plaines, Ill.): The major and perhaps insurmountable barrier to endoscopic spine surgery is cost. With minimally invasive approaches, lumbar decompression surgery (microdiscectomy, laminectomy) can be achieved outpatient with short operative times, minimal blood loss and with predictably excellent outcomes. Improving on this in a tangible way with an alternative surgical technique will be difficult to demonstrate. Equivalence is not enough. Endoscopic spine surgery entails substantial additional cost (capital equipment and disposables) that are not offset by additional reimbursement. Additional cost without additional reimbursement and without an easily appreciable difference in patient outcome are daunting obstacles. If patients start demanding endoscopic spine surgery on a widespread scale, then there may be change, but I think this is less likely.

Vladimir Sinkov, MD, of Sinkov Spine Center in Las Vegas. Endoscopic spine surgery offers a lot of advantages to patients as being the least invasive option currently available in spine surgery. It is a very new and different set of skills for a spine surgeon to learn, however. Therefore, there is a lot of hesitancy in adoption and a steep learning curve. For better adoption, there needs to be more and better courses that surgeons can attend and learn, just like the industry did with minimally invasive spine surgery techniques. Instrumentation needs to become more "user friendly" and there needs to be better acceptance from payers with reasonable reimbursement.  

John Burleson, MD. Hughston Clinic Orthopaedics (Nashville, Tenn.): We need more training programs teaching the technology to residents and fellows. Endoscopic surgery can be daunting to tackle for a new surgeon if they didn’t see these performed by their mentors in training. New surgeons are also a little intimidated to ask a hospital to purchase equipment that they might not end up using much.

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