Despite pushback from payers and some reimbursement and training obstacles, many spine surgeons expect endoscopic spine surgery to become more prominent in the U.S. over the next decade.
Eleven spine surgeons from independent practices and health systems across the country discuss what's next for 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. Becker's invites all spine surgeon and specialist responses.
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Editor's note: Responses were lightly edited for clarity and length.
Question: How will endoscopic spine surgery evolve in the US over the next decade?
Vik Mehta, MD. Hoag Hospital (Newport Beach, Calif.): There will be tremendous growth in endoscopic spine surgery over the next decade. Faster recovery time, less pain and better relief of symptoms will be primary drivers behind the growth of this approach. Additionally, as fusions come under more pressure from patients and payers, more proven techniques such as decompressions to achieve relief of pain will come to the forefront. We have many patients in their 70s, 80s and even 90s who remain highly active with degenerative lumbar disease and stenosis as a primary pain generator. Providers who can safely and effectively help these patients get back to an active life using endoscopic and other minimally invasive techniques will be quite busy.
Sheyan Armaghani, MD. Orlando (Fla.) Health Jewett Orthopedic Institute: With improvements in optics, navigation and instrumentation, I wouldn't be surprised if endoscopic surgery became the standard for most, if not all, disk herniations and single level stenosis cases. As more teaching institutions begin to adopt the technique, you will also see more surgeons making it a part of their practice. This is already the case in many countries, especially in Asia. More long-term data needs to be collected on endoscopic fusions. I see endoscopic surgery as being similar to tubular surgery which began more than 20 years ago. Now the tube is 7 mm wide with a camera instead of 18 mm to 22 mm.
Peter Derman, MD. Texas Back Institute (Plano): I am optimistic that endoscopic spine surgery will become more widely adopted over the next 10 years in the U.S. It is currently a niche technique that requires motivated surgeons to proactively seek training. However, interest is growing, and we will eventually hit a critical mass of endoscopic spine surgeons at major training institutions such that large numbers of future surgeons will be exposed to it during their residencies and fellowships. These trainees will witness the benefits of endoscopic spine surgery firsthand and will have a head start on the learning curve. Other trends promoting the adoption of this technique will include growing patient demand (as the general public becomes increasingly aware of spinal endoscopy); an expanding body of high-quality research supporting its benefits; and increasing utilization driving industry competition to push down capital and disposable expenses.
From a technical perspective, there are many exciting avenues in which endoscopic technology can continue to develop. Integration with navigation, augmented reality, and robotics stands to reduce reliance on fluoroscopy and increase efficiency, particularly in more complex cases. Improvements in surgical instruments will allow for more rapid resection of bone, ligamentum flavum and other tissues. Future optics may provide true depth perception and facilitate three dimensional visualization of anatomical structures. The development of massively expandable interbody cages will provide ALIF-like anterior support through an ultra-minimally invasive single position posterior approach. The possibilities for endoscopic spine surgery are endless, and the future is bright.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: My prediction is the tremendous amount of deformity surgery being done, albeit there is and will be good data to justify it, will be met with a backlash from payers. Whether or not the surgeries are indicated will be irrelevant for the payers. Their main issue is to create value for their shareholders, not pay for quality work. Endoscopic spine surgery could offer an alternative in some cases in lieu of a large correction. It pains me to paint a picture this way, because endoscopy is a fascinating way to solve problems that used to require large incisions being done in the hospital setting. The market pressure from payers is a small but significant driver. However, in a more optimistic tack is patient demand. As the field becomes more and more recognized as a legitimate surgical approach, patient demand will drive the market and the skill set of individual surgeons. The learning curve will bend as residents become trained by experienced surgeons during their residencies and fellowships. Things are looking up, and for the patients’ outcomes as well hopefully.
Philip Schneider, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Endoscopic spine surgery began in the 1990s and has evolved slowly since its inception. For endoscopic surgery to make a big jump in the next decade, we must incorporate artificial intelligence and robotic technology. AI is becoming increasingly popular across several industries, proving effective in medical practices. If we incorporate artificial intelligence in endoscopic spine surgery, I predict the practice will evolve exponentially.
Nick Jain, MD. DISC Sports & Spine Center (Newport Beach, Calif.): I believe increasing adoption of this technology will lead to more patient demand for endoscopic procedures as patients will realize that minimally invasive alternatives are becoming more mainstream, similar to what has happened in Korea.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Endoscopic spine surgery is performed with tubular retractors which reduce the need to cut through soft tissues, effectively minimize blood loss and post-operative discomfort while promoting faster recovery and healing. However, endoscopy may not be appropriate for all spine surgery indications, as complex spinal diagnosis such as scoliosis, spinal instability, trauma or cancer may be better managed with a traditional open or minimally invasive spinal procedure. As the fund of knowledge, comfortability and surgeon experience grow, so will indications and recommendations to patients.
Issada Thongtrangan, MD. Spine Surgeon at Microspine (Scottsdale, Ariz.): I am positive that it will get more adopted by surgeons and patients. Patients are far more educated than ever before, especially through direct consumer social media platforms. The parties that will be against it are the payers, despite overwhelming evidence such as the level-one studies showing the safety and efficacy of endoscopic spine surgery in many aspects of spinal disorders, including endoscopically-assisted fusion or full endoscopic fusion. There will be more development on how to incorporate this technology with navigation, robotics, AI, etc. I also think there will be evolving techniques where we can correct the segmental deformity or achieve sagittal balance by releasing all or even osteotomy using a combination of Navigation and endoscopic technology. Surgeons' education and training are essential as well as direct consumer education to patients.
Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): Endoscopic spine surgery will likely evolve to have more customized instruments and increased competition from medical device companies to supply the most user-friendly equipment. Additional advancements over the next decade will include 3D navigational components for endoscopic procedures and robotic-assistance in unison with the current technologies. An integrated approach to technology is the wave of the future with endoscopic spine procedures. Such developments will provide a more seamless workflow during surgery.
Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): Endoscopic surgery has been around for a long time and hasn't progressed because current uses are not validated. To progress, there has to be a revolutionary change.
Chester Donnally, MD. Texas Spine Consultants (Addison): Hopefully more literature will come out for the cervical spine, and this can be an alternative to ACDFs in certain cases.