Endoscopic spine surgery is advancing faster than the workforce trained to perform it.
That, Ben Burch, MD, believes, is the field’s real bottleneck.
“I don’t think we have a technology problem in spine surgery,” Dr. Burch, an orthopedic spine surgeon at Atlanta Spine Institute, told Becker’s. “I think we have a training pipeline problem.”
Most practicing spine surgeons were not trained in endoscopy during residency or fellowship. The faculty who trained them often were not either. As endoscopic techniques expanded in North America, established surgeons first had to learn the procedures themselves before training programs could begin incorporating them.
That gap is starting to narrow. More faculty are gaining experience, more programs are exposing trainees to endoscopy, and surgeon interest continues to rise.
But Dr. Burch sees a more difficult challenge ahead. A weekend course can introduce the technology. It cannot create an endoscopic spine surgeon.
The fastest way to discredit endoscopy
When Dr. Burch teaches surgeons new to endoscopy, he starts with something less technical than scope orientation or instrumentation: patient selection.
“The fastest way to discredit endoscopic spine surgery is to do it on the wrong patient,” he said.
Early in the learning curve, he encourages surgeons to choose straightforward pathology rather than immediately attempting revisions or technically demanding cases. That matters because the smaller incision can create a misleading impression.
Endoscopic surgery may be less disruptive for the patient. That does not make it easier to perform. “It tends to be easier on the patient and harder on the surgeon,” Dr. Burch said.
The technical learning curve is only part of the challenge. Dr. Burch often sees surgeons complete a training course, return to practice and then hesitate to schedule their first case.
He understands why. An operation a surgeon has performed hundreds of times can become almost muscle memory. Recreating the same objective through a small working corridor changes the visualization, instrumentation and rhythm of a familiar procedure.
That creates what Dr. Burch describes as a psychological barrier. His advice is not to rush through it. Choose an appropriate patient. Book extra operating room time. Give the team room to learn. And accept that the first endoscopic discectomy should not be expected to move at the pace of a procedure the surgeon has performed conventionally for years.
“You basically just have to rip the Band-Aid off,” he said. “You’ve got to do the cases.”
Endoscopy should not become the indication
Dr. Burch is enthusiastic about endoscopic surgery. He is equally wary of turning that enthusiasm into ideology.
“I’m not a zealot,” he said. “I am passionate about it. I love doing it, and I think it’s a phenomenal advancement for our patients. But I’m not going to go tell a surgeon that they’re not a good surgeon because they don’t do endoscopic surgical procedures.”
For him, the hierarchy is straightforward. First comes the diagnosis. Then the operation the patient actually needs. Only then comes the question of how best to access the spine.
That distinction is important as patient awareness grows and “endoscopic spine surgery” increasingly becomes something people request by name. Dr. Burch does not typically tell patients he is booking an “endoscopic surgery.” He is performing a discectomy, laminectomy, decompression or, in select cases, a fusion.
The endoscope is the approach used to accomplish that goal. “It’s an access tool,” he said.
That mindset also guards against a predictable risk as surgeons become more comfortable with a new technique: expanding its use simply because they can. Technical possibility does not automatically make endoscopy the better operation.
The learning curve should expand with the pathology
Dr. Burch’s own progression illustrates how he believes adoption should work. He began with more localized pathology and relatively straightforward decompressions.
As his experience increased, so did the range of cases. Training in both uniportal and biportal techniques gave him different approaches for different problems. He finds biportal endoscopy useful when a wider decompression is needed because the visualization and working portals can move independently. Uniportal approaches can be well suited to more localized pathology where a direct trajectory is sufficient.
Eventually, he expanded into more complex procedures, including fusion and revision surgery. Some of what he encountered surprised him.
In revision cases, scar tissue might intuitively appear to make endoscopy more difficult. Dr. Burch found that irrigation used during the procedure can help separate tissue planes, while magnified visualization can make anatomy unusually clear.
Still, his takeaway is not that every difficult case should become endoscopic. It is that the endoscope should be viewed as another way of reaching a surgical objective rather than as an operation unto itself.
“Don’t view it as, ‘I’m going to go do an endoscopic case,’” he said. “You’re using an endoscopic technique or an endoscopic approach to assist you with accomplishing a goal that you would have otherwise done through some other technique.”
That distinction could become increasingly important as the technology moves from early adopters toward mainstream spine practice.
A course teaches the technique. Mentorship builds the surgeon.
Dr. Burch does not believe formal courses should disappear. He believes they are the beginning.
The more important infrastructure may be the network surgeons build afterward. He still discusses difficult cases with colleagues despite performing a substantial portion of his decompressions endoscopically. Surgeons with more than 1,000 endoscopic cases do the same.
That is normal in complex spine surgery, he said, and endoscopy should be no different. For a surgeon trying a new approach, even a colleague confirming, “You’ve got a great plan,” can make a meaningful difference.
“The most important thing is to reach out to mentors and lean on them,” Dr. Burch said. The mentorship extends beyond what happens inside the patient. Surgeons also need to know how to build the program around the operation.
The operating room has a learning curve too
Introducing endoscopy changes the room. An OR team accustomed to a conventional microdiscectomy suddenly sees a video tower, irrigation bags, tubing, light cords and different instrumentation.
That can make a familiar spine procedure look considerably more complicated. Dr. Burch said the transition can be easier in ASCs or facilities that already perform arthroscopy in other specialties. Nurses and surgical technicians who work with knee or shoulder scopes may already understand much of the infrastructure.
Sometimes the most effective explanation is the simplest. “It’s like a knee scope,” Dr. Burch tells teams. “We’re just doing it on the spine.”
That operational learning curve is one reason he thinks the conversation about endoscopic adoption has focused too narrowly on surgeons. Building a sustainable program requires facility buy-in, equipment, trained staff and a workflow that makes the procedure reproducible. It also requires economics that make sense.
The economics still measure the wrong things easily
Endoscopy presents an uncomfortable value equation. Take a relatively straightforward operation such as a discectomy.
Introducing endoscopic equipment can make the immediate procedure more expensive. The hoped-for value shows up somewhere harder to put on a spreadsheet: the patient’s recovery.
Dr. Burch sees that disconnect as one of the field’s unresolved challenges. “Dollars are easily measured, but patient outcomes are more difficult to measure, at least to put onto a spreadsheet,” he said.
That can make the initial conversation with hospitals and ASCs difficult. Dr. Burch has helped introduce endoscopic programs in both settings and said cost was an early source of resistance.
He has since seen the conversation change. Some facilities that once questioned the investment are now approaching surgeons about bringing endoscopic capabilities to their organizations. He suspects patient demand is part of the shift.
But coding, reimbursement and capital requirements remain significant enough that Dr. Burch routinely hears from surgeons who know how to perform the procedure yet do not know how to build the program around it.
“That’s the kind of stuff they don’t teach surgeons in medical school and training,” he said. For endoscopy to scale, that knowledge may have to become part of the training pipeline too.
In 10 years, the label may disappear
Dr. Burch’s view of where this ends is strikingly simple.
“I think in 10 years we won’t be calling it endoscopic spine surgery,” he said. “We’ll be calling it spine surgery.”
He does not mean every operation will be performed through a scope. Large deformity reconstructions and other complex procedures will continue to require different approaches.
His analogy is rotator cuff surgery. Open repair was once standard. As arthroscopic technology and surgeon training matured, the less invasive approach moved from specialized technique toward routine skill.
Dr. Burch sees a similar trajectory beginning in spine. The strongest signal may not be coming from manufacturers or even surgeons.
It may be coming from patients. He increasingly sees people travel from outside Georgia specifically to ask whether their condition can be treated endoscopically. He also pointed to research in which more surgeons said they would prefer an endoscopic operation for themselves than actually performed the technique in their own practices.
That gap captures where the field stands. Interest is ahead of training. Demand is ahead of infrastructure. And the technology may be moving faster than the systems required to deploy it safely.
Closing those gaps will matter more than simply putting additional scopes into operating rooms. The future Dr. Burch describes is not one in which every spine surgeon becomes an endoscopy specialist. It is one in which the technique becomes ordinary enough that they no longer need to be called one.
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