Endoscopic spine surgery has moved from niche technique to conference headliner in a matter of years. Andrew Chung, MD, an orthopedic spine surgeon with Phoenix-based Banner Health, has watched that shift from the inside, and he has a warning for the field: The excitement is running well ahead of both the evidence and the actual uptake.
“I think, though, as you probably have heard from others, buzz doesn’t always necessarily reflect adoption,” Dr. Chung told Becker’s.
Dr. Chung is not a skeptic. About 50% to 60% of his practice is now endoscopic, roughly 200 cases a year. But he came to the technique the long way. He trained in orthopedics at Mayo Clinic in Phoenix, completed a neurosurgical and orthopedic spine fellowship at the University of Southern California in Los Angeles and spent six months in an advanced minimally invasive spine fellowship at Cedars-Sinai in Los Angeles — all without performing a single endoscopic case, because few U.S. programs were teaching it at the time. He learned through weekend courses, cadaver labs and visits to surgeons in South Korea before adopting it about four years ago.
That path informs his concern about how the technique is being sold. Some of the marketing around endoscopy frames fusion and hardware as things to avoid, a message Dr. Chung said can mislead patients who have deformity, instability or other conditions where endoscopic surgery is likely to fail.
“Unfortunately, there’s a lot of marketing around endoscopy, saying ‘fusion is bad, and hardware is bad, get an endoscopic surgery,’ and I think while there’s some truth to that, I think that’s a dangerous sentiment as well,” he said.
Overselling the technique, in his view, puts its long-term growth at risk with surgeons, patients and payers alike.
“It still falls short, and I think we have to be very careful with our messaging if we want endoscopy to be something that continues to credibly grow, not only within the spine community but also from a patient acceptance standpoint and beyond that from an insurance standpoint,” Dr. Chung said.
Patients are increasingly arriving with the idea already in mind. Dr. Chung said he has noticed more interest over the past year or two, including among older patients who are researching options on their own.
“As people get more savvy, even our 70-, 80-year-olds, are on AI,” he said. “They’ll come in and they’ll be like, ‘Hey, have you heard of this arthroscopic or laparoscopic spine surgery?’ I’m like, ‘Well, it’s not called that, but yeah, it’s called endoscopy, and that’s what I do.’”
Setting expectations cuts both ways, he said. Some patients ask for endoscopy when it isn’t the right fit. Others are told they aren’t candidates by surgeons whose endoscopic skill set is limited to simpler procedures.
“I look at their case and I’m like, well, no, you absolutely are, but it’s the lens that you’re looking from, right?” Dr. Chung said. “If all you can do is microdiscectomies through an endoscopic surgery or technique, and you can’t do a decompression or a fusion, that doesn’t mean that it’s not possible or that it’s not a good option.”
His own practice, he said, is to tell patients plainly when a procedure is outside what he does well and refer them to a colleague who does.
The gap between enthusiasm and training is another pressure point. Because endoscopy was largely absent from fellowships less than a decade ago, Dr. Chung said today’s newly trained surgeons will need several more years of experience before they can build and teach programs of their own. In the meantime, demand is pulling the technique toward clinicians outside spine surgery.
“I do think that the hype, to some degree, almost dangerously so, drives adoption in a non-standardized fashion,” he said.
The more fundamental problem, Dr. Chung said, is that the field has not yet delivered the kind of outcome gap that drove surgeons to adopt laparoscopic colectomy or arthroscopic anterior cruciate ligament reconstruction.
“We’re not there yet when it comes to the majority of how endoscopy is performed right now,” he said.
Most endoscopic cases today are relatively simple procedures, such as discectomies and laminotomies, that surgeons can already perform well through other minimally invasive approaches. For those, Dr. Chung said, studies show little difference in outcomes beyond the first few months. That leaves surgeons weighing a learning curve he estimated at roughly 70 cases, with slower operating times and the risk of added complications along the way, against marginal benefit. Payers are asking a version of the same question.
“Why are we going to pay more for a procedure that doesn’t really move the meter in outcomes, right? I mean, that’s just a reality,” he said.
Where Dr. Chung does see the technique proving its value is in complex cases that make up a large share of everyday spine practice: multilevel decompressions, fusions combined with decompressions, multilevel cervical work and foraminotomies that could spare some patients a fusion. Open multilevel laminectomies in older patients often mean hospital stays of several days, blood transfusions, discharges to skilled nursing facilities and complication risks he put at 10% to 20%.
His team has been tracking its own endoscopic results in that population. Patients in their 70s and 80s undergoing multilevel decompressions are going home the same day or the next, with minimal blood loss and few complications, he said. The group recently presented the findings at a Society for Minimally Invasive Spine Surgery meeting and has more work in the publication pipeline.
“That’s where the delta becomes more meaningful, right?” Dr. Chung said.
Data like that, he said, is what will ultimately convince surgeons, patients and payers — not marketing. And while he expects the training pipeline to mature, he sees the field as being in an in-between stage.
“So, point being, I think we’ll get there,” he said. “We’re just in the process of getting there.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
