Sanjay Konakondla, MD, a neurosurgeon, trained for almost the opposite kind of spine surgery.
During fellowship at Providence, R.I.-based Brown University, he expected to spend his career performing tumor resections, major reconstructions and other complex operations. Across the hall, neurosurgeon Albert Telfeian, MD, was working through tiny incisions and an endoscopic camera, often sending patients home within hours.
The contrast changed Dr. Konakondla’s career.
He began incorporating endoscopy into his practice, eventually building a program at Danville, Pa.-based Geisinger Health before joining Dr. Telfeian in New York. Today, the two neurosurgeons have built the New York City-based Endoscopic Spine Institute of New York around a simple premise: When a patient’s problem can be solved with less surgery, that option deserves serious consideration.
Patients are increasingly arriving with the same expectation.
That demand is helping push endoscopic spine surgery beyond the relatively small group of surgeons who pioneered it. Hospitals are building programs. More practices advertise the technique. Surgeons are learning it.
But Drs. Konakondla and Telfeian see a new challenge emerging with that growth. Offering endoscopy is becoming easier. Mastering it is not.
‘We’re not trying to fix the picture’
Their approach starts with what Dr. Konakondla calls a quality-of-life question.
“If you woke up tomorrow and blank was gone, what would that be?” The answer can narrow an MRI full of abnormalities to the symptom that actually matters.
“We’re not trying to fix the picture,” he said. “It’s less about what the pictures show and more about what you feel.”
Spine imaging frequently reveals multiple degenerative findings. Dr. Konakondla’s argument is that the existence of an abnormality does not automatically justify treating it. Instead, the surgeon has to match the patient’s symptoms to the anatomy and decide how much intervention is necessary.
For selected patients with a focused nerve problem, that may mean an endoscopic decompression rather than a larger operation addressing every abnormality on the scan.
And if the smaller procedure does not solve the problem, Dr. Konakondla said, it generally does not eliminate the larger operation that would otherwise have been available.
“You don’t burn any bridges,” he said. That philosophy does not make endoscopy appropriate for everyone. It also does not make it easy.
Smaller surgery can be harder surgery
A smaller incision can disguise a steeper technical challenge. Endoscopic surgeons operate through a narrow corridor with a limited view. Anatomy that is exposed directly during a larger operation has to be understood beyond what the camera immediately shows.
“Just because it’s smaller and it’s a smaller incision doesn’t mean it’s easier,” Dr. Konakondla said. “It’s actually harder.”
That learning curve helps explain why adoption remains uneven. So do incentives.
“Surgeons get reimbursed for the work they show, not the work they save,” Dr. Konakondla said.
He was not suggesting surgeons choose larger procedures simply because they pay more. His point was structural: A surgeon who already performs a reliable operation may have little incentive to invest significant time learning a more technically demanding technique that generates less reimbursement or institutional credit.
That creates an unusual tension. Patients increasingly seek smaller operations at the same time the healthcare system may give surgeons few reasons to undertake the training required to provide them.
Drs. Konakondla and Telfeian said they have seen more than 50 spine surgeons choose endoscopic procedures when they themselves became patients. For the two surgeons, that is one of the clearest signals of where demand is heading.
An endoscope does not make an endoscopic program
The growth of patient interest has produced another problem: Endoscopy is increasingly visible on hospital and practice websites, but the range of procedures surgeons can actually perform varies considerably.
Drs. Konakondla and Telfeian said they regularly see patients who were told elsewhere that endoscopy was not an option, only to learn after another evaluation that their condition could potentially be treated that way.
The difference, they argue, is often experience. As surgeons perform more cases and learn to reach more difficult anatomy, the boundaries of what they can treat endoscopically can expand.
“You could buy an endoscopic tower,” Dr. Konakondla said. “You don’t necessarily do endoscopic spine surgery.”
That distinction is becoming more important as major institutions invest in the field.
Dr. Telfeian now serves as a clinical professor of neurosurgery at New York City-based NYU Grossman School of Medicine and Dr. Konakondla as a clinical associate professor. Both are also affiliate attending neurosurgeons and endoscopic spine surgeons at NYU Langone Health.
Dr. Konakondla said NYU approached the practice as its volume grew, creating an affiliation intended in part to expand endoscopic spine capabilities within the health system.
The significance is larger than two academic appointments. Endoscopy is becoming institutional.
And that raises the same question that has followed robotics, navigation and other spine technologies: Does acquiring the technology actually change care?
The danger is marketing outrunning delivery
Dr. Konakondla worries spine surgery has sometimes suffered from what he calls “overmarketing and underdelivering.”
Endoscopy is not immune. A program can advertise minimally invasive technology without having the experience to offer it across difficult cases. A small incision can become a marketing claim rather than evidence that a patient received the right operation.
For Drs. Konakondla and Telfeian, the measure is not whether a practice owns the equipment. It is whether the surgeon can select the right patient, perform the procedure safely and remain accountable for the recovery afterward.
That last piece is deliberately central to their model. Every postoperative patient receives a call from one of the surgeons. Dr. Telfeian had made three of those calls before 8 a.m. on the morning of the interview.
“The comprehensive good care seems so obvious, but it’s so rare,” Dr. Konakondla said.
The conversations go beyond wound checks and neurologic symptoms. They ask how the patient slept, whether the family has questions and how the return home is going. That may seem separate from the technical evolution of endoscopic surgery. The surgeons see it as part of the same philosophy.
The goal is not merely to make the incision smaller. It is to identify the problem that matters to the patient, perform no more surgery than necessary and remain involved after the procedure is over.
Endoscopic spine surgery no longer has to prove that patients and institutions are interested. The harder test comes with popularity.
As more surgeons and hospitals put “endoscopic” on the door, the field will have to decide what should be required behind it.
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