The case against building an endoscopic spine program usually comes down to arithmetic. The disposable instruments cost more per case than open surgery. And on paper, every patient steered toward a minimally invasive decompression is a patient who did not generate the revenue of a spinal fusion.
The math is sound. The conclusion, a panel of spine surgeons argued at Becker’s 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC Conference in Chicago, is backward.
The return on an endoscopic program does not live in the margin on any single case, they said. It lives in volume: in the patients who would have refused surgery, left for a competitor or never qualified at all.
The arms race is already on
The argument lands at a moment when the technology has tipped from a specialized skill to a competitive expectation. Xiaofei Zhou, MD, associate program director and a neurosurgeon at Cleveland-based University Hospitals, introduced endoscopic spine surgery at her institution about 18 months ago and watched administrators treat adoption as a matter of keeping up.
“They see every other hospital acquiring endoscopic spine. And so the acceleration is just keeping pace,” Dr. Zhou said. “It’s because everyone else is doing it. If you don’t, you’re kind of left behind.”
Ryan Sauber, MD, an orthopedic surgeon at Pittsburgh-based Allegheny Health Network, put it in blunter terms.
“There’s this ‘arms race’ feeling that if you don’t have endoscopy, you’re left behind,” Dr. Sauber said. “If you don’t get in right now, you’ll be two, three, five years behind your competition.”
The fusion revenue objection
The financial resistance the surgeons meet is specific, and it tends to surface at the moment someone has to sign the check. Dr. Sauber summarized the objection he hears most.
“If you’re doing a microdisc on somebody instead of a fusion, then we’re missing out on all that revenue that would have been generated by the fusion,” he said.
His rebuttal is his own caseload. “I was in a pretty steady state in my career doing probably 30 to 40 microdiscs a year prior to endoscopy,” Dr. Sauber said. “This year I’ll be at 150 or 180.”
Those were disc cases that “otherwise wouldn’t have come to me, would have gone somewhere else,” he said. And once the patients arrive, he said, they stay.
“You have a patient for life after that,” Dr. Sauber said. “They seek opinions from the people that try to avoid the fusion.”
New patients, not just redirected ones
Patrick Kim, MD, a neurosurgeon and assistant professor of neurosurgery at Tampa, Fla.-based USF Health, described a second source of volume: patients a system would otherwise never have counted as surgical candidates. At his institution, patients who arrive in the emergency room with an acute ruptured disc start on a protocol of steroids, gabapentin and anti-inflammatories.
Those who still cannot stand or walk after a few days become candidates for an endoscopic procedure, an option Dr. Kim said his more traditional partners would not have put on the table. “Having a less invasive option certainly lowers the bar,” Dr. Kim said. “I’m not saying we should operate on everybody.”
For Dr. Zhou, the clearest evidence came from her own value analysis committee, which pressed her not on the cost of each case but on what the capability did to her practice overall.
“How much has offering this increased your clinic volume?” she recalled the committee asking. Her total volume rose, she said, and the range of patients she could treat widened. She had been reluctant to perform a large fusion on an 18-year-old or an 85-year-old, which kept her surgical population narrow. Minimally invasive techniques let her operate across that span.
“My overall volume, not just in endoscopy, has increased. I’m now seeing patients with a wider range of ages,” Dr. Zhou said. That, she argued, is the frame administrators miss. “If you’re looking at a systems growth perspective, having this single technology kind of expands everything for your institution,” she said.
Patients are crossing state lines
The volume is not only clinical. It is geographic. Ben Burch, MD, a spine surgeon at Atlanta Spine Institute, said the shift he has watched over the past four years is in how hospitals and ASCs value the technology as a draw.
“It’s going to be an investment in marketing because patients are demanding it,” Dr. Burch said, “and we’re actually seeing patients coming across state lines to seek it.”
The early resistance he met was the mirror image of today’s enthusiasm.
“Why do we need to invest in technology that’s going to make a discectomy more expensive?” Dr. Burch recalled administrators asking. “You could just do an incision and do a discectomy.”
Patient demand has since flipped that conversation. Dr. Sauber said the opening slide in his lectures lists the things patients say when they walk in, and one line recurs. “I’ll never have spine surgery.” The same patients, he said, often agree to an endoscopic procedure once they grasp how much smaller it is than the operation they feared.
The program fragility problem
Then comes the harder part. The volume only materializes if the program outlasts the surgeon who started it, and the panel was candid about how often it does not.
Dr. Sauber said the dropout rate among surgeons trained in endoscopy is high, though he did not offer a specific figure. Many quit during the documented learning curve, which he put at 30 to 50 cases before efficiency returns. Early cases that take 2 1/2 to three hours eventually settle to 30 to 45 minutes, but only for surgeons who keep their volume up.
“If you’re going into this thinking that you’re going to do a handful of cases per year, that program is probably destined to fail,” Dr. Sauber said.
The structural risk is concentration. Most endoscopic programs, the panel agreed, rest on a single surgeon. Dr. Zhou learned what that means firsthand.
“When I started, I was the only one who championed it,” Dr. Zhou said. “And then I went off on maternity leave and the entire program fell apart because there was no one else who knew how to do it.”
When she returned, she rebuilt the program around her partners instead of herself, offering to be on site for the start of any case they booked. “Any case you book, I will be there. I will be inside the hospital and you just call me,” she said.
Dr. Kim, who said the hardest group to convince was his own partners, takes a similar approach, walking skeptical colleagues through simple indications first and reminding them that “smaller incision doesn’t mean it’s easier. It’s actually more challenging.”The throughline is that the business case and the staffing case are the same case. A program built to capture volume cannot depend on one person to capture it.
“I’m not in competition with my partners. I want them to thrive,” Dr. Zhou said. “I want them to do this so we can build a program, not just build a surgery around one person.”
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.
