Endoscopic spine surgery is gaining traction, but surgeons remain divided on whether its benefits justify the added cost, operating time and learning curve.
Some point to faster recovery and less tissue disruption as reasons to adopt the technique, while others question whether it offers enough improvement over established minimally invasive approaches. Across both sides, surgeons emphasized that patient outcomes, not technology or marketing, should drive adoption.
Eight spine surgeons told Becker’s what would make endoscopy a routine part of their practice, or keep its role limited.
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 have been lightly edited for clarity and length.
Question: Endoscopic spine is expanding quickly, but adoption still varies widely. What would have to be true for you to make it a routine part of your practice, or decide it does not belong there?
Jeffrey Carlson, MD. Orthopedic Spine Surgeon at Orthopaedic & Spine Center (Newport News, Va.): Endoscopic spine surgery has been widely marketed as a minimally invasive approach that allows for same-day surgery, less pain and less blood loss than open surgery. I’m sure this is true, but we rarely perform open spine surgery anymore. Our lumbar fusion patients undergoing three-level procedures or fewer are discharged the same day from our surgery center, do not require transfusions and are comfortable enough to participate in physical therapy with only oral pain medications for 10 days. The learning curve for endoscopic spine surgery, additional operating room time and cost of equipment make it a difficult sell for surgeons already performing minimally invasive procedures.
Jeff Lehmen, MD. Spine Surgeon at SSM Health Spine Surgery Center (Jefferson City, Mo.): Endoscopic spine surgery is expanding quickly, but I think its appeal is driven, to some extent, by marketing rather than a clear advantage for most patients. Its applications remain relatively narrow, and it must be compared with established minimally invasive discectomy and decompression techniques, which allow me to remove bone efficiently, confirm adequate decompression and repair a dural defect if one occurs. These tasks can be more difficult with endoscopy, and complications related to dural tears may carry additional risks, including seizures. The equipment is expensive, reimbursement does not reflect that cost, and the learning curve may expose patients to complications as surgeons gain proficiency.
When I recently needed spine surgery myself, I chose a conventional minimally invasive approach because my priority was the best chance of getting better, not the technique’s label. I would make endoscopy a routine part of my practice if it demonstrated meaningful patient benefits across enough of the cases I treat, with acceptable safety and cost. Absent that evidence, I see it as a selective tool rather than a routine one.
Jonathan Rasouli, MD. Spinal Neurosurgeon at NeuroSpine Plus (Paramus, N.J.): For endoscopic spine surgery to become a routine part of my practice, reimbursement needs to better reflect the work involved, and the equipment needs to be more intuitive and ergonomic. The workflow also has to be practical enough to integrate into a busy surgical practice. I am open to adopting it where it offers a meaningful advantage over the techniques I already use. If it adds complexity and cost without improving patient care, I would be comfortable keeping its role limited.
Casey Slattery, MD, orthopedic spine surgeon with Hoag Orthopedic Institute (Irvine, Calif.): I use endoscopy primarily for microdiscectomies and plan to expand its use only as my comfort level and training allow. What keeps it in my practice is patient recovery. Endoscopy involves less soft-tissue trauma and a smaller incision than traditional approaches. However, these cases take longer, and I would not expand the technique to other areas of spine surgery if it meant significantly longer operations without a clear benefit to patients.
Issada Thongtrangan, MD. Endoscopic and Minimally Invasive Spine Surgeon at MicroSpine (Scottsdale, Ariz.): Endoscopic spine surgery has been a routine part of my practice since 2016, but I do not believe it should replace every conventional approach. It is a valuable tool when it offers a meaningful advantage for the right patient and pathology.
Endoscopy must achieve the same quality of decompression or treatment as traditional surgery without compromising safety or durability. In appropriately selected lumbar disc herniation and stenosis cases, recent meta-analyses show comparable patient-reported outcomes to microscopic procedures, with less blood loss, shorter hospital stays, fewer wound-related complications and faster return to work in many series. That aligns with my experience: less tissue disruption can mean a smoother early recovery.
But endoscopy should not be adopted simply because it is new, marketable or minimally invasive. Surgeons need structured training, appropriate equipment, team support and an understanding of the learning curve. It is safer to start with straightforward cases and expand indications as proficiency and outcomes support it. A smaller incision does not automatically mean a minimally invasive operation if decompression is incomplete or the indication is wrong.
Endoscopy is not appropriate when it cannot reliably achieve the surgical objective or when the pathology, patient anatomy, instability, deformity, revision status or degree of neural compression makes another approach safer or more durable. The goal is to solve the patient’s problem, not perform a particular procedure.
Surgeons should evaluate their own outcomes, including pain relief, function, complications, revisions and patient satisfaction, against established standards. If endoscopy consistently delivers equal or better results for selected indications, it deserves a place in practice. If not, surgeons should be willing to limit or abandon it. Technology should follow outcomes, not the other way around.
David Weiner, MD. Assistant Professor of Orthopedic Surgery at MedStar Health (Columbia, Md.): For endoscopy to become routine in my practice, I would need to see reproducible benefits for the patients and pathologies I treat. Showing that an operation can be done through a smaller portal is not enough. Modest improvements in early postoperative pain make the added time and cost difficult to justify for healthcare systems that emphasize lean operations.
Jacky Yeung, MD. Director of Neurosurgical Oncology, Fairfield Region at Hartford (Conn.) HealthCare: For endoscopic spine to become routine, it has to be reproducible, safe and offer a real advantage over standard minimally invasive surgery, not just a smaller incision. For the right pathology, I want equivalent or better decompression with less muscle disruption, less pain and faster recovery. If those benefits are not consistent, or the technique compromises visualization, efficiency or safety for some surgeons, then it should remain selective rather than routine.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Recently, concerns about endoscopic spine surgery have centered on operating time, limited visualization and the risk of inadequate decompression. Transitioning from a familiar, reliable treatment approach to an entirely different technique with limited indications presents a challenge for many surgeons, including recent graduates.
Based on local experience and discussions with colleagues, cautious surgeons have found few applications beyond free-fragment disc herniations in young, healthy patients. Even among minimally invasive surgeons, concerns remain about the technique’s limited utility and procedural time.
For experienced surgeons whose practices are built on decades of patient safety and outcomes, the trade-offs of adopting a new technique may outweigh its appeal. Ultimately, patients and their functional recovery are what matter. Preventable complications, unexplained impairments or inadequate treatment outcomes are unacceptable when established, proven approaches are available.
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