Ryan Sauber, MD, began performing uniportal endoscopic spine surgery at Pittsburgh-based Allegheny Health Network in May and is navigating the successes and challenges coming along.
Dr. Sauber discussed his pitch to the health system, how he's handling payer hurdles and his advice to others wanting to adopt endoscopic spine.
Note: Responses were lightly edited for clarity.
Question: How did the launch of the uniportal program start? What was your pitch, and did you encounter any major challenges?
Dr. Ryan Sauber: I was introduced to endoscopic spine surgery in fellowship six years ago, and began learning about the technique more in depth about one year ago. I was involved in a training course last fall prior to purchasing any equipment or making any commitments. It was about that time that I realized that if I had a disc herniation, I would want someone to treat me endoscopically versus the minimally invasive technique I was currently using. I went back to my health system and requested the funds for the equipment. My pitch was multifaceted and included the marketability of the approach, anticipated increased spine surgery volume, improved patient outcomes and reduced complications. Primarily, however, I focused on the fact that a uniportal discectomy was the only way that I would want myself or my family to be treated if they had a disc herniation. This argument seemed to resonate with my health system administrators.
I encountered many challenges along the way, some of which I am still working through. After considerable early support, there was a months-long delay to actually find and allocate the funds to purchase the capital equipment. I went through a business plan with my administrative team to ensure that the program would be financially sound. Coding and billing has been difficult and time consuming. Finally, there have been several insurance company denials for surgery because the technique is still considered experimental to some. The last insurance denial specifically told my patient that I should only perform the surgery open and the endoscopic surgery that I recommended to them was not indicated. In general, patients are not thrilled with the idea of even a minimally invasive tubular surgery after you have promised them endoscopic surgery.
Q: What advice do you have for health systems and physicians who want to bring endoscopic spine surgery to their own practice?
RS: As an employed physician, my advice would be to continuously strive to improve the care that you provide to patients. If a new technique comes along which is clearly beneficial, advocate for your patients and insist that your health system provides the best possible care.
Make it personal. Ask them which technique they would prefer for themselves or their family.
I would also encourage interested surgeons to dive into training prior to purchasing any equipment. There are several good courses and pathways available now that were not available even a few years ago. There is a vibrant and active community of surgeons in endoscopic spine who are very interested in helping others to join their ranks.
Finally, I would advise surgeons and health systems to look ahead into the future. Is there really any possibility that endoscopic spine surgery doesn’t become the standard of care moving into the future? How often are open rotator cuff repairs or open meniscectomies performed? As someone who has performed open spine surgery, tubular spine surgery, and now endoscopic spine surgery, I certainly feel it is the future of spine care.
Q: What will it take to increase endoscopic spine surgery adoption? Where do you see the technology in the next few years?
RS: It is an open secret that many (perhaps most) of the advances in spine surgery center around coding. Even within the limitations of uniportal endoscopy, there is the potential to perform highly complex procedures with substantial bone resection. A comprehensive overhaul of the coding of endoscopic surgery with a modern understanding of the myriad of approaches to cervical, thoracic and lumbar pathology needs to be undertaken to see more broad uptake of endoscopic techniques. Fortunately, public awareness of endoscopic spine surgery seems to be growing. Legacy media as well as social media have become interested in less invasive spine surgery techniques and as patients become more aware of their options, they are likely to start requesting endoscopic spine surgery.
As a new adopter, my endoscopic practice is limited to endoscopic lumbar disc herniation surgery. I see myself progressing in the near future to more extensive decompressive surgery for arthritic spines and eventually to cervical and thoracic surgery as well as fusions. I don't know that anyone really knows what the limits of endoscopic surgery are and I am excited to be a part of the group who are trying to find out.