Endoscopic spine surgery is poised to play an increasing role in patient care, but questions about dominating techniques and payer responses remain, Brandon Hirsch, MD, said.
Dr. Hirsch, of Newport Beach, Calif.-based DISC Sports & Spine Center, spoke with Becker's about the developments and challenges ahead for endoscopic spine surgery.
Note: This conversation was lightly edited for clarity.
Question: What caused you to become interested in spinal endoscopy and what has your experience been with the technology?
Dr. Brandon Hirsch: I finished fellowship in 2018 and began practice in Arizona, where I focused primarily on treating degenerative and deformity related spine problems using minimally invasive techniques. As you probably know, spinal endoscopy has gotten a lot of traction in the U.S. over the last five years as it is even less invasive than traditional techniques. This interest and my discussions with close colleagues about their early experiences in spinal endoscopy caused me to take a good hard look at the technology and adopt it.
Endoscopy allows us to speed up recovery even faster than traditional minimally invasive techniques because we are using even smaller incisions, causing less muscle trauma, and getting visualization inside the spine at a 4k resolution that we just can't achieve with other techniques. That allows us to do a safer and more effective job of opening up space for the nerves in treating spinal stenosis and achieving disc space preparation in the case of fusions. Endoscopic approaches also enable us to preserve more of the facet joint anatomy, which allows us to preserve stability of spinal segments and avoid fusion.
The technology has a lot of promise, and the growth and interest are justified. I've had experience with both biportal and uniportal endoscopic approaches. This refers to whether the procedures use one incision working through a portal inside of the endoscope versus using two incisions, one for the endoscope and the other for instruments. Both techniques are applicable to certain pathologies based on each surgeons experience and preferences. I've used these techniques to treat disc herniations and spinal stenosis, which are two of the most common pathologies that we treat as spine surgeons.
Q: Of the two endoscopic methods, which do you think will take off more?
BH: You're likely to get different answers depending on which spine surgeon you ask, but in my opinion biportal techniques appear easier to adopt for most surgeons. Orthopedic surgeons train extensively in arthroscopy of the hip, knee, shoulder, ankle, wrist and elbow, which is done with two or more portals. One portal has a camera, and the other has working instruments. That's a very natural setup for an orthopedic surgeon. Some areas of neurosurgery training do involve endoscopy as well, but I can't quite speak to whether that is more applicable to a biportal versus uniportal technique. That being said, there are plenty of applications for and plenty of highly skilled surgeons using uniportal techniques. The argument for that technique is everything is done through one incision through the camera. Proponents of uniportal surgery would argue this is less disruptive to the surrounding soft tissue compared with biportal techniques, resulting in faster recovery. I believe there are pros and cons to both techniques. In my practice, I favor uniportal endoscopy for foraminal pathology and soft disc herniations, whereas I use biportal endoscopy more frequently to treat canal and lateral recess stenosis. That said, if you spoke to a surgeon who is really focused on uniportal surgery, they might tell you they can do just as good of a job treating all of these pathologies in that manner. At this point we dont have a clear answer that one technique is superior to the other. Over the next 10 years, we will see more studies comparing these techniques.
Q: Are you involved in any kind of endoscopic spine research yourself?
BH: At DISC, we are expanding rapidly and are fortunate to have a group of surgeons interested in research and academics. They have all trained at top academic centers in spine and orthopedics and want to continue to advance the field outside of the traditional academic practice model. Studying endoscopy will definitely be a focus of ours. Great research in endoscopy is being done by multicenter study groups and we hope to use our data to collaborate on those efforts going forward. Disc replacement is another area of research interest for us. The practice has a tremendous amount of experience with both cervical and lumbar disc replacement spanning decades.
Studying and demonstrating the advantages of these technologies going forward will be a priority. In addition to disc replacement and spinal endoscopy, we plan to study how surgical facilities impact patient outcomes and cost. DISC has a very long history of doing a full spectrum of spine surgery at freestanding surgical centers, and we believe that we're able to give a high-quality experience without having patients go to larger, multispecialty facilities. A lot of what we're going to be looking at is comparing what we do here in the ASC to surgery done in the hospital setting. We believe our outcomes are as good or better in the ASC, with a superior patient experience at a lower cost to payers and patients.
Q: Do you have any predictions or concerns in terms of payer response and CMS for endoscopic spine?
BH: I have hopes and dreams of what our regulators will do, but it's really hard to know for sure. One of the things that has inhibited the adoption of endoscopic spine surgery is related to payment and economics. Endoscopic spine surgery is actually very prevalent in other parts of the world, but it's been challenging to get traction in the U.S., because there really aren't codes that are unique to an endoscopy that are recognized by the payers. Currently, most endoscopic surgery is still reimbursed using the same standard microdiscectomy or laminectomy codes, but it does take extra effort, expertise, time and training that those codes don't really represent. There were and still are endoscopic spine surgery-specific codes, but they are not typically accepted by payers. They're often described as being experimental from a payer perspective, even though we know that's not the case. This means that some surgeons may risk non-payment for their work despite taking the extra time and effort to learn and apply these ultra-minimally invasive techniques. Adoption of spinal endoscopy has been limited by these disincentives in the U.S. My hope is that, with time, Medicare will have a greater willingness to reimburse for codes representing innovative techniques that have real benefits for patients.
Q: We know spine surgery is trending more to the outpatient setting. In 10 years, what do you think that will look like? Will almost all minimally invasive surgeries be in the ASC? Will we see some newer or more complex cases go outpatient?
BH: I think the acuity of cases done in the free-standing outpatient center is likely to continue to increase. What we're doing at our centers today are cases that many surgeons historically would perform only in hospital settings. We do anterior lumbar exposures safely and routinely because we have excellent vascular access and tried and true perioperative protocols. Surgeons at our centers have the equipment, the staff expertise and the setup to handle higher acuity spine cases. I have to imagine that other groups who are serious about outpatient spine surgery are going to make similar plans.
Over the past two decades, it has also become more and more challenging for spine surgeons to work in the hospital setting, particularly if they're not an employee of the hospital. It is also difficult for a traditional hospital to give a high-quality patient experience around spine surgery because the facility has to be able to provide care for many different health conditions at varying levels of acuity. Some inpatient facilities do this well because spine surgery is the main focus of the hospital. Unfortunately, nationwide this is more the exception than the rule. A highly specialized center that routinely does outpatient spine surgery every day is going to provide a better experience for both patients and their surgeons.