Making the Case for Endoscopic Spine Surgery

Rapid growth makes the ultra-minimally invasive option an appealing choice for facilities that can marry surgeon preferences with the right strategic vendor relationships.

Success in the rapidly growing endoscopic spine surgery (ESS) space often comes down to striking a delicate balance between two sometimes disparate factors: Your surgeons’ preferences and your vendor relationships.

“You need to find the right surgeons who are willing to work with you to use the lowest-cost option with the highest quality of service,” says Prashanth Bala, MS, MHA, vice president for ASC operations at Shields Health with direct oversight of strategy and operations for New England Surgical Suites (NESS) in Natick, Mass., a collaboration among Shields Health, Reliant Medical Group and several private practice physicians. “Without this balance, you’re going to either have quality issues because the surgeons aren’t going to be comfortable with the products you give them, or you’re going to lose money on every case you do because you bought something that’s too expensive and your surgery center is going to lose money. Threading that needle and finding the right surgeons and the right vendor partner is key.”

Mr. Bala should know — he says his NESS center began performing ESS cases in April of this year and is currently the only surgery center in the state of Massachusetts doing so. That exclusivity is likely to end in the near future with a surge in endoscopic spine cases expected and a growth rate of outpatient spine as high as 30% by 2026 according to some estimates.

Minimal incision, reduced tissue damage

ESS is an extra-minimally invasive approach to treating patients with chronic back and leg pain that uses a high-definition camera attached to an endoscope and inserted through a tiny incision — or dual incisions — in the patient. The key benefits of this approach are the minimal nature of the procedure and the return to full function due to a decrease in collateral tissue damage, according to Alex Vaccaro, MD, PhD, MBA, president of Rothman Orthopaedic Institute in Philadelphia. “The main difference between endoscopic spine surgery and other techniques is ESS significantly minimizes the tissue disruption necessary to make contact with the targeted tissues of interest like compressive soft tissue or bony lesions,” he says, adding that ESS also can eliminate the need to place implants in spinal structures.

John O’Toole, MD, MS, professor for the department of neurosurgery at RUSH University Medical Center in Chicago, says that limiting tissue disruption has a domino effect on the patient’s recovery process. “Minimal tissue disruption results in reduced postoperative pain, and therefore, a reduced need for postoperative pain medications — all of which produces earlier mobilization, a return to normal levels of activity and fewer opioid-related complications,” he says.

Evolving visualization

PURCHASING POWER From an equipment and instrumentation perspective, endoscopic spine surgery does require more investment in technology and tools, so vendor partnerships are especially crucial to ASCs’ success in this space.

Although ESS has been traditionally relegated to hospitals, many ASCs are all-in on the opportunity to bring this procedure to their centers — and technological advances are certainly expediting that migration. “A significant advancement in the field of endoscopic spine surgery is the evolution of the high-definition camera,” says Dr. Vaccaro. “This is extremely important to allow optimal visualization of all the neurovascular structures, surrounding soft tissues and bone.”

The incision size, says Dr. Vaccaro, is basically the size of the endoscopic camera, working portals or instruments being used. For comparison purposes, consider the following: “A traditional open procedure for single-level lumbar decompressive surgery may be two inches or 50mm — an MIS tubular portal may be as wide as 22mm,” says Dr. Vaccaro. “Endoscopic working portals may be on average between 10-13mm in size.”

From an equipment standpoint, Dr. Vaccaro says ESS does often require more technology and tools than other traditional approaches to spine surgery. “This includes different camera scope angles, monitors, a fluid bag irrigation system, different tools for burring, undercutting bone and angled curettes and pituitaries,” he says, adding that specialized instruments have been developed for suture placement and knot tying as well as incisional closing.

The equipment needed — particularly to start a practice — can be off-putting to facility leaders already wondering if they can succeed in this space. Mr. Bala urges patience and lots of research on the available vendor pool. For instance, when he first looked into ESS, he thought any surgeons he used would only do the procedure a certain way, which wasn’t an option. “When we got further and further into that conversation, the economics just weren’t going to work out to buy $450,000 worth of capital equipment,” he says. “The price at the pump was still too high — it would have eaten up all our reimbursement.”

Instead, Mr. Bala and his team kept doing their research and eventually landed on a vendor that fit, a company that is leading the market in dual-port ESS. “It’s still endoscopic spine, but two small incisions provide you the same level of visualization,” he says. The key was patience and finding a way to reconcile the surgeons’ needs with the right company for the facility. “It’s finding the right vendor partner that is willing to work with you on pricing, support and a technique that your surgeons are willing to use,” says Mr. Bala. “It’s also about finding the right surgeons who are willing to work with you to use the lowest-cost option but also provide the highest quality of service.”

The heart of ESS

FORMAL TRAINING To master the intricacies of the endoscopic spine technique, surgeons should undergo a focused apprenticeship that offers plenty of exposure to ESS.

First and foremost, your facility must have the right surgeons driving your endoscopic program. That often means extensive training on this technique. “If you want to succeed in ESS, you should preferentially perform a fellowship with surgeons familiar with the technique,” says Dr. Vaccaro. “Mastering this technique often a takes a focused apprenticeship.” And if the fellowship didn’t include endoscopic exposure? “Then I would attend as many courses as possible and then visit surgeons who are facile in this approach to really learn the technique,” he says.

This expertise plays a vital role in patient selection, another area of ESS in which all successful service lines excel. As Dr. Vaccaro points out, not all candidates are suitable for this approach.

“The best candidates are those who have symptomatic foraminal or exit nerve root stenosis,” he says. “It is also very useful for removal of free fragment disk herniations once clear visualization is obtained.” Dr. O’Toole agrees that careful selection is paramount and believes that young, healthy patients with “simple” spinal disorders — such as disc herniations at a single spinal level — are the ideal candidates, but points to the low-trauma approach of ESS as a reason for facilities to consider other patients, especially those who aren’t a good fit for traditional procedures. “The minimally invasive nature of ESS makes it an appealing option in patients whose age or comorbidities might preclude typical open spine surgery — as long as the pathology treated is appropriate,” he says.

You need to find the right surgeons who are willing to work with you to use the lowest-cost option with the highest quality of service.
Prashanth Bala, MS, MHA

The importance of finding the right surgeon is echoed emphatically by the non-surgeon Mr. Bala. “The first model we used was asking, do we have the surgeons that are capable?” he says. “We needed to ensure they were trained and fully capable of taking care of all the patient needs.” To make sure everyone was not only capable but also well-prepared for ESS cases at the surgery center, Mr. Bala brought his vendor in and had a handful of spine surgeons and other staff come to do a cadaver lab at the facility.

“They trained that evening, they did the cadaver lab at our facility, they tested it and then they did their first case not long after that and found that the technique was excellent,” he says.

Forging ahead

Mr. Bala knows his ESS program is filling a need — one that is rapidly growing — and he’s happy the surgery center is positioned accordingly. “This is our attempt at saying, patients that require spine surgery have benefitted from excellent quality of care in hospitals, but now we want to drive that same high quality of care in our outpatient setting,” he says. “We’re fortunate enough to be the ones who are leading that right now.”

Based on the excitement and demand for outpatient endoscopic spine surgery, it’s only a matter of time before he has plenty of company. OSM