Barriers, Costs, and Surgeons’ Perspectives on Endoscopic Spine Surgery: A Unilateral Biportal Endoscopy-Focused Survey Analysis

Objective: Unilateral biportal endoscopy (UBE) and endoscopic spine surgery (ESS) are minimally invasive techniques, but their integration into routine surgical practice remains variable. Factors influencing global adoption, particularly cost, training, reimbursement, and institutional support, remain incompletely characterized. This survey study evaluated ESS practice perspectives among members of 2 international UBE societies, focusing on surgeon expertise, reimbursement models, training exposure, and perceived barriers.Methods: An electronic survey was developed and distributed to spine surgeons affiliated with the European Society of Unilateral Biportal Endoscopy Association and World Unilateral Biportal Endoscopy-America. The questionnaire assessed surgeon demographics, ESS experience, reimbursement patterns, cost-related barriers, training exposure, and expectations for future ESS use. Descriptive statistics were used to summarize response patterns, and subgroup differences were assessed by region.Results: Seventy-eight surgeons responded, most of whom were orthopedic surgeons (60.3%) practicing primarily in private hospitals (57.7%). Half of respondents had 1–5 years of ESS experience, and 34.6% had less than 1 year of experience. Lumbar pathology was treated with ESS by all respondents (100%), whereas cervical (47.4%) and thoracic (38.5%) ESS were less common. Only 7.7% of respondents reported that insurance coverage for ESS was “very easy.” Key barriers included startup costs, limited hospital support, and reimbursement challenges. Nevertheless, 42.3% of respondents reported “very high” patient interest, 41.0% reported “very high” surgeon interest, and 55.1% were “very optimistic” about ESS growth in their country over the next 5 years.Conclusion: This survey identified substantial optimism regarding ESS among members of UBE-focused societies, despite persistent barriers related to training limitations, inadequate reimbursement, and high capital investment. These findings may not be generalizable because the survey was limited to selected UBE-focused societies and did not evenly represent all geographic regions. Expanding formal ESS training, reducing capital and disposable costs, and refining reimbursement models may support broader adoption.