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Q: Where is the trend of spinal fusions headed in the future?
Hyun Bae, MD, Director of Education at Cedars Sinai Spine Center, Los Angeles: I think we're going to see a decrease in spinal fusions. Payors have really clamped down on fusion. I think that on the reimbursement side, we are definitely going to see a trend toward reimbursement for fusions decreasing with the government payors as well as private payors.
Robert J. Banco, MD, Associate Clinical Professor in Orthopedic Surgery Department of Tufts University School of Medicine, Founder of Boston Spine Group: What we are seeing now is a confluence of two major issues in spine; one is the aging population — baby boomers are still demanding healthcare because they don't want to slow down, and the second is the explosion of spinal technology development that is a perfect storm for the increase in the number of spinal fusions delivered annually. I think that will probably slow down at some point and peak again at another date when we have another surge in new development.
Jeffrey Cantor, Spine Surgeon, South Florida Spine Clinic, Fort Lauderdale: The utility of using spine fusion techniques has increased because the procedure has become less invasive. We have developed techniques where we can use spinal fusions that have less interference with the adjacent levels. In the past, the types of spine fusions that we did dramatically changed the structure, anatomy, and the physics of the spine. The newer techniques allow us to do much stealthier operations that permit us to fix an unstable structural problem without dramatically altering the structure of the non-affected areas.
For example, in the past we would perform a laminectomy and posterior lateral fusion, which substantially alter the engineering of the spine. Newer techniques such as interbody fusions allow us to fix a broken segment and maintain the tension bands and the structure responsible for holding the spine together. These newer techniques not only lead to less adjacent-level failure, but have other substantial patient benefits like less dissection, less tissue trauma, less post-op pain and shorter hospital stays.
With the above said, in certain situations there are good and compelling reasons to avoid spinal fusions with advanced and less invasive techniques. Spinal fusions are an excellent solution for structural instability cases, but should always be our last option and not something, as surgeons, we should take lightly.
Jaideep Chunduri, MD, Spine Surgeon, Beacon Orthopaedics & Sports Medicine, Cincinnati: If you follow strict outlines on stability, the data we have proves fusion is a good procedure. In the 1990s, everyone had cage rage; now we are in an era of fusion rage, but if patients have the indications to perform the procedure it can be very helpful. I think the current rates of spinal fusion will remain the same for a while.
Dennis Crandall, MD, Founder and Medical Director of Sonoran Spine Center, Phoenix: Looking forward, as we research the effects of spinal fusion and begin to investigate other motion preserving technology and less invasive technology, we are understanding better that there are certain disease processes and techniques that can be used for patients whereas in the past the only option was spinal fusion.
Going forward, we will see a trend of somewhat of a decrease in the total number of spinal fusions done, in a real sense, as surgeons shift to more motion-preserving techniques and technology.
Stephen T. Onesti, MD, Director of Neurosurgery at South Nassau Communities Hospital, Oceanside, N.Y.: In the future, we may have government and insurance reviews to determine whether insurance company and government payors will continue to reimburse for [spinal fusions] if there is a perception that surgeons are doing too many. They would be looking for outliers who are performing a high volume based on their population they serve. I haven't experienced this in the New York area, and for some of the patients I see I think it is very appropriate.
Sheeraz Qureshi, MD, MBA, Spine Surgeon at Mount Sinai Medical Center, New York City: I think it will depend on a couple of things: certainly, what the insurance companies dictate will have an effect because if insurance companies refuse to pay for a patient to undergo a particular procedure, we aren't going to be able to do the procedure. I think that's a dangerous situation because we don't want insurance companies dictating the care we deliver to patients.
On the other hand, we want to make sure we are doing it for the appropriate indications. Additionally, in all areas of the spine, we are trying to figure out motion preserving procedures.
Robert Watkins, Jr., MD, Co-Director of Marina Spine Center at Marina Del Rey Hospital, Calif.: The improvements in the surgical technology have made performing spinal fusions more effective, therefore they are done more often. Computer navigation allows us to put instrumentation such as pedicle screws into the spine minimally invasively with three-dimensional visualization, which makes the procedure safer and faster. In some difficult cases 20 years ago surgeons wouldn't recommend surgery for patients because it was too dangerous, but now it can be done more safely because of computer navigation.
When someone develops mechanical instability, and instability is a natural part of the aging process, fusion is effective most of the time. Fusions are here to stay; as technology advances, surgeries will be done less invasively and more safely.
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