As innovation accelerates in spine surgery, many surgeons say the most disruptive changes are unfolding in payer policies, outcomes tracking and practice economics that increasingly dictate how, when and where surgeons can operate.
Six spine surgeons discuss the under-the-radar spine trends.
Note: Responses were edited for clarity.
Question: What under-the-radar trend in spine surgery could significantly affect how physicians practice over the next few years?
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: One of the most important trends is the evolution of the payer landscape. There are a couple things going on. One is the No Surprises Act. Although it is the law there are places where it is trying to be eroded by insurance companies. Insurance companies are going to try to change who the arbitrators are of the No Surprises Act, which would affect the qualified payment amount. Keep in mind the insurance companies who are losing over 80% of those arbitrations are not going to take it lying down. You have to keep in mind that all it takes for the insurance company to start winning those things again is to change who the arbitrators are in those cases. So we have to be careful about getting too excited about the No Surprises Act.
The other thing is insurers are still doing some crazy things. For instance, I had a case where a patient had an interior lumbar surgery, and in order to get there you have to have a vascular surgeon access the abdomen in order to get you through and pass the blood vessel safely. The insurance company decided to try to claw back the entire amount of the surgery, saying that wasn’t necessary. They’re sending these letters saying that you didn’t need an assistant to get into the abdomen, which is patently false. Now you have to go back and fight and document and submit the reasons why. It’s pretty much like you’re trying to justify your reason for living, which I never understood.
A positive trend is there are more non-physicians in the public space understanding what is going on in healthcare. I would highlight someone like Mark Cuban, and it’s very clear he understands what is ailing healthcare — consolidation of hospitals and the bad behavior by insurance companies. He knows this because he kept asking questions, and I told him that you have to break up the big hospital monopolies. You have to break up the big insurance companies. Hospitals should not be in the business of real estate. Quite frankly, insurance companies should not own physicians or banks … More people like him are looking at why healthcare is so broken, and they’re also going to have their different takes on things. The good thing is there seems to be more attention happening on this.
Philip Louie, MD. Virginia Mason Franciscan Health (Seattle): A move toward a “scorecard”-driven spine care; particularly with the integration of outcomes, workflow, and cost data at the surgeon and episode-of-care level.
Historically, spine surgeons have practiced with limited feedback beyond complications and volume. That’s changing as registries, payers, health systems, and enabling technologies begin to link clinical outcomes, resource utilization, and true episode-based costs. This shift will increasingly influence indications, implant choices, operative efficiency, and perioperative pathways (often before surgeons realize it’s happening).
Gbolahan Okubadejo, MD. The Institute for Comprehensive Spine Care (New York City): The impact of minimally invasive techniques. There’s a variety of companies marketing these techniques with variability in extensiveness of pathology being addressed. Ultimately, surgeons have to decipher what techniques will be most appropriate to adequately address the pathology accounting for our patients’ symptoms. Surgeons who are adept at using both traditional and newer technology-focused techniques will be able to more consistently get the best outcomes with their surgical procedures. Surgeons should be on the look out for patients who may have had spine procedures performed in some cases, but still require further attention to gain full symptom resolution.
Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): The positive trend is further promotion and dissemination of minimally invasive spine surgery techniques. This leads to lower rates of surgical complications, less pain, and quicker recovery.
The negative trend is the persistent financial and bureaucratic burdens that are driving surgeons away from private practice and into large, consolidated institutions with employment models. This trend already does and will further lead to higher costs of care, lower access to care, and sometimes to worse quality of care as the physicians lose their autonomy and the ability to provide best care for their patients.
Vijay Yanamadala, MD. Hartford (Conn.) Healthcare: While robotics and AI surgical planning dominate headlines, several quieter trends may prove more transformative:
AI-powered clinical documentation – Platforms like Abridge, Nuance DAX, and similar tools are restoring one to two hours daily to surgeons’ lives by eliminating after-hours charting. This matters because it’s fundamentally changing patient encounters. Physicians can maintain eye contact and engagement rather than typing. Unlike surgical AI, it’s available now, scaling rapidly, and directly addressing burnout. The downstream effects could be profound: better patient relationships, more time for conservative management discussions, and improved surgical decision-making when physicians aren’t exhausted from documentation burden.
Systematization of conservative care pathways – Insurance companies and health systems are implementing structured, evidence-based protocols requiring documented conservative management before surgical authorization. While this creates administrative burden, it’s forcing practices to develop robust non-operative programs or partner with digital MSK platforms. Practices that embrace this proactively, rather than viewing it as obstruction, will be better positioned as value-based care models expand.
The outpatient/ASC migration for complex procedures – What was once considered hospital-only (multilevel decompressions, fusions, even some deformity corrections) is rapidly moving outpatient. It’s changing patient expectations, reimbursement models, and which surgeons can compete. Practices without ASC relationships or outpatient capabilities may find themselves limited to only the most complex cases.
Transparency in outcomes and costs – Public reporting of surgeon-specific complication rates, revision rates, and episode-of-care costs is expanding beyond registries into consumer-facing platforms. Patients increasingly have access to data that was previously internal. Surgeons who’ve already embraced transparent outcome tracking and conservative surgical indications will thrive; those who haven’t may face uncomfortable scrutiny.
The biologics reckoning – After years of expensive biologics and growth factors with limited evidence, payers are increasingly restricting coverage. The next few years may see significant rollback in reimbursement for products that haven’t demonstrated clear superiority over standard techniques. This could fundamentally change how surgeons approach fusion surgery and which companies dominate the market.
Decline in fellowship-trained spine surgeons – Applications to spine fellowships have decreased while demand continues growing, partly due to lifestyle concerns and medical-legal risk. This workforce shortage could shift practice patterns — more general orthopedic and neurosurgeons performing bread-and-butter cases, increased reliance on APPs, and potentially higher compensation for fellowship-trained surgeons willing to handle complex cases.
Digital physical therapy platforms – Apps and virtual PT programs with AI coaching are becoming legitimate alternatives to traditional physical therapy, especially for motivated patients in underserved areas. While quality varies, the best platforms generate outcomes data that may satisfy conservative care requirements before surgery, fundamentally changing the pre-operative pathway.
The common thread: these trends reward practices built on evidence-based decision-making, operational efficiency, and genuine patient-centered care rather than procedural volume.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Once again, without underscoring the undeniable, the declining issues of recurring and immedicable reimbursements for healthcare will continue to plague both practitioner and health system as continued paring of remuneration persists. The stratified, historical, and prevailing realities have affected many to obviate and shift care to better-equipped facilities where acuity is more suitably and appropriately managed. Other trends following the refined scrutiny surveillance of all complex interventions have the overuse of multilevel fusion extensions in the thoracolumbar spine delayed and further assessed. Basing treatment decisions on prospectives and potentials is under duress, no longer viable and approved under the most explicit reasons.
