Before Ziya Gokaslan, MD, enters the operating room, he increasingly wants the operation to have happened once already.
Not on the patient, but on a digital model of the patient’s spine. Using medical imaging, surgeons can create a “digital twin,” test different surgical strategies virtually and estimate how each could affect the patient’s alignment.
“We take the patient’s imaging information and create a digital twin,” said Dr. Gokaslan, chief of neurosurgery at Rhode Island and The Miriam hospitals and chair of neurosurgery at The Warren Alpert Medical School of Brown University in Providence, R.I. “Executing the procedure hypothetically in that twin allows us to see where the patient is going to land at the end of it.”
The technology represents a broader transition in spine surgery. The field is moving away from choosing an operation primarily by diagnosis and toward designing care around the individual carrying it.
Age, anatomy, bone quality, medical conditions, activity level and tolerance for risk can all change which procedure makes sense. Dr. Gokaslan believes AI could help spine programs process those variables and become one of their greatest competitive advantages over the next five years.
Its value will not come from replacing the surgeon. It will come from improving the decisions around surgery: who should undergo an operation, which intervention best fits that patient and how precisely the plan can be executed.
The hardest decision comes first
A successful operation begins with a deceptively difficult question: Should this patient have surgery at all?
Two patients may have similar nerve compression on an MRI but require entirely different treatment plans. A competitive athlete may prioritize returning to intense physical activity. An older adult with poor bone quality and several medical conditions may benefit from a smaller intervention, or from avoiding surgery altogether. The pathology matters. So does the patient’s life outside the imaging.
“Spine patients bring a very significant number of variables to the table,” Dr. Gokaslan said. “Really, every patient presents a new challenge.” Surgeons must consider the condition of the bone, the shape and alignment of the spine, the available implants and the invasiveness required to address the disease. The central challenge is matching the magnitude of the operation to both the pathology and the person.
That judgment has historically depended heavily on a surgeon’s training and experience. Those will remain indispensable, but the growing volume of clinical and outcomes data creates an opportunity to make the decision more systematic. Dr. Gokaslan envisions AI tools comparing an individual patient with data from similar cases and showing which procedures have produced the strongest results under comparable circumstances.
“Selecting the right patient for the right procedure, I think, is going to be significantly AI-assisted,” he said. The algorithm would not make the final decision. It would give surgeons another source of evidence as they weigh the risks, benefits and trade-offs of treatment.
A patient-specific plan needs the right surgeon
Better planning will matter little if a program cannot execute the recommended operation consistently. That is why Dr. Gokaslan believes precision spine care will accelerate another transformation: the rise of the super-specialist.
At Brown, the spine program includes surgeons whose practices are concentrated in areas such as deformity, endoscopic surgery and spinal tumors. The goal is to pair a patient-specific plan with a physician who performs that type of operation regularly.
Spine surgery has become too complex for every surgeon to offer every procedure with the same depth of experience, he said. Programs seeking more predictable outcomes will increasingly need teams with complementary areas of expertise. AI may help identify the appropriate operation. The organization must still have the right surgeon to perform it.
The operating room becomes a digital space
AI’s role will not end when the surgical plan is complete. The operating room is already becoming more digital through advanced imaging, navigation and robotics. Software can identify anatomy and generate proposed screw trajectories for the surgeon to review and adjust. Navigation systems can then help reproduce the plan during the procedure.
“Robots are typically for hardware placement at the moment, but that is changing very rapidly,” he said.
Eventually, he believes robotics could assist with additional parts of an operation and function more like another member of the surgical team. The emerging model is not an autonomous robot replacing the physician. It is a connected system in which patient data informs the plan, software models the likely result, navigation guides execution and robotics improves consistency.
Outcomes could then be fed back into the program’s data systems, strengthening future recommendations. Each operation would become both a treatment and another opportunity to learn.
Precision may mean doing less
More sophisticated planning will not necessarily produce larger operations. It may help surgeons identify the smallest intervention capable of achieving the patient’s goal.
Dr. Gokaslan sees particular value in patients with metastatic spine disease. These patients may already be receiving chemotherapy, radiation or other treatment for a primary cancer. A prolonged recovery after spine surgery can delay the therapy most important to their survival.
The goal therefore extends beyond relieving compression or stabilizing the spine. Surgeons must solve the immediate problem while minimizing disruption to the patient’s cancer care.
A patient with a metastatic tumor compressing a nerve root might once have undergone an open decompression and stabilization. In an appropriately selected case, a surgeon may now be able to perform a targeted endoscopic decompression, relieve the pain and help the patient return to cancer treatment sooner. The value of the operation is measured partly by what it allows the patient to resume.
Outpatient or inpatient may be the wrong question
The migration of spine surgery into ASCs is often discussed as a shift of entire procedures from hospitals to outpatient facilities. Dr. Gokaslan expects the boundary to become more fluid.
Some complex reconstructions are performed in stages, and not every stage may require the same setting. A less invasive anterior or lateral component could potentially be performed on an outpatient basis, while a portion involving extensive posterior reconstruction, osteotomies or long fixation may still require hospitalization.
“It will be a mix and match,” he said. “Wherever we can do parts of a complex surgical procedure in an outpatient setting, I think that will be done, whereas the rest will still be done in the inpatient setting.”
Over time, he expects the outpatient spine population to grow. The patients remaining in hospitals will increasingly be those with the greatest medical needs and most complex operations. That evolution will require organizations to define what kind of spine program they intend to build.
The investment leaders cannot avoid
For orthopedic and spine leaders, one of the most consequential decisions over the next five to 10 years may be where to place capital: outpatient growth or advanced inpatient care.
An outpatient strategy could include an ASC equipped for common decompressions, laminectomies, anterior cervical procedures and selected minimally invasive reconstructions. A program centered on complex inpatient care may require deeper alignment with a hospital, trauma center, cancer institute or academic medical center capable of supporting deformity, tumor and trauma cases.
Both models will require technology. Dr. Gokaslan believes image-guided navigation and sophisticated planning software will become increasingly important even in outpatient environments. Leaders must also invest in the clinical teams capable of using those systems reliably.
“The times really have changed,” he said.
Technology alone, however, does not create a precision spine program. Organizations will need specialized surgeons, trained operating room teams and data infrastructure that measures outcomes and costs throughout the episode of care. The strongest programs will know more than whether an operation was completed successfully. They will understand which patients benefited, how durable the outcome was and what the care ultimately cost.
The threat no algorithm can predict
For all the promise of AI, digital twins and robotics, the issue that worries Dr. Gokaslan most is far less futuristic. It is reimbursement.
A spine program may develop a clinically sound business plan around an ASC, navigation platform or minimally invasive service line. A federal or state policy change can quickly alter the economics supporting that investment.
“The rules of engagement can change overnight,” he said. Physicians are particularly exposed because hospital associations, pharmaceutical companies and device manufacturers often have more effective lobbying strategies protecting their interests.
Healthcare resources are finite. When one sector secures a larger share, less remains for the other participants. That uncertainty can make even a sensible investment risky. It can also slow the adoption of treatments that appear to benefit patients while reducing the broader burden on the healthcare system.
When efficiency is not rewarded
Endoscopic spine surgery illustrates the contradiction. For selected patients, endoscopy can reduce tissue disruption, shorten recovery and help avoid hospitalization. It may provide a more targeted way to treat disc pathology or foraminal narrowing. Coverage and reimbursement, however, remain inconsistent.
“You think it’s the right thing to do, and you think it’s financially beneficial for all the parties involved, and yet you don’t get rewarded for it,” Dr. Gokaslan said.
That tension could become more consequential as precision medicine produces increasingly targeted interventions. Technology may help surgeons identify a smaller operation for the right patient. A reimbursement system that continues to favor larger interventions may fail to recognize the value of that precision. The clinical model may be ready before the payment model is.
The operation begins before the incision
For much of spine surgery’s history, competitive advantage was closely associated with the surgeon’s technical skill. That will remain essential.
But Dr. Gokaslan believes the next era will be defined just as much by what happens before and after the procedure: collecting the right data, selecting the right patient, modeling the operation, assigning the appropriate specialist and measuring the result over time.
The most advanced spine program may not be the one performing the greatest number of surgeries. It may be the one best able to explain why a particular operation is right for a particular patient, and anticipate the result before the patient enters the operating room.
In that future, the first operation will take place in pixels. The second will take place in the patient.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
