Six days after undergoing another lumbar operation, Todd Lanman, MD, a spinal neurosurgeon at Beverly Hills, Calif.-based Lanman Spinal Neurosurgery, was already thinking beyond recovery. Not simply about when the soreness would subside, but about the question he increasingly asks when treating his own patients: What will this spine allow someone to do 10 years from now?
That was not always the central concern. When Dr. Lanman began practicing more than three decades ago, patients typically arrived at his office with one overriding objective. They wanted relief from severe pain. Fusion was often the principal surgical option, and preserving motion at the treated level was rarely the first question patients asked.
Today, the conversation starts somewhere else.
Patients want to know whether they will still be able to hike, travel, play pickleball and remain active into their 80s and 90s. They ask how surgery will affect their posture and range of motion. Some arrive having researched artificial discs by name. Others want to know whether nutrition, exercise, peptides or other emerging treatments can accelerate their recovery.
“Twenty-five or 30 years ago, they just wanted to get out of pain,” Dr. Lanman told Becker’s. Now, he said, they want pain relief, better head positioning and “functional and active motion to maintain the lifestyle they want to live.”
Those expectations are expanding the definition of a successful spine operation. It is no longer enough to ask whether the procedure relieved today’s pain. Surgeons are increasingly being asked what the operation will mean for the patient’s movement, alignment and health years later.
The patient has changed
The internet has given patients unprecedented access to information about spine surgery, and an equally unprecedented amount of marketing, anecdote and misinformation to sort through.
Dr. Lanman keeps a coffee mug in his office that reads, “Don’t confuse your Google search with my medical degree.”
The joke reflects a real change in clinical practice. Some patients arrive with printouts and strong opinions about which procedure or implant they want. They may know that one artificial disc produces less artifact on an MRI or that another uses a particular bearing material. They may have heard a friend describe a successful operation and assume the same treatment should work for them.
Dr. Lanman does not dismiss that research. He uses it to begin a more detailed discussion. He keeps models of several artificial discs in his office and explains how their materials and biomechanics differ. He then returns the conversation to the patient’s anatomy, using standing and flexion-extension radiographs to assess alignment and how the cervical spine behaves under normal load.
The same device can perform differently depending on the patient’s anatomy, degeneration and spinal geometry.
“It might have been good for your friend, but it’s not good for you,” Dr. Lanman said he sometimes tells patients.
The tension is becoming familiar across medicine: Patients are arriving better informed, but more information does not automatically produce the right clinical decision.
Artificial disc replacement is not a consumer choice between interchangeable products. Implant designs differ in their fixation, materials, centers of rotation and influence on alignment. The surgeon still has to determine whether motion should be preserved at all, and, if so, which design best fits the patient.
The patient’s preference belongs in that decision. It cannot replace it.
The fourth dimension is time
Dr. Lanman describes his broader approach as “4D Health.” The fourth dimension is time.
Traditional spine surgery is often organized around the pathology directly in front of the surgeon. A disc is compressing a nerve, so the surgeon removes it. A segment is unstable, so the surgeon fuses it.
Dr. Lanman argues that the immediate pathology is only part of the problem. He also considers the condition of neighboring levels, the patient’s age, alignment, activity goals and the biological environment in which recovery will occur.
He pointed to a recent case involving a 52-year-old patient who required an L5-S1 fusion but also had substantial damage at the disc immediately above it. Dr. Lanman said he combined the fusion with an artificial disc at L4-5 because he believed the already compromised segment would be unlikely to tolerate the additional mechanical demands over the next decade.
That kind of forward-looking intervention is not a universal standard. Surgeons can reasonably disagree about whether treating an adjacent level before it becomes clearly symptomatic prevents future surgery or exposes the patient to an additional procedure that may never have been necessary.
The example captures the tension inside the fourth dimension. Treat too narrowly, and a technically successful operation may contribute to the next spinal problem.
Look too far ahead, and the surgeon risks treating a future that might never arrive. Time does not provide an automatic answer. It changes the question the surgeon must answer.
Motion was only half the problem
The first major promise of artificial disc replacement was motion preservation. Rather than permanently immobilizing a diseased level through fusion, surgeons could remove the damaged disc while retaining movement.
Dr. Lanman believes the next stage of cervical arthroplasty will focus more heavily on what that movement looks like, and whether the operation leaves the patient in appropriate alignment.
The cervical spine normally has a backward curve known as lordosis. Degeneration, aging and prolonged time spent looking down can contribute to a forward head position and loss of that curvature. Patients may compensate by continuously engaging the muscles at the back of the neck to hold the head upright.
That is why Dr. Lanman no longer considers motion alone an adequate measure of success.
A disc can move and still leave the patient poorly aligned. Dr. Lanman participated in the U.S. investigational trial of the Synergy Disc and performed the first commercial procedure after its FDA approval. He views its lordotic design as one example of the industry’s broader effort to incorporate alignment into motion-preserving surgery.
Synergy Spine Solutions reported that surgeons chose the device’s 6-degree lordotic option in 98 of its first 100 commercial U.S. cases. That figure demonstrates early utilization, not independent evidence of long-term superiority. Whether the device’s design ultimately changes revision rates, adjacent-level surgery or function over decades will require longer follow-up.
The more important development is the question surgeons are beginning to ask. Not simply whether the implant moves, but where that movement leaves the patient.
Where disc replacement reaches its limits
Dr. Lanman expects surgeons to continue expanding the cohort of patients considered for artificial disc replacement. He has already become more willing to use arthroplasty in cases that earlier in his career might have been treated with fusion. He attributes some of that expansion to greater experience with decompression and the removal of bone spurs around the nerve roots.
But motion preservation has boundaries. Instability, poor bone quality, severe facet degeneration, deformity and extensive bony disease can make fusion the more appropriate operation. Preserving motion at a segment with painful facets or inadequate stability may preserve the source of the patient’s pain rather than solve it.
Large bone spurs around the uncinate joints can present another obstacle. If they are not adequately removed, continued movement after disc replacement can allow the remaining bone to keep irritating the nerve.
Dr. Lanman said he addresses this problem through complete uncinate resection, removing the obstructing bone to fully decompress the nerve root. He estimates he has used the technique in 150 to 200 cases.
He also said cadaver testing performed at a laboratory in Ohio found no meaningful loss of biomechanical stability after one-, two- and three-level uncinate resections. Those findings have not been published, and Dr. Lanman’s experience should not be read as settled evidence that the technique is appropriate or reproducible across practices.
Operating near the vertebral arteries carries significant technical risk, and many surgeons remain cautious about aggressive uncinate removal.
Still, the debate illustrates one way the boundary between fusion and motion preservation is moving. Procedures once considered incompatible with arthroplasty may become possible as decompression techniques, implant designs and surgeon experience evolve.
Whether those expanded indications produce durable results will need to be demonstrated, not assumed.
Half the correction happens after the operation
Dr. Lanman’s own history as a spine patient has influenced how he thinks about recovery. He has undergone multiple spine operations and said he has personally tried several therapies patients ask about, including peptides, growth hormone and other medications used in recovery or aging medicine.
Personal experience, however, is not clinical evidence. The regulatory status and quality of human data vary considerably among those therapies. Dr. Lanman said his role is to explain what is FDA approved, what is not and when a medication would be used outside its approved indication. Those discussions have become more common as patients seek ways to reduce inflammation, promote healing and return to activity faster.
But his larger recovery philosophy is less experimental. “Half of the correction for the patient is the surgery,” he said. “The second half of the correction is the patient rehab after.”
Dr. Lanman works with a small network of physical therapists, trainers and nutrition professionals and said he tailors rehabilitation to the patient’s procedure, age and anatomy. He encourages patients to maintain as much strength as their condition safely allows before surgery.
“The stronger you’re coming into surgery, the stronger you’re coming out,” he said.
That idea is increasingly relevant as spine care moves toward episode-based measures of value. A successful operation can still produce a disappointing functional outcome if the patient enters surgery severely deconditioned, lacks an appropriate rehabilitation plan or cannot rebuild strength afterward. Conversely, a carefully designed prehabilitation and recovery strategy may improve what the patient can ultimately do with the surgical correction.
The implant changes the anatomy. Recovery determines how the patient lives with it.
Fusion may eventually need the explanation
Dr. Lanman believes the balance between fusion and artificial disc replacement will continue to shift.
“In 10 years from now, insurance companies won’t ask, ‘Why do you want an authorization for a fusion?’” he said. “They’re going to say, ‘Why aren’t you doing an artificial disc?’”
That remains a prediction, not the current standard. Fusion is indispensable for many patients and will remain so. Artificial disc replacement is constrained by anatomy, regulatory indications, evidence, payer coverage and surgeon training. It is not appropriate simply because maintaining motion sounds preferable.
Dr. Lanman nevertheless expects the presumption surrounding fusion to weaken as motion-preserving technologies accumulate longer-term evidence.
Payers may eventually evaluate not only the cost of the initial procedure, but the possible downstream costs associated with nonunion, revision surgery, lost motion and treatment at neighboring levels. Surgeons could increasingly be expected to explain why a segment must be immobilized when a validated motion-preserving option exists.
Future technologies may broaden that conversation further. Dr. Lanman expects progress in facet replacement, although he said reliable fixation remains difficult. He also anticipates artificial discs that can provide more sophisticated correction across multiple planes rather than addressing sagittal alignment alone.
Each advance will bring the same challenge. A device can make a new operation technically possible before the field fully understands which patients should receive it or how it will perform over a lifetime.
An operation measured in decades
The modern spine patient is asking for more than relief. Patients want to stand upright, preserve movement, remain independent and continue the activities that give their lives meaning. They want to know not only whether an operation will work, but what it will permit them to do years later.
That has made spine surgery’s assignment more complicated. Relieve the compression. Restore stability where stability has been lost. Preserve motion where motion remains healthy. Correct alignment without overcorrecting. Choose an implant for the patient’s anatomy, not the patient’s internet search. Prepare the body for recovery.
Then consider what each decision may mean long after the postoperative visits end. Dr. Lanman’s fourth dimension is not a particular implant, medication or surgical technique. It is the recognition that an operation performed today will continue acting on the patient’s body for decades. Spine surgery still happens in three dimensions. Its success increasingly will be judged in the fourth.
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