For years, some of the biggest advances in spine surgery have happened inside the operating room: better implants, navigation, robotics, minimally invasive techniques.
Rachel Bratescu, MD, an orthopedic spine surgeon at Washington, D.C.-based George Washington University Hospital’s Spine and Pain Center, believes the next major gains may come earlier.
Dr. Bratescul increasingly thinks about surgery as a process that begins well before the first incision, with a patient’s bone health, nutrition, muscle mass, diabetes control, smoking status and overall physiologic reserve. The reason is simple: A technically perfect operation can still produce a poor result in a patient who is not prepared to heal.
“A technically flawless fusion performed in someone who is malnourished or an active smoker, vitamin D deficient, has a history of osteoporosis, is frail or has poorly controlled diabetes may still produce a suboptimal outcome,” Dr. Bratescu told Becker’s.
That idea represents what she sees as one of the most important shifts in spine surgery over the past decade. The field has spent years refining how surgeons operate. Now, more attention is turning toward who is being operated on, and whether something can be changed before surgery to improve the odds of a durable result.
“The surgery process really begins before the actual incision itself,” she said.
Spine surgery cannot always take patients as they are
Some spine operations are urgent. At a level 1 trauma center, Dr. Bratescu sees cases where there is little time to optimize anything before surgery. But much of spine care is different.
Many procedures are elective, and some are performed largely to restore function and quality of life. In those cases, she believes spine surgeons should increasingly borrow a lesson already familiar in other areas of orthopedics: Surgery does not always have to begin the moment an indication exists.
Historically, she said, spine surgery was often approached as something that needed to be done, with surgeons largely accepting patients in their current condition.
That mindset is changing. A patient with uncontrolled diabetes may benefit from better glycemic control first. Someone with osteoporosis may need treatment to improve bone quality. A smoker may have an opportunity to quit. A malnourished patient may need nutritional support before undergoing a major reconstruction.
The delay can be frustrating for patients eager to feel better, but Dr. Bratescu argues that the timeline should be judged against the outcome the patient will live with for years.
“Optimization isn’t about creating barriers to surgery,” she said. “It’s about creating better outcomes.”
That distinction matters as health systems look for ways to reduce complications, revisions and avoidable readmissions. The fastest route to the operating room is not always the fastest route to recovery.
Age is a poor substitute for frailty
The growing emphasis on optimization is also changing how surgeons think about age. Dr. Bratescu has operated on patients in their 80s who recovered well. She has also seen significantly younger patients struggle because they had far less physiologic reserve.
The difference, she said, is often frailty. Frailty captures more than chronological age. It can incorporate muscle loss, bone density, obesity, diabetes and other medical or physiologic factors that influence how much stress a patient can tolerate and how effectively the body can recover.
Dr. Bratescu has studied sarcopenia, or loss of muscle mass, but she sees it as one piece of that larger picture.
“Frailty is really about how much reserve a patient’s body has to handle the stress of surgery and recover,” she said. “I’ve operated on healthy patients in their 80s who recovered beautifully, while much younger patients with severe frailty have struggled.”
That is an increasingly important distinction as the population ages. A birth date alone tells a surgeon relatively little about whether a patient can withstand a major spine operation. Two patients of the same age may have radically different nutritional status, muscle strength, bone quality and medical risk. Optimization therefore becomes less about applying universal cutoffs and more about understanding the individual patient’s reserve.
The question shifts from, “Is this patient too old for surgery?” to, “Is this patient prepared for this operation?”
The spine does not belong to one specialty
Dr. Bratescu’s own training has reinforced that broader view. She is among a relatively small group of spine surgeons with formal training spanning both orthopedic and neurosurgical spine surgery. She completed orthopedic residency training before fellowships that included both orthopedic and neurosurgical spine care.
The two disciplines historically developed different strengths, she said. Orthopedic spine surgeons have often had greater exposure to deformity correction, osteotomies and complex bony reconstruction. Neurosurgeons traditionally receive more training involving the spinal cord, intradural pathology and other neural structures. But the patient does not arrive divided into orthopedic and neurosurgical anatomy.
“Everything is connected,” Dr. Bratescu said. “Spine surgery is not just about the bony anatomy, and it’s not about the neural anatomy and the spinal cord. It’s about everything as a unit.”
That is why she sees collaboration as more important than the label on an individual surgeon. For a complex patient, the most effective team may include orthopedic spine surgeons, neurosurgeons, physical medicine and rehabilitation physicians, primary care physicians and physical therapists before and after surgery.
The same principle applies to optimization. Bone health may require one specialist. Nutrition may require another. Physical conditioning or rehabilitation may begin before surgery rather than after it. The surgeon may perform the operation, but the outcome is shaped by a much larger system of care.
AI could turn optimization into something more personal
The next evolution may be making that preparation far more individualized. Today, surgeons can identify risk factors such as osteoporosis, diabetes, malnutrition and frailty. But those factors rarely exist in isolation.
Dr. Bratescu expects AI-based predictive models to increasingly combine imaging, laboratory values, bone density, nutritional status, frailty and other comorbidities to produce a more detailed picture of surgical risk.
The value, she said, should not be simply generating a score. It should be making the result actionable.
A surgeon could eventually tell a patient that based on their current health profile, six weeks or several months of targeted preparation could meaningfully reduce a specific risk before surgery. That could make optimization less generic.
Not every patient needs the same tests, the same delay or the same intervention. One may need stronger bone. Another may need better nutrition. Another may need conditioning or tighter diabetes control. The technology could help identify which changes matter most for each person.
That is also where Dr. Bratescu believes the future of spine surgery is headed more broadly: toward more personalized care rather than simply more sophisticated operations.
The field will continue to develop better implants, navigation systems and minimally invasive techniques. But those advances cannot compensate for a patient who is not prepared to heal.
“We need to focus not just on operating well, but on preparing patients to heal well,” Dr. Bratescu said. “The future of spine surgery isn’t just about better technology. It’s about better biology, better preparation and more personalized care.”
Patients may remember that their operation was postponed. What matters more is whether it worked.
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.
