Ask five spine surgeons how to treat the same patient, and Tan Chen, MD, said one may get six answers.
For Dr. Chen, an orthopedic spine surgeon at Falls Church, Va.-based Inova Health, that variability captures the strange moment spine surgery is in.
Surgeons can operate through smaller corridors, place implants that were impossible to deploy a decade ago, preserve motion instead of automatically fusing and send increasingly complex patients home sooner. AI may soon help predict which of those options will work best. But more options have not necessarily produced more consensus.
“Spine surgery is kind of in this renaissance right now,” Dr. Chen told Becker’s. “There are so many different technologies that everybody’s trying, and everybody’s innovating in their own ways.”
The field’s next challenge may therefore be less about inventing another way to operate than determining which innovations should endure.
The rise of the posterior approach
Lumbar fusion illustrates how quickly the technical landscape is changing. Anterior and lateral approaches gained popularity partly because they gave surgeons broad access to the disc space and room for larger implants. Traditional posterior approaches were more constrained by the need to protect nerve roots and the dura.
Newer technology is narrowing that gap, Dr. Chen said. Navigation can help surgeons work more precisely through limited corridors. Improved instruments allow more thorough disc preparation, and expandable cages can enlarge vertically and laterally after insertion.
For selected patients, Dr. Chen sees the possibility of achieving substantial correction through a minimally invasive posterior operation without an access surgeon, repositioning the patient or exposing them to some of the risks associated with anterior approaches.
The difference can be meaningful for the patient. Dr. Chen said a one-level minimally invasive posterior fusion may take roughly an hour to 90 minutes in experienced hands, with some patients going home the same day. A comparable anterior operation followed by posterior fixation can require substantially more operating room time and often an inpatient stay.
“If we can prove that this technology is as powerful as it is, I think it’s really going to take off,” he said.
Motion preservation exposes another barrier
Motion-preserving surgery raises a different question: What happens when an operation is technically appealing but the economics discourage surgeons from adopting it?
Dr. Chen is particularly interested in cervical and lumbar arthroplasty. Cervical disc replacement has become increasingly established, he said, while lumbar motion preservation remains much less straightforward. A lumbar disc does not function alone. Degeneration may also involve the facet joints and other structures that control motion.
He compares the problem to a tricycle.
“If you have a bad disc, you probably also have bad facets,” Dr. Chen said. “Do you need to fix the entire tricycle?”
New technologies are beginning to explore more comprehensive ways of preserving lumbar motion, but Dr. Chen said reimbursement remains a significant barrier even where arthroplasty is better established. He added that cervical disc replacement can demand more technical precision than an anterior cervical fusion. The surgeon has to carefully prepare the endplates, position the implant and preserve the mechanics of the motion segment.
Yet, he said, reimbursement can be lower.
“There’s a lot more finesse to doing an arthroplasty than there is to a fusion,” Dr. Chen said.
That mismatch matters. If one procedure requires more time and technical effort while paying less, surgeons have less incentive to learn and adopt it even when they believe patients could benefit.
Faster recovery is a system, not a technique
The same caution applies to minimally invasive surgery. A smaller incision alone does not create a rapid recovery, Dr. Chen said. “It’s never just one thing.”
His enhanced recovery approach starts before the operation. Patients may need optimization if they are already taking significant amounts of opioids. Anesthesia plans can emphasize multimodal, opioid-sparing pain control.
During surgery, the goal is to minimize unnecessary muscle dissection, blood loss and tissue disruption. After surgery, the questions become more practical: Does the patient actually need a drain? Can pain be controlled well enough for discharge? Can the patient get out of bed and walk the same day?
Dr. Chen said drains can sometimes become the only reason an otherwise ready patient remains hospitalized. Meanwhile, some patients still come to clinic expecting spine surgery to mean weeks or months in bed. He spends considerable time dismantling that assumption.
“You are walking out of the hospital,” he tells appropriate patients. The evolution of spine surgery, in his view, is therefore not simply toward smaller operations. It is toward designing the entire episode around doing no more disruption than necessary and returning patients to function sooner.
Where AI may help
AI may prove most useful in helping surgeons decide which operation to perform.
Dr. Chen sees particular promise in predictive models that can synthesize imaging, spinal alignment, disease severity, symptoms and outcomes data to better match patients with procedures.
Spine surgery still leaves substantial room for judgment, and different surgeons may reasonably choose different approaches for the same pathology. Dr. Chen said AI could eventually bring more evidence to those decisions, helping clarify when a smaller operation may be enough, when a larger reconstruction is warranted and which patients are most likely to benefit from each.
From invention to consensus
Dr. Chen compares spine surgery today with hip and knee replacement decades ago. Joint replacement once went through its own period of competing implant designs, materials and techniques. Over time, evidence accumulated and the field became more standardized.
Spine has not reached that point. Surgeons are still experimenting with approaches, implants, motion preservation, endoscopy, minimally invasive techniques and new combinations of them.
“Nobody truly knows what is best,” Dr. Chen said.
That uncertainty is part of what attracted him to spine surgery. It is also the field’s central challenge.
The next decade will almost certainly bring more ways to operate. Progress will depend on learning which ones patients actually need.
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.
