Put 10 spine surgeons in a room with the same patient, Stephen Lockey, MD, said, and you may get 11 or 12 different answers.
That variability has long been part of spine surgery. Imaging can show several abnormalities. Multiple operations may be technically possible. Different surgeons may reasonably favor different approaches.
Dr. Lockey believes the field is getting better at narrowing those choices. But personalized spine care, in his view, does not begin with a robot, an algorithm or a surgical plan.
It begins with a more basic question: Should this patient be operated on at all?
“At some point, you have to ask whether their alignment, bone quality, and overall physiologic health and age are compatible with the operation they need,” Dr. Lockey, assistant professor of orthopedic surgery and spine fellowship director at the Charlottesville-based University of Virginia, told Becker’s.
That distinction is becoming more consequential as spine surgery gains increasingly sophisticated tools for measuring bone quality, muscle health, alignment and operative risk.
Technology can tell surgeons more about what is possible. Dr. Lockey believes the next phase of personalized care will be defined by how well they decide what is appropriate.
Surgery starts with how small a patient’s world has become
Dr. Lockey treats many patients at UVA who arrive after previous spine operations or with complex pathology. He is cautious about adding another procedure simply because imaging shows something that can be corrected. Instead, he talks with patients about what pain or dysfunction has taken away from them.
“I tell patients you really shouldn’t consider an operation until you feel like your world shrinks to the point it’s no longer compatible with quality of life,” he said.
That threshold is different for everyone. One patient wants to hike five miles with a spouse. Another wants to walk to the mailbox. The MRI may look similar. The operation that makes sense may not be.
That is where Dr. Lockey believes personalization begins: not with anatomy alone, but with anatomy placed alongside the patient’s health, expectations and definition of a meaningful recovery.
Bone quality is moving into the first visit
Some of those decisions can now begin before Dr. Lockey has even met the patient. At UVA, full-length imaging can provide a surrogate assessment of lumbar bone density. If the scan suggests poor bone quality, that can immediately change the treatment pathway.
Instead of proceeding toward surgery and discovering osteoporosis through hardware failure or another postoperative complication, Dr. Lockey can direct the patient toward UVA’s bone health clinic first.
That shift has changed how he thinks about the role of a spine surgeon.
“I never thought going into a surgical subspecialty that I could fill a little bit of what seems like a primary health gap,” he said.
Five years ago, he said, screening was far less routine. Now a patient with poor bone quality can be identified earlier, connected directly with a bone health provider and treated before returning for surgical consideration.
For Dr. Lockey, that is what individualized care looks like in practice. The personalization is not always a different implant or a more complex operation. Sometimes it is delaying surgery until the patient is more likely to withstand it.
Risk data is changing what happens before the operating room
Bone density is only one part of that equation. Dr. Lockey also considers frailty, nutritional status, sarcopenia, dialysis dependence and other comorbidities that can change the risk of a major spine operation.
In trauma, surgeons do not always have the luxury of waiting. A patient with mechanical instability or neurologic compromise may need surgery despite significant physiologic risk.
In those cases, the data changes preparation rather than indication. A patient with poor nutritional status may need nutrition services engaged immediately. A frail or sarcopenic patient may need more deliberate rehabilitation and medical co-management.
“We have to work with the cards we’re dealt,” Dr. Lockey said.
Elective surgery creates more room to intervene. The earlier surgeons identify poor bone or muscle quality and medical risk, the more opportunity they have to optimize the patient before the operation rather than manage the consequences afterward.
That represents an important shift in spine. Risk is becoming something to act on upstream, not simply document before surgery.
Spine’s fragmentation can undermine personalization
The challenge is that patients do not always arrive through a coordinated pathway. A patient with buttock pain may begin with primary care, move to physical therapy, then see a joint replacement specialist because the symptoms appear to come from the hip. Hip imaging may be normal. An injection may fail.
Only later does someone identify the lumbar spine as the source. Dr. Lockey has watched similar journeys play out across healthcare.
As medicine becomes increasingly subspecialized, he said patients can develop what he jokingly calls “doctoritis,” moving from one specialist to another while accumulating more information but not necessarily getting closer to an answer. That fragmentation becomes more problematic as the population ages and patients carry more complex conditions.
“The integrated medicine piece is going to become more and more important,” Dr. Lockey said.
For spine, that means stronger connections among primary care, pain management, joint replacement, bone health and other specialties that frequently encounter the same patients. Personalized surgery cannot work particularly well if the system struggles to identify which patients belong in the spine clinic in the first place.
The plan should become more personalized than the technology
Once surgery is appropriate, Dr. Lockey sees enormous potential in patient-specific planning. A surgeon can increasingly combine age, sex, bone quality, muscle quality, prior operations, alignment and the location of the disease to determine what an individual operation should accomplish.
That is where he welcomes the growing investment in planning technology. But he draws a line between using technology to inform a plan and becoming dependent on it to execute one.
“We have to be careful as we move into this space because we don’t want to be too dependent on enabling technology for the execution,” he said.
As a fellowship director, Dr. Lockey wants trainees to leave UVA capable of performing spine surgery even when a particular navigation or planning platform is unavailable.
They still need to understand anatomy. They still need to interpret an X-ray. They still need to recognize the feel of a pedicle and know when something is wrong. Technology should extend that skill set, not become a substitute for it.
His ideal future is one in which patient data helps determine the operation most likely to relieve pain and disability while minimizing complications, readmissions and the need for revision.
The algorithm may help define the target. The surgeon still has to know what the target means.
The hardest decision remains difficult to teach
That becomes especially apparent when Dr. Lockey trains fellows. The most difficult question is not how to perform an operation. It is whether a technically possible operation is actually the right one for the person sitting in front of them.
“That is the ultimate question,” he said. There is no formula that answers it perfectly.
Dr. Lockey said surgeons 15 or 20 years into practice would be unlikely to claim certainty every time. For now, that judgment is learned by watching mentors speak with patients and families, interpret imaging and weigh quality of life against medical risk and the magnitude of the operation required.
“It really gets down to the reason we all became doctors in the first place, which is to get to know patients,” he said.
His philosophy is to perform the smallest effective operation that addresses the actual source of the patient’s pain or neurologic dysfunction. That sounds simple. It becomes harder when imaging offers several abnormalities to choose from.
AI is making the MRI conversation harder, and better
Dr. Lockey increasingly sees another wrinkle in those discussions: Patients arrive knowing far more about their scans. Many have entered their radiology report into an AI tool before the appointment.
They ask about individual levels of stenosis, foraminal narrowing and other findings. Some record their visits, generate transcripts and return after researching the conversation further.
Dr. Lockey welcomes the higher-level questions. But more information does not necessarily make the surgical decision easier.
“If you’re over the age of 50 or 60, I’m going to find all kinds of things on the MRI,” he said. “If we were operating on imaging, I’d operate all day, every day.”
The surgeon’s job is to determine whether what appears on the scan actually explains the patient’s symptoms. Sometimes it does not.
Pain attributed to the lumbar spine may come from the hip or sacroiliac joint. A dramatic MRI finding may have little to do with the complaint that brought the patient into clinic.
In that sense, AI is making one of spine surgery’s oldest lessons more important. Seeing an abnormality is not the same as finding the problem.
The next leap happens before the patient leaves the OR
Ten years from now, Dr. Lockey expects personalization to extend further into the operation itself.
Today, surgeons can enter the OR with increasingly sophisticated plans for alignment and correction. What remains less precise is determining, in real time, whether the operation actually achieved those targets.
Surgeons assess imaging, examine the correction and make a judgment. Often, the definitive standing radiograph does not come until after surgery.
By then, the opportunity to make another adjustment in the operating room has passed. Dr. Lockey expects that to change.
He envisions software that can evaluate the correction intraoperatively and tell the surgeon whether specific alignment targets have been met, or whether another release, a larger interbody implant or additional correction is needed before closing.
“I think in the next 10 years we’ll know before we leave the operating room if we got the surgery we wanted,” he said.
That would represent another major step toward truly individualized spine surgery. Not simply choosing an operation for a diagnosis. Choosing it for a particular patient, planning the exact result that patient needs and knowing before the operation ends whether the surgeon achieved it.
The algorithms will get better. The imaging will get better. The feedback will become more precise.
But Dr. Lockey’s argument is that the most important part of personalized spine care still happens before any of that technology is useful. The surgeon has to know which problem is worth solving, and which operation is worth doing.
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