Spine surgery has no shortage of new tools.
Navigation can place screws with extraordinary precision. Robotics can automate parts of an operation. AI can process data that would take a surgeon hours to review. Patient-specific implants and planning platforms promise to tailor surgery more closely than ever before.
Dean Chou, MD, has watched enough generations of spine technology arrive to be skeptical of novelty for novelty’s sake.
“Is it just a new widget because it’s new, or is it actually efficacious?” Dr. Chou, chief of spine surgery and vice chair of neurosurgery at New York City-based Columbia University Vagelos College of Physicians and Surgeons, told Becker’s.
For Dr. Chou, who helped pioneer minimally invasive spine techniques and still performs open surgery when appropriate, the standard is straightforward: A technology has to make clinical sense, improve on the alternative and ultimately produce better outcomes.
That sounds obvious. In a field moving this quickly, it can be surprisingly difficult.
A technically elegant operation can still be the wrong operation. Greater precision does not automatically create greater value. And the more data surgeons gain about alignment, anatomy and risk, the easier it can become to lose sight of the question that came first:
What is actually bothering the patient?
A plausible idea is not evidence
Spine surgery is full of technologies that make intuitive sense.
For Dr. Chou, that is not enough. He pointed to innovations that appeared compelling conceptually but created problems once they were used clinically. The only reliable way to know whether an advance is safer or more effective, he said, is to study what happens to patients after surgeons begin using it.
“We really need the outcomes data,” he said. “If you use a new device or technology and don’t report the outcomes, you don’t know: Is it working, or is it just something we’re doing to our patients?”
That creates an unavoidable tension in surgical innovation. Someone has to be early enough to generate the evidence, but being first cannot justify continuing to use a technology if the results fail to support it.
For Dr. Chou, the first filter is whether an operation is clinically and biomechanically sound. The second is whether it meaningfully improves on the existing approach by reducing morbidity, improving effectiveness or both.
Less invasive is not automatically better. A minimally invasive approach that limits visualization or pushes a surgeon outside their expertise can leave the patient worse off than a well-executed open procedure.
“You don’t want to change an existing surgery just because something is new and then have the patient end up with a poorer outcome,” Dr. Chou said.
The technique should change because it improves the operation, not simply because it makes the operation newer.
Navigation passed the test for him
Dr. Chou’s own practice shows what happens when a technology clears that bar. He trained to place spinal screws freehand, without navigation or intraoperative imaging guidance.
Today, he has moved almost entirely in the opposite direction. “I’ve converted completely now to navigation because you see the value,” he said. The reason is not simply that navigation produces a more impressive image in the operating room. Dr. Chou believes its accuracy has meaningfully improved the safety and effectiveness of instrumentation, including helping surgeons select appropriate screw length and diameter.
He sees robotics differently. Although robotics may offer advantages over freehand or fluoroscopy-based techniques, he said the more relevant question is whether current systems meaningfully outperform modern navigation.
“I think at the early iterations of robotics, it’s probably not 100% clear, and they may be equivocal,” he said.
Future generations may change that equation. The distinction matters because “more precise” is not necessarily the same as “better.” Once one technology is already producing highly accurate results, the next innovation has to demonstrate more than incremental technical sophistication. It has to create a difference that matters to the patient.
AI is here. Trust is not.
Dr. Chou has little doubt AI will change medicine. He has considerably less certainty about exactly how. For complex spine planning and risk prediction, he still sees the technology as early.
“I would say that it’s in its infancy right now,” he said. “It is still a tool, and it is one tool in the armamentarium of everything.”
He has already seen the limitations firsthand. When he experimented with an AI system to generate an image of an interbody cage positioned in a disc space, he said the system repeatedly placed the implant in anatomically inappropriate locations, including the spinal canal, neural foramen and aorta.
AI systems can produce confident outputs that are simply wrong. That makes understanding the technology’s limitations as important as understanding its capabilities.
Dr. Chou expects those limitations to narrow as models improve and gain access to richer clinical information. For now, however, AI remains something a surgeon should interrogate rather than obey.
The question is not whether AI can produce a recommendation. It is whether the surgeon knows enough to recognize when that recommendation makes no sense.
The next breakthrough may be the target, not the tool
Asked which emerging technology could most meaningfully change spine surgery over the next decade, Dr. Chou did not choose a robot.
He chose the target. More specifically, he pointed to determining what alignment and surgical correction an individual patient actually needs.
“I think one big area of growth and refinement is going to be target planning,” he said.
Spine deformity surgery has become increasingly sophisticated in measuring alignment and defining corrective goals. The next step is making those targets more individual. How much correction does this patient need? What alignment gives them the best chance of restoring function without overcorrecting? How should age, anatomy, symptoms and quality-of-life goals change what “normal” should look like?
Better target planning could affect far more than an X-ray. Dr. Chou believes more individualized goals could reduce complications and improve outcomes by helping surgeons design an operation around what the patient actually needs rather than applying the same target broadly.
And he does not expect one technology to accomplish that alone. AI, custom implants, imaging, navigation and planning systems may become most valuable when they stop functioning as separate innovations and begin working together.
That may be the more consequential version of precision surgery. Not simply a more customized implant, but a more customized decision.
Precision can become a distraction
There is also a danger in increasingly sophisticated planning. The more surgeons can measure, the more tempting it becomes to treat the measurement.
Dr. Chou worries spine surgery can become consumed by alignment parameters, numbers and technical possibilities while drifting away from the symptom that brought the patient into the office.
He offered a simple example. A patient can have abnormalities across five spinal levels but only one symptomatic nerve root. Technology may give the surgeon the ability to reconstruct everything.
That does not mean the surgeon should.
“If the patient only has an L5 radiculopathy, do we really need to treat five levels of their spine?” he said.
Sometimes the more personalized operation is the smaller one. That is where Dr. Chou believes spine’s technology conversation needs to broaden. Patient-specific care cannot merely mean patient-specific rods, implants or alignment calculations. It has to begin with a patient-specific goal.
“We’ve gotten a little lost, or the water has gotten a little muddled, by all these numbers and parameters being published,” he said. “But in reality, it’s the patient.”
That is the tension running through modern spine surgery. The field can see more, measure more and plan with a degree of precision surgeons a generation ago did not have.
The risk is mistaking the ability to do more for a reason to do it. Dr. Chou’s standard for the next decade is therefore less futuristic than it sounds: Keep the technology. Keep improving it. But keep the patient’s actual problem as the North Star.
Because the most advanced spine operation is not the one with the most technology. It is the one that solves the problem the patient came in to fix.
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.
