Spine surgeons spend years learning when and how to operate. Recent Becker’s conversations suggest another skill becomes increasingly important with experience: knowing when not to.
For some patients, that means surgery is unlikely to improve the symptoms driving the visit. For others, poor bone quality, frailty or other medical risks can delay an operation. And as more complex procedures move outpatient, surgeons are also drawing lines around which patients should not be treated in an ASC.
The “no,” in other words, can mean no surgery, not yet or not in this setting.
When the MRI does not match the patient
One of the clearest reasons to step away from surgery is a mismatch between what appears on imaging and what the patient is actually experiencing.
Brandon Ortega, MD, an orthopedic spine surgeon at Long Beach, Calif.-based Lakewood Orthopaedic Institute, told Becker’s in June that his decision begins with a basic question: “Do the patient’s symptoms actually correlate with the imaging findings?”
Degenerative findings can be incidental, he said. When pain does not follow the level of compression, psychosocial factors are significant, conservative treatment has not been meaningfully attempted or the likely functional improvement does not justify the risk, he does not view surgery as the right answer.
Noam Stadlan, MD, a neurosurgeon at Arlington Heights, Ill.-based Endeavor Health Neurosciences Institute, told Becker’s that for most spine procedures performed for pain or limited neurological deficit, surgeons must weigh the likelihood of success against the risks. He said that likelihood depends in part on how well the patient’s symptoms match the pathology seen on imaging.
When conservative care has not really failed
Experience has also made some surgeons more cautious about interpreting “failed conservative care” as an automatic pathway to the operating room.
Vijay Yanamadala, MD, of Hartford (Conn.) HealthCare, told Becker’s that his threshold for recommending surgery has become more conservative, particularly for patients with chronic axial back pain. Five years earlier, he said, he might have offered surgery after a patient had “failed conservative care.” He now believes three months of basic physical therapy does not necessarily constitute failure and that surgery may not address the underlying factors contributing to a patient’s pain.
“Being a good surgeon sometimes means saying no,” Dr. Yanamadala said.
Christopher Shaffrey, MD, chief of the spine division at Duke University in Durham, N.C., has similarly emphasized restraint. “I’m a believer that you should do the least invasive or the least involved treatment that gives people the quality of life that they desire,” he told Becker’s. At Duke, he said, patients often begin in the health system’s nonoperative Spine Health program before being considered for more complex surgery.
When the patient is not ready to heal
Sometimes the answer is not “no.” It is “not yet.”
Rachel Bratescu, MD, an orthopedic spine surgeon at George Washington University Hospital’s Spine and Pain Center in Washington, D.C., told Becker’s that bone health, nutrition, muscle mass, smoking, diabetes control and overall physiologic reserve can affect how well a patient tolerates and recovers from surgery.
She said an otherwise technically successful fusion can still produce a suboptimal result when the patient enters surgery malnourished, actively smoking, vitamin D deficient, osteoporotic, frail or with poorly controlled diabetes.
“Optimization isn’t about creating barriers to surgery,” Dr. Bratescu said. “It’s about creating better outcomes.”
Yu Po Lee, MD, of UCI Health in Orange, Calif., has changed his own approach for similar reasons. He told Becker’s that he now waits on some patients with osteoporosis and refers them for endocrinology treatment before surgery. He has also referred patients with obesity for medical optimization before proceeding.
That shift is also showing up earlier in the evaluation process. Stephen Lockey, MD, assistant professor of orthopedic surgery and spine fellowship director at the University of Virginia in Charlottesville, told Becker’s that poor bone quality, frailty, nutrition, sarcopenia and other health factors can change the pathway before an elective operation is scheduled. At UVA, patients with poor bone quality can be referred for treatment before returning for surgical consideration.
When the patient’s life has not narrowed enough
An abnormal scan alone may also be insufficient when the patient remains highly functional. Dr. Lockey told Becker’s that he is cautious about adding another operation simply because imaging shows something that could technically be corrected, particularly among patients with previous spine surgeries or complex pathology.
“I tell patients you really shouldn’t consider an operation until you feel like your world shrinks,” he said, referring to the point at which symptoms meaningfully interfere with quality of life.
Jeff Gilligan, MD, a neurosurgeon at Elite Brain & Spine of Connecticut in Danbury, told Becker’s that surgery may not be appropriate when the likelihood of meaningful improvement is low, including for some patients with chronic neck or low back pain, or when the risks outweigh the potential benefits because of age, frailty or medical comorbidities.
“One of the most important decisions a spine surgeon makes is deciding when not to operate,” Dr. Gilligan said.
When the case does not belong in an ASC
The growth of outpatient spine has created another type of “no”: A patient may be appropriate for surgery but inappropriate for a particular site of care.
Michael Burdi, MD, of DISC Newport Beach in California, performs selected multilevel posterior lumbar fusions in an ASC. But he told Becker’s that patient selection remains critical.
“If somebody is critically ill, you probably won’t do that case at the surgery center,” he said.
For older patients, Dr. Burdi said comorbidities can make the hospital a better setting, and he checks bone-density scans before outpatient fusion to identify patients whose bone quality may create additional risk. Three-level fusions account for about 5% of his ASC case mix, with most of his outpatient procedures involving one or two levels.
His experience illustrates an increasingly important distinction: Declining to perform a case in an ASC is not the same as declining the surgery altogether. The procedure may still be appropriate, but the patient may need the resources available in a hospital.
The line is not always permanent
Some patients whose surgery is initially delayed ultimately become better candidates. Others may improve enough that an operation is no longer necessary.
Dr. Shaffrey told Becker’s that optimization at Duke includes bone health, blood glucose, nutrition and structured prehabilitation. He also described patients whose symptoms improved after weight loss with GLP-1 therapy to the point that they no longer felt they needed the back surgery they had originally been considering.
Praveen Mummaneni, MD, co-director of the University of California San Francisco Spine Center, told Becker’s that five-year Quality Outcomes Database findings challenged some assumptions about patient selection. He said patients with obesity and smoking histories still made measurable gains after surgery, although their improvement was not necessarily the same as that of younger, healthier patients.
For some patients, the right decision may be to delay surgery or not operate at all.
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.
