For years, spine surgery’s approach to risk prediction largely revolved around one question: Which patients are most likely to have a complication?
Rafael De la Garza Ramos, MD, thinks the harder question is becoming more important. Which patients are actually going to benefit?
Dr. De la Garza, director of spine research at New York City-based Montefiore Einstein and assistant professor of neurosurgery at Albert Einstein College of Medicine, treats complex spine conditions including tumors, deformity and patients requiring revision surgery. His research has focused extensively on frailty and surgical outcomes.
He has watched prediction evolve from retrospective studies largely focused on complications toward prospective data that increasingly incorporates patient-reported quality of life.
That shift has opened the door to a different kind of prediction.
For Dr. De la Garza, better risk prediction is only part of the equation. A patient at elevated risk of a complication may still have something meaningful to gain from surgery. The harder task is determining what an operation could realistically accomplish for that individual.
“It’s not just about the complications,” he said. “It’s who’s going to benefit.”
Where frailty scores fall short
Frailty has become an important part of surgical risk assessment, but Dr. De la Garza believes many existing measures capture only part of it.
The concept originated around increased vulnerability in older patients and has evolved into something much broader. Frailty can encompass physical function and energy as well as mental factors, body composition and the support a patient has outside the hospital.
Many commonly used indices, however, remain heavily weighted toward comorbidities.
“We don’t take into account the mental aspect, body composition, muscle mass or muscle quality,” Dr. De la Garza said. “We don’t take into account social support or social vulnerability.”
The challenge is building a tool sophisticated enough to capture those dimensions without making it too cumbersome to use.
“We want simple tools,” he said. “But simple tools aren’t able to capture the true nature of frailty, which is much more complex.”
That limitation becomes particularly important as prediction improves. If surgeons become increasingly adept at identifying risk without becoming equally good at identifying potential benefit, some of the most complicated patients remain difficult to evaluate.
Dr. De la Garza believes the field needs to get better at both.
When doing nothing carries a cost
That calculation becomes especially difficult in complex and revision spine surgery.
Dr. De la Garza rarely tells patients they “have to” undergo surgery. Instead, he frames the decision around what surgery could improve, what risks would be required to pursue that improvement and whether continuing without surgery is acceptable to the patient.
“Spine surgery is not life-or-death surgery,” he said. “It’s about balancing the risks with the potential benefits, whether that’s improving a patient’s pain or function.”
Sometimes, a patient’s condition has affected daily life enough that accepting significant surgical risk becomes reasonable to that individual.
“Sometimes patients say, ‘I really can’t continue like this. It’s debilitating and affecting my daily life,’” Dr. De la Garza said. “That’s when surgery can become an easier choice, because the alternative is no longer acceptable to them.”
For patients facing a second, third or fourth operation, or a complex, multistage procedure, those conversations may happen several times. Dr. De la Garza also encourages patients to bring family members into the discussion.
Ultimately, he said, the decision depends not simply on how much risk exists but whether that risk is acceptable to the person taking it. That is something a complication score alone cannot answer.
The problem with defining a ‘good outcome’
There is another challenge: Patients do not necessarily want the same thing from surgery. One patient’s priority may be walking. Another may care most about reducing pain, even if mobility remains limited.
“Not every patient has the same expectations or the same goals,” Dr. De la Garza said.
That is one reason he sees limitations in evaluating success primarily through average outcomes across groups of patients.
Researchers are beginning to develop more individualized and composite measures. Dr. De la Garza pointed to recent work in spine oncology that evaluates whether an individual patient achieves multiple benchmarks after surgery, such as avoiding a major complication, being able to walk at 90 days and maintaining or improving performance.
The goal is to move closer to determining whether a particular patient achieved a meaningful result rather than simply how a population performed on average.
That shift could become particularly important as spine surgery faces greater scrutiny over utilization and the value of surgical care.
Dr. De la Garza pointed to spinal fusion as an example. He acknowledged that the procedure has likely been overused, but cautioned against allowing its broader reputation to obscure appropriate indications.
“There’s still a group of patients who may benefit,” he said. “Hopefully, we’re getting better at identifying who those patients are.”
The prediction tool Dr. De la Garza wants
Five or 10 years from now, Dr. De la Garza hopes surgical prediction looks markedly different. His vision is a patient-specific report that tells a surgeon two things: the risks of the proposed operation and the likelihood that it will accomplish what that individual patient wants from surgery.
“What are their priorities for surgery, and what are the chances that our proposed surgery achieves those outcomes?” he said.
AI could play a significant role. Existing frailty indices often use overlapping variables, while potentially important information remains difficult to incorporate into conventional models. Dr. De la Garza said future tools could draw from the medical record alongside biomarkers, genetic information, body composition, inflammatory markers and other data to develop a more complete assessment.
“Prediction is never going to be perfect,” he said. “But I think it’s going to be very helpful for both the surgeon and the patient to get a sense of what surgery could provide them.”
For spine surgery, that could represent an important change in how risk is used. The goal would no longer be simply to identify the patient most likely to have a complication. It would be to put that risk in context: what the patient wants, what life without surgery looks like and what an operation has a realistic chance of restoring.
That matters even more, Dr. De la Garza said, as surgeons face increasing pressure to demonstrate the value of the procedures they perform.
“We need to be better at predicting who’s going to benefit,” he said. “Not everybody wants the same thing.”
The next generation of prediction needs to answer a harder question than whether surgery is risky: Is the potential outcome worth the risk to this patient?
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