Spine surgery has more options than ever, but more choices have not necessarily made the biggest decisions any easier.
From the push to avoid fusion to the rapid adoption of endoscopy, surgeons are confronting questions about how much intervention is appropriate, what qualifies as meaningful innovation and who should ultimately control treatment decisions.
Recent conversations with spine surgeons reveal five fault lines shaping the specialty.
1. When surgery is the wrong answer: The first divide begins before a patient enters the operating room when determining who actually needs surgery.
Zayed Almadidy, MD, a neurosurgeon at Advocate Health Care in Oak Brook, Ill., has built an audience of more than 1 million TikTok followers by explaining spine procedures. But one of his central messages challenges the assumption that seeing a surgeon should lead to surgery.
“There is a lot of underestimation of the power of physical therapy, steroid injections, nonoperative management and rehabilitation,” Dr. Almadidy told Becker’s.
The challenge is determining when conservative treatment is appropriate and when delaying an operation could do more harm than good. That judgment becomes increasingly complicated as patients arrive with expectations shaped by social media, new technologies and competing treatment philosophies.
2. How far to go to avoid fusion: Motion preservation has expanded the options available to spine surgeons, but avoiding fusion is not always the best outcome.
Farah Musharbash, MD, a spine surgeon at Atlantic Brain and Spine in Morristown, N.J., increasingly uses endoscopic procedures, artificial disc replacements and other motion-preserving approaches. Yet his revision practice has also exposed the consequences of operations that do not adequately address the underlying pathology.
“To me, a fusion is sort of the last resort,” Dr. Musharbash told Becker’s. “But many times, it’s the right thing to do.”
Roger Härtl, MD, is challenging another assumption: that a less invasive operation necessarily produces better outcomes. He is the Hansen-MacDonald Professor of Neurological Surgery and director of neurosurgery spine at Weill Cornell Medicine, as well as neurosurgical director of Och Spine at NewYork-Presbyterian/Weill Cornell Medical Center in New York City.
His team has developed a classification system to measure surgical invasiveness, but Dr. Härtl cautioned that minimizing tissue disruption does not automatically make a procedure safer or more effective.
Together, those perspectives point to a larger question: When does doing less become doing too little?
3. How quickly endoscopy should become mainstream: Endoscopic spine surgery is gaining ground, but its eventual role in the specialty remains unsettled.
Ki-Eun Chang, MD, a neurosurgeon at Naval Medical Center San Diego, has made endoscopy the foundation of 90% to 95% of his practice. He warned that spine training programs that fail to incorporate the technique risk falling behind as the next generation of surgeons increasingly expects exposure to it.
Daniel Park, MD, an orthopedic spine surgeon at Chicago-based Midwest Orthopaedics at Rush and an early U.S. adopter of biportal endoscopy, sees growing demand among trainees but is more measured about how widely the technique will spread.
He estimates that endoscopy could eventually reach roughly 40% of U.S. spine surgeons, rather than becoming universal. He also argues that the field must move beyond demonstrating what is technically possible and establish where endoscopy delivers meaningful clinical advantages over existing approaches.
The question is shifting from whether endoscopy has a place in spine surgery to how broadly it belongs in practice, and what evidence should drive that expansion.
4. Whether innovation is outpacing training: As minimally invasive technologies blur traditional boundaries between surgical and nonsurgical specialties, questions about who is qualified to perform increasingly complex procedures are intensifying.
The North American Spine Society released a patient safety position statement in September calling for structured training, supervised clinical experience and objective competency assessments before physicians independently perform spine interventions.
Brian Su, MD, chair of the society’s Task Force on Patient Safety for Spine Interventions, emphasized that the issue extends beyond specialty credentials to whether physicians have the training required to safely perform particular procedures.
Kern Singh, MD, chief of the spine section at Midwest Orthopaedics at Rush, has raised a related concern about endoscopic training. He told Becker’s that completing a certain number of cases does not necessarily establish independent competency.
The tension is not simply between innovation and safety. It is whether the infrastructure needed to train, evaluate and support physicians can keep pace with the procedures entering clinical practice.
5. Who actually controls patient care: Some of spine surgery’s most consequential decisions are increasingly influenced by forces outside the operating room.
In a recent Becker’s LinkedIn poll of 187 respondents, 73% identified insurer requirements as the greatest influence on spine surgeons’ control over patient care, far ahead of health system policies, government regulation and private equity ownership. Surgeons have described authorization processes that dictate conservative treatment requirements, demand increasingly specific documentation and restrict coverage for certain procedures.
Kasra Ahmadinia, MD, director of minimally invasive spine surgery at Advanced Orthopedics of Oklahoma in Tulsa, described changing insurer requirements that can prolong the path to surgery.
“The goalposts are moved all the time,” he told Becker’s.
Beyond administrative burdens, coverage policies can determine when patients receive surgery, which procedures are financially accessible and how much time surgeons spend defending treatment decisions. The central tension is between what surgeons believe patients need and what insurers will authorize.
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.
