How the spinal tech 'game of musical chairs' will drive the direction of the industry

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The neurosurgical and spine surgery industries could see an influx of investment in several technologies and procedures, including small-scale robotics, augmented reality and endoscopic spine surgery, one neurosurgeon predicts. 

Camilo Molina, MD, is a neurosurgeon at Washington University Physicians in St. Louis. He recently spoke with Becker's about surgical trends, how he sees the neurosurgery industry evolving and one solution to improve communication between surgeons and payers. 

Editor's note: Responses were lightly edited for clarity and length.

Question: What are some of the biggest challenges facing your industry today?

Dr. Camilo Molina: We have a number of challenges. Number one, there are rising healthcare costs putting an increased pressure on us to provide increasingly higher quality of care, but with reduced cost to both the patients and the healthcare system. And this is at the same time that we are being constantly inundated with more and more increasing enabling technologies and biologics that have the potential to maybe improve the efficiency or outcomes of the case, but they come at a greater cost. So balancing being pulled in two different directions while the insurance companies are trying to hold the reins puts the surgeon in an incredibly difficult position.

I am a neurosurgeon, but my predominant field is in spine surgery. I do complex spine surgery, and I work together with the orthopedic spine surgeons as well. I would say that a common theme to being a modern spine surgeon is that it is a very burgeoning field. The pedicle screw was truly only FDA approved in the mid-1990s. To think that it's only been available for 30 years and now become the absolute workhorse of major spinal reconstructions, it seems like it's a relatively new field in terms of everything we're able to do now. And we are at this inflection point where we're beyond being able to instrument the spine and reshape the spine. We're thinking about what is the best shape for the spine and how do we individualize this and how do we minimize all the potential complications that go along with this? It creates a very unique challenge because all the solutions that are put out there, sometimes not necessarily [more] efficacious than what's been conventionally done, require a significant amount of learning curve and additional costs to the case. That's very unique to the orthopedic spine and neurosurgical spine field, because there's so much money being thrown into creating these new, enabling technologies and biologics ... and it's everywhere around us. It's difficult to tease out value and improved outcomes versus just really excellent marketing.

Q: What surgical trends are you following?

CM: I do a lot of deformity surgery, so it's always interesting to see the trends in terms of what approaches are being done. I feel like 30 to 40 years ago I wasn't practicing them, but anterior approaches were very popular and then entirely posterior approaches became very popular. Now, there's a swing back to anterior approaches and lateral approaches. So it seems that everything comes in waves and one's not necessarily better than the other, but one thing I do see more that's becoming very prevalent and even see it in the insurance companies paying attention to it, is that people really care about alignment. It's not that [people] didn't care before, but they care about it in a very objective, defined way now. They want to know pelvic and lumbar parameters and alignment parameters in surgeries. That's fascinating because these were conversations that were confined to conferences and academic spaces only 10 to 15 years ago. And now an insurance company, if I say that I'm doing a deformity surgery, they'll reply with a clarification statement saying, well, what are the pelvic incidents? What's the needed correction? So I see a trend in that from both the regulatory space as well as the practicing space, not only in academics or specialized centers, but also in the community that people are really starting to pay attention to sagittal balance and I actually think that's fantastic.

There has been a very admirable effort within the major journals and conferences, and now by the industry-leading companies, that whenever the theme of a conference or a new product or implant comes up, they always say, you can get this amount of lordosis, this amount of correction with this implant. It's hyperlordotic. We can plan your rods out for you with artificial intelligence so your patient has an ideal balance. All these things. And people start to perk up and pay attention and they go, well, why is that important? And they say, well, look at long-term outcomes. Your rate of revisions are less, your rate of failures of your implants are less if your patient's spine is balanced with their head over their pelvis. I think it's multifactorial, but it certainly is coming from all directions.

Q: How do you see the neurosurgery and spine surgery fields evolving in the next three to five years?

CM: There's a large diaspora of very brilliant ideas and companies out there and I expect in the next three to five years, some of the market-leading companies that can really shake and move and drive the big direction of the market to play the game of musical chairs and settle into what the future of the field is going to be and really push it in one direction or another. If I had to guess, I think the majority of the investment and effort is going to be put behind smaller profile, cheaper robotics, augmented reality, endoscopic spine surgery and artificial intelligence. 

Q: If you could change one thing about the industry, what would that be?

CM: I would love to have a more seamless way to communicate with the payer. I wish there was a more seamless way to communicate with them and have less of an adversarial relationship in terms of what is best for the patient and best for the healthcare system. For one, I think there should be some honors on the insurance companies if there are any questions to always have the cases reviewed by a true peer, so either an orthopedic spine surgeon, neurosurgeon or spine surgeon. And then further to be a common language or a common set of criteria that is preset and agreed upon that will result in that patient's care not being denied. But that doesn't exist. Some insurance companies have that, some don't.

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