The definition of complex spine surgery is changing. Here's how.

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Spine surgery has evolved dramatically in recent decades as new technology and techniques have made some procedures more minimally invasive, efficient and quicker to recover from. In some cases, surgeries that once required a lengthy hospital stay can now be done in a few hours at most, with patients going home the same day.

The evolution of minimally invasive procedures and outpatient care are also having spine surgeons rethink the definition of what complex spine surgery is now. Several spine surgeons shared their thoughts on the evolution of "complex spine surgery" with Becker's.

Note: Responses were lightly edited for clarity.

Question: How will the definition of complex spine surgery evolve in five years?

Vincent Arlet, MD. University of Pennsylvania (Philadelphia): Every spine surgeon calls themselves a complex spine surgeon, yet only a few do perform complex spine surgery (three-column osteotomies, en bloc resection severe deformity, severe revision spine surgery, etc.). So in five years, surgeons performing authentic complex spine surgery will be required to call themselves highly complex spine surgeons. 

Joseph Ferguson, MD. MedStar Health (Washington, D.C.): I think complex spine surgery has already evolved so much in the last 20 or so years. We saw some of the improvement in fixation with pedicle screws, and now we are seeing excellent sagittal correction with interbody devices via ALIF and XLIF procedures. These procedures tend to carry less morbidity and complications than traditional three-column osteotomies. I suspect we are seeing a plateau in technological advancements as we now move into the era of navigation and robotics. I think the trick going forward is to make complex surgery more "routine" in terms of anesthesia parameters, efficiency of surgery and getting the patient off the table faster with less soft tissue damage. Much of this can be done through minimally invasive procedures and limiting the morbidity associated with large open procedures whenever possible.

Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): Spine surgery will always be complex, but the collateral damage created during and as a result of our surgical procedures will continue to diminish. We utilize less invasive approaches. We spare soft tissues. We replace structures and preserve motion and biomechanics more so than previously done. This should all lead to better longevity for the procedures we perform. This improvement in collateral damage should also help curtail complications, especially medical comorbidities created by large procedures. This will be important as we deal with an aging population. Many will develop spinal stenosis and degenerative deformity that could have safe and effective surgical options to preserve independent function and quality of life in ways we would never have considered a decade ago.

Ali Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): As instrumentation in spine surgery becomes routine and outpatient operations involving instrumentation have increased in frequency and availability, the definition of complex spine surgery will need to change. Single-position and single anesthesia anterior-posterior operations are being performed in ASCs across the U.S., and navigation and robots are more common in outpatient settings. Those operations that involve deformity correction, substantial reconstruction or multiple stages through unique approaches will define complex spine surgery. Higher risk operations, such as intramedullary tumor resections, may also be considered complex, especially when done in ASCs.

Joseph O'Brien, MD. Virginia Hospital Center (Arlington): Complex spine surgery used to be defined as three or more spinal levels fused. Now, I can perform lateral interbody fusion with percutaneous screw fixation from L2 to L5 in under two hours without a blood transfusion. Hospital stays are typically 2.1 days. So I think that we will be treating more "complex" pathology in a more simplistic manner in the next five years. Revisions are much more simple now as well. An add-on fusion can be done with little to no morbidity as compared to prior methods.  

Issada Thongtrangan, MD. MicroSpine (Scottsdale, Ariz.): In my opinion, there will be three aspects. The patient, the nature of the surgery and the surgeons. Patients who have several comorbidities won't be appropriate in an ASC setting. Surgeries that are expected to require blood transfusion, longer duration of surgery, multispecialties for perioperative management and expected to be in the hospital longer than one night stay — these will be done in the hospital. 

Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Complex spine surgery has been an ill-defined term for as long as it has existed. Many groups have tried to classify it based on disease pathology — spinal deformity surgeries or spine tumor surgeries; based on number of levels — three or more levels or six or more levels; or even based on duration of the surgery or expected blood loss. Where the term complex spine surgery is most useful is probably in the coordination of multidisciplinary perioperative processes for these surgeries. The Seattle Spine Team Approach takes this type of approach, where classification of a case as a complex spine surgery involves prescripted communication between the anesthesia and surgical teams, the presence of two attending surgeons, regular interval checks on blood loss and labs, and intraoperative transfusion thresholds that are pre-established. As innovations like cell saver, TXA, navigation and others have modified the way we do surgeries, this definition will continue to evolve. The most important part in signaling a surgery to be complex is in bringing about a protocol that will enable the team to safely get that patient through the surgery and perioperative care.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): In the past, a complex spinal surgeon was fellowship trained in the subspecialty concentration of spinal disorders which usually followed the PGY-7 year.  Neurosurgical/orthopedic training programs enfolded this concentrated field of study by designating most graduates competent in the management of spinal disorders for board eligibility and privilege. The level of competency remains dependent on exposure during this period of training and garnered experience over time. My belief is the definition of complex spinal surgery will continue in the management of the severely comorbid patients, anatomic challenges such as obesity and congenital malformations, chronic conditions, and failed back diagnosis and the revision surgery.  

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