Spine surgery's boons

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The advancements in total disc replacement and minimally invasive spine surgery pose strong opportunities for the specialty amid ongoing healthcare challenges, Robert McLain, MD, said.

Dr. McLain, who is president of the Western Orthopaedic Foundation, discussed the healthcare trends he's watching and the opportunity in spine surgery that excites him most.

Note: This conversation was lightly edited for clarity.

Question: What are some other orthopedic and healthcare trends that you're following coming into 2025?

Dr. Robert McLain: The issues I think that are most concerning are the problems of contraction in health systems. I saw this in the Midwest with the closure of hospitals and the collapse of hospital systems. In the West Coast, virtually every system you talk to has taken a financial beating over the last couple of years. They're talking about red ink everywhere, so their ability to take on salaries and take on physicians is very tight. I know a number of physicians that have found themselves at a point in their career where they would like to keep working, but it's just not fiscally reasonable, and they can't find anybody that would give them an interview. We're losing some people just because of the contraction in the hospital systems and the economics of the environment. 

The transition that was most exciting to me when I was finishing up my career in Cleveland is also exciting out here. Advances in technology really have changed what we're able to do, particularly in spine surgery. We have the ability to do some really wonderful things with disc arthroplasty, outpatient surgery, and to do things on a more economical basis while getting patients mobilized much quicker. 

I'm also watching preapprovals and denial of care. Everybody knows what's on the table, and recent events have been tragic, but for my patients it's been tragic for several years. I think the individual physicians in practice and physicians in major medical centers and academic institutions, they're all fighting the battle of using their best judgment and their expertise to come up with a plan and then having to negotiate with an institution to get approval for. That makes it hard to deliver care to patients. And that's that's as big a problem out here as it's as it's been anywhere.

Q: In terms of technology, can you dive into any specific spine or orthopedic technologies that you really think will take off in 2025?

RM: I started doing disc arthroplasty about 15 years ago as part of the Investigational Device Exemption trials in Cleveland, and it has really revolutionized what we can do for young people. The ability to extend the indications to other patients has been a real boon. I have had a lot of patients who are older than what was included in the research studies, but they're very fit people. They're patients that have had previous surgery and were denied by their payer groups, but if we could get them approved for an adjacent level disc arthroplasty, it has really been a boon. It prevented people from needing multiple fusions. It's maintained function. 

In some older patients, 40 years ago, physicians would say, "You're elderly so just rest." But these are active people that want to maintain their range of motion and their function, and the advances in disc arthroplasty and the application has really been a boon to my patient population. Patient satisfaction is huge. The procedures are less disruptive because you don't have to wait for fusion. 

That's a technology which has been around, but it's gaining the proper place in spine treatment. The advances in minimally invasive surgery, the ability to access the spine through more minimally invasive approaches with less morbidity. Those advances are really making surgical treatment possible in cases where you know the morbidity outweighed the potential benefit. Now we can do procedures on an outpatient basis that get people back to good function without the long downtime, the big surgical incisions or the hospitalization, and those have been real boons. 

For robotic technologies, I'm still waiting to see whether that's going to be a big change or just a very elegant way of doing what we've always done. But the ability for technology to augment our treatment nowadays is really pretty exciting.

Q: What advice do you have for spine orthopedic surgeons to thrive financially in 2025?

RM: It's an environment that's in flux right now. I think an opportunity is to work with a large group that has already adopted strategies for dealing with their payers and making sure that their cost basis and their organization is well tailored. I think it's very difficult to step out into a small private practice right now. Some guys can do that, and probably in smaller communities where the region doesn't have a tremendous amount of competition. 

The hospital-employed physician I think is a position that's going to be in flux for the next few years. I think hospitals are proving to be a little bit more difficult for physicians to cope with than they thought, but those positions are also going to be more valued down the road by the employers than they are right now. Find the right people to work with in an environment that you're going to enjoy being in. That still remains one of the things young surgeons should be looking for.

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