The most pressing challenges in MIS spine surgery today


Five spine surgeons weigh in on the challenges facing MIS spine practitioners.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

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Questions: What are the biggest challenges to MIS spine care today?


Michael Gordon, MD. Spine Surgeon at Hoag Orthopedic Institute (Irvine, Calif.): Becoming overwhelmed by the promise of MIS in the face of the realities of the spinal pathology being treated. We must not over-promise and under deliver, and we must remember proper patient selection is paramount.


Most MIS surgeries for disc herniation, spinal stenosis and lumbar instability patterns have as a goal nerve decompression and spinal stabilization. Indications for surgery must balance invasiveness of intervention with the magnitude of underlying pathology treated. In an effort to minimize soft tissue trauma by using a minimally invasive technique, a surgeon may compromise outcome because of the limitations of MIS surgery. There is always the threat that, in a desire to perform a minimal-access procedure, the surgeon can be blinded to the risks of under-decompression, failure to accomplish a fusion due to underlying inadequate bone surface preparation or failure to achieve good sagittal balance in the cervical or lumbar spine. MIS techniques, which are very reliable in the treatment of one- or two-level pathology, may fail when confronted by factors such as poor bone quality or excessive deformity.


Managing patient expectations with realities of surgery can also be difficult. [Typically] one or two levels are easily done MIS, but what about this hypothetical patient? Picture a 73-year-old obese (BMI 36), diabetic, osteopenic woman with mild smoking-related chronic obstructive pulmonary disease and an old myocardial infarction. She has severe lumbar spinal stenosis with a coronal and sagittal deformity at L2 to S1 measuring 35 degrees. She expects, based on advertising she has seen, that an MIS surgery can be done with combined decompression and fusion with segmental fixation and percutaneous screws as well as anterior column support with MIS/TLIF or XLIF at five levels. An open procedure in many hands, although more "invasive," can be done more quickly and effectively than a multilevel MIS case.


Which is a greater surgical risk to this patient: an eight-hour MIS case of L2 to pelvis decompression and fusion with multiple small incisions, or a five-hour multilevel open "360?" Don't forget the radiation exposure which can easily top 10 minutes in a multilevel case.


Payam Farjoodi, MD. Orthopedic Spine Surgeon at Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): One of the limitations of MIS spine care is a steep learning curve. As MIS surgery becomes more widely accepted and performed, I see this learning curve improving. Radiation exposure is also a challenge associated with many MIS techniques.  The evolution of navigation will minimize the amount of fluoroscopy required for MIS surgery.


Vladimir Sinkov, MD. Spine Surgeon at New Hampshire Orthopaedic Center (Nashua): There is already a lot of evidence out there that MIS spine surgery can deliver the same good results as open but with fewer complications and quicker recovery, and in some cases, can actually deliver better outcomes as well. The next step is surgeon training — the learning curve is steep and it is not easy for a busy practicing spine surgeon to take time away from work and family to learn a new procedure. MIS surgery is more instrument-intensive and requires a lot more intraoperative imaging or navigation. This adds time, at least initially, and expense to the procedure with no additional reimbursement to the surgeon or the healthcare facility.  


It has been shown that at least financially MIS still makes sense because of the savings due to the shorter hospital stay, less need for blood transfusions and faster return to work and function. The challenge is to convince more surgeons, hospitals and payers with this data. This will allow MIS spine surgery to become the standard of care in the future.


Richard Kube, MD. Founder and CEO of Prairie Spine & Pain Institute (Peoria, Ill.): There are multiple challenges to MIS spine care. What we face most frequently is insurance coverage for spinal procedures in an ambulatory setting. The technology and techniques have outpaced the payers. Many procedures we perform are not covered or only partially covered. Regardless of the savings the ambulatory setting provides the payer, there is great resistance to changing the way the payer is willing to contract and educating them regarding their missed opportunity at increased value for their healthcare dollars is arduous. Some self-insured participants are beginning to wake up to this opportunity, but we are still a long way from making this a mainstream idea.


Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: By far, the biggest challenges are reimbursements. Getting paid fairly and on-time has become nearly a full-time job in and of itself. Truly, this is a self-defeating proposition for insurance companies. In effect, they are driving doctors en masse towards employment. This in turn will drive up their costs, as they will need to fork out even more money as organizations grow and leverage their size in negotiating contracts. I predict that this reimbursement road-blocking they engage in will ultimately push us towards a single-payer system. Then, the insurance companies will be a cipher.


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