Dr. Fred Naraghi: Cervical disc replacement, spinal fusion will continue to be dominant procedures

Written by Alan Condon | January 29, 2020 | Print  |

Fred Naraghi, MD, of Comprehensive Spine Center in San Francisco is moving his practice to Klamath Falls, Ore., in February.

Dr. Naraghi specializes in minimally invasive cervical and lumbar disc surgery, sciatica, spondylolisthesis, spine disorders, degenerative spinal disorders and spinal stenosis.

Here, he discusses his upcoming practice move and how he sees cervical artificial disc replacement and spinal fusion developing in the future. 

Note: Responses are lightly edited for style and content.

Question: What prompted your move to Oregon from California? What are your practice goals for the next year?

Dr. Fred Naraghi: My move was due to two reasons: financial and personal. As the cost of care increases and reimbursements decline for all practitioners, looking at cost and quality, which determine value, it's increasingly difficult to provide effective care, especially for private practitioners. I've been fortunate to have worked with some of the best-known spine surgeons in San Francisco.

On the personal side, as my two sons are now in college and dental school, my wife and I have more flexibility. Oregon is a beautiful state and I'm very excited to join an outstanding team at Klamath Orthopedic Clinic and looking forward to helping patients stay healthy and active. I'm developing relationships with primary physicians so that, as a team, we can help get our patients back to their active lifestyles.

Q: How do you see cervical artificial disc replacement and cervical spinal fusion developing in the next five to 10 years?

FN: Cervical disc replacement is gaining significant popularity due to lower reoperation rates and less adjacent segment deterioration — especially for a two-level — although some of the data is still debatable. Reimbursements and payer preauthorization remain a contributing factor against disc replacement, but I think cervical disc replacement will continue to potentially become the dominant procedure. 

Cervical fusion has enjoyed the most favored nation status and is still considered the most efficient procedure in spine today in terms of cost, reimbursement and outcome. Both procedures are great to have in our armamentarium. 

Question: In your opinion, what is the most exciting development on the horizon for spinal fusions?

FN: A number of developments are influencing spinal fusions. Minimally invasive surgery, including endoscopic lumbar fusions are gaining more popularity, especially as endoscopic implants that could be placed through the scope become more available. Other advances like biologics are continuing to develop. However, the caveat with biologics is the significant lack of any meaningful clinical data to show superiority of one versus another. 

Advances in implants, techniques, anesthesia and perioperative multimodal pain control are making outpatient spinal fusions safer and more practical at surgery centers. I think following the trend of total knee and hip arthroplasty, a growing trend would be to do more spinal procedures at surgery centers, especially as the cost of care can be lowered through ASCs versus traditional hospitals. It is imperative to improve our minimally invasive techniques in order to perform successful outpatient spinal surgery.

Q: Do you see spine surgeons moving away from spinal fusions in the future?

FN: Spinal fusion will continue to be indicated for instability, deformity correction and as a salvage procedure. But I think as we look at value-based care and try to make care more efficient for our patients — and considering outcomes and adjacent segment issues — fusion for disc degeneration will continue to decline.

Q: What do you see as the next big trend in spine?

FN: Augmented reality navigation systems, allowing superimposing 3D imaging data in real-time onto the loops or glasses to help surgeons with screw insertion, will continue to improve, although the cost is still prohibitive for most navigation and robotics. Other big trends include advances in preoperative and postoperative pain control and allowing spinal procedures to be more practical at surgery centers. 

The combined modality approach for spinal cord injury, including dorsal column stimulation with improved signal processing and cellular therapies are exciting upcoming advances. 

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