From spine robotics to endoscopic surgery, here are the ideas that took some time for physicians to fully embrace.
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. Becker’s invites all spine surgeon and specialist responses.
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Editor’s note: Responses were lightly edited for clarity.
Question: What’s an idea in spine surgery that you didn’t understand at first but now embrace?
Tan Chen, MD. Geisinger Musculoskeletal Institute (Danville, Pa.): I had initial reservations about the extensive use of minimally invasive spine surgery techniques, as I was concerned about the limited visualization and the steep learning curve associated with mastering these approaches. However, as I delved deeper into the literature and observed the favorable outcomes — such as reduced postoperative pain, shorter recovery times, and less muscle disruption — I began to appreciate the undeniable benefits of these techniques. Embracing MISS has not only enhanced my surgical repertoire but has also allowed me to provide my patients with options that promote quicker return to function and improve overall satisfaction.
Michael Dorsi, MD. DISC Surgery Center at Thousand Oaks (Calif.): Spinal robotics. We have developed a large spinal robotics program over the past five years with the addition of our sixth Globus Excelsius robot. This technology has been widely adopted by my colleagues, and has greatly improved the safety and efficacy of spinal fusion procedures in our area. It has been an exceedingly useful tool, particularly in minimally invasive degenerative cases and trauma.
Spinal robotics is in its infancy, and it is certain that in the years to come, it will continue to evolve in its applications and likely eventually become the industry standard.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The importance of how the anatomy fits together is by far the most important thing I embrace. We are all taught the basics of spine surgery — indication, approach, placement. The key thing is the very thing we learned in medical school — before residency. Remembering and applying that knowledge during an operation are really important. Knowing where and when you will see things during surgery is key to a safe and effective operation. Just getting through a surgery is not enough — and using the anatomy to your advantage can oftentimes save patients future surgeries. This is true many times, but not every time.
Brandon Hirsch, MD. DISC Surgery Center (Newport Beach and Carlsbad, Calif.): One idea I was uncertain about in my first year of practice was the feasibility of anterior lumbar approaches in the outpatient setting. That uncertainty was due to a lack of experience. While I do not think all facilities and all surgeons should be doing outpatient anterior lumbar approaches in an ASC, the procedure is certainly safe and effective when the patient, the surgeon and the facility are appropriate.
The role of an experienced approach surgeon is critical. At DISC, we have experienced, highly trained staff, anesthesiologists, surgeons and nurses who do these procedures multiple times a week, every week. At this point in my career, I now embrace the idea of outpatient lumbar disc replacement, which was not the case in my first year of practice.
Jonathan Rasouli, MD. Northwell Health (Staten Island, N.Y.): Endoscopic spine surgery. Early in my career, I didn’t see the value — especially coming from a practice focused on complex spinal deformity where large exposures, osteotomies, and instrumentation are often required. I was skeptical of ultra-minimally invasive procedures that seemed to prioritize small incisions over structural correction, and honestly, I spent a good portion of my practice revising failed “minimally invasive” fusions. But after gaining experience with endoscopic techniques, I’ve come to appreciate their utility in the right patient population. They can meaningfully decompress nerves with less morbidity and faster recovery. That said, for endoscopic spine surgery to see broader adoption, we still need improvements in equipment, reimbursement, and training. The potential is real — and I’m a believer now.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Computer guided surgery, robotics or image guided surgery, which is commonplace, state of the art and assuredly casts aspersions on levels of care when not part of any health system’s armamentarium in specialty surgical care. Initially, deliberated by the traditionally-trained as a replenishment to training gaps, is now expertly utilized for pinpoint anatomic accuracy and surgically fragile areas. Being a skeptic at first and current convert has allowed supplemental expansion in practice patterns and continued modernization in a complex specialty.
