Lawrence Lenke, MD, Chief of Spinal Surgery at Washington University School of Medicine in St. Louis and Jerome J. Gilden Distinguished Professor of Orthopedic Surgery and Professor of Neurological Surgery, discusses the biggest challenges and opportunities in spine surgery today and where the specialty is headed in the future.
Dr. Lenke is a past president of the Scoliosis Research Society and active member of the North American Spine Society. This year, NASS honored Dr. Lenke with the Leon Wiltse Award, which recognizes excellence in leadership and/or clinical research in spine care. He also recently chaired the task force of a new journal, Spine Deformity, which debuted in January and served as an inaugural deputy editor.
Q: What are the biggest challenges facing the spine surgery field today, from your experience?
LL: The number one challenge is still defining our specialty. Spinal surgery and spinal surgeons come from either orthopedic surgery or neurological training background, but they focus their practice only on spinal procedures. It's becoming a subspecialty of medicine and surgery of its own. It's been a long evolutionary process, but ultimately I think we are going to see spinal surgery as its own discipline, instead of surgeons dabbling in spine part-time.
Our results are improving now with surgeons exclusively performing spine surgery and we are gaining recognition as a separate field over time. However, it's a challenge to change the shortcomings and failings we've had with failed spine surgery syndromes seen in the past and even still today. Over time, I think we're going to see that rate decrease because spinal surgeons are more focused just on the spine.
Q: Where are the opportunities for spine surgeons to further progress the field today and achieve better outcomes for their patients?
LL: Our field is relatively new and we are behind other specialties in gathering outcomes data to show the benefit of what we do for our patients. That has become important in the current healthcare environment. Spinal surgeries can be very expensive with the equipment we use, and the recovery involved, so we want to make sure we can provide superior outcomes to patients and show our value in the healthcare economic environment.
Spinal surgeons are asked to justify the value they add to the overall healthcare of patients, and collecting data showing our treatments are substantiated and warranted is essential. My practice focuses on complex spinal deformities where we often perform long procedures and patients spend a week in the hospital and several months recovering. The intervention is extensive and the price tag is large; however, the vast marority of the patients are very appreciative of the procedure, but the question is what the value of treating these unique patients is versus the many health issues we have in society as a whole.
So we will need to show why it's valuable to spend a lot of resources for these patients to have surgery. That's going to be a big challenge for spinal surgeons, especially for complex procedures. The simpler surgeries done in an outpatient setting aren't as expensive, so it's easier for us to show the value of that work. Additionally, for us to demonstrate the value of what we do, patients must be part of the advocacy efforts.
Q: Minimally invasive procedures have been a huge trend in spine surgery over the past few years. How do you see these new techniques evolving in the future?
LL: A lot of the surgeries now are performed through smaller incisions with less tissue disruption and morbidity. Some specialties adopted minimally invasive procedures quickly, such as laparoscopic cholycestectomy, but that change hasn't been so rapid in spinal surgery.. The surgeries we do are challenging to perform safely and reproducibly, and we're looking for procedures that will help us spend less time performing surgery. We have made some nice progress in these areas, especially for degenerative spine problems with short level fusions.
I think we will continue to move forward with minimally invasive procedures. The training programs now are very formal and orthopedic and neurological spinal surgery fellows have access to additional training for minimally invasive spinal surgery techniques. I think the more people who specialize just in spinal surgery will help our field. When you focus on spine, you are better with indications, procedures and outcomes.
Q: Many spine surgeons are concerned about achieving access to care for their patients when insurance companies deny surgical requests. How can surgeons approach these situations to make sure their patients have access to the best care possible?
LL: The first thing we must do, as spinal surgeons, is show we have superior outcomes for these patients. We have to publish our results with honest reporting of our research to show we are doing a good job for them.
Patients also must band together and promote coverage for their benefit. If I'm trying to advocate for approval for a procedure from the insurance company, they think I'm self-promoting, but if the patient advocates and the surgery is indicated, insurance companies may consider switching coverage decisions. It will be very important for prospective spinal surgery patients to be their own advocates in the future. That hasn't been a part of our environment in the past, however times are changing and we have to fight for reimbursement for appropriately indicated care.
Many surgeons are starting to educate their patients about that now because we are seeing insurance companies deny care for reasons we don't understand. Ultimately, patients must be much more proactive in advocating for their own care.
Q: What can spinal surgeons do now to prepare themselves for success in the future?
LL: The first thing surgeons can do is become committed to spinal surgery and really focus their practice. When you do one thing, you do it well and achieve better outcomes. Within spinal surgery now, there are seven or eight subspecialties, including cervical spine, lumbar spine, pediatric and adult deformity etc.
I also think all spinal surgeons must begin tracking their outcomes on all patients. We all need to show the value of what we are doing and help our profession. We can't just depend on academicians to show the value of what we do. There has been a paradigm shift now demanding that all surgeons gather outcomes and data to prove what they do.
Q: In light of your recent recognitions, who have been your major influences throughout your career and where do you continue to turn for further development?
LL: The influences came from mentors and several spine surgeons who I worked with early in my career from an academic perspective. These influential surgeons include Ronald DeWald, MD, John Kostuik, MD, David Bradford, MD, Robert Winter, MD, Keith Bridwell, MD, Oheneba Boachie-Adjei, MD, Randy Betz, MD, and Harry Shufflebarger., MD.
I also learned a tremendous amount from many of my patients who have taught me about how much of a positive impact we can have on our patients through our hard work. There are several patients I have surgically treated who have been defining moments for me where I tackled challenging problems and they were very appreciative of my work. Those situations gave me the confidence to continue to help even more complex patients coincident with my experience.
The other influence that continuously drives me and helps motivate me is the interaction I have with our spinal surgery fellows. We train four fellows per year and they are our assistants in surgery, and we spend a lot of time with these surgeons finishing their formal training and honing their skills. These are energetic people who keep us on our toes and ask questions that in turn help us hone and optimize our techniques. These interactions have been a major component of my continued career development.
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