The biggest opportunities in spine from 9 surgeons


From innovations in biologic treatments to physician advocacy and migrating cases to the outpatient setting, nine spine surgeons discuss the biggest opportunities in the field today.

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.

Next week's question: What do you see as the biggest threat to physician ownership?

Please send responses to Alan Condon at by 5 p.m. CDT Wednesday, May 19.

Note: The following responses were lightly edited for style and clarity.

Question: Where do you see the biggest opportunities for spine surgeons today?

Sanjay Khurana, MD. Hoag Orthopedic Institute Surgery Center (Marina Del Rey, Calif.): The progress of minimally invasive surgery over the past two decades is finally being realized in the outpatient environment. We are increasingly performing higher-acuity cases from microscopic and endoscopic decompressions to multilevel disc replacements and anterior and posterior lumbar interbody fusions. The migration of these procedures to the ASC have become a win-win for patients, physicians and payers alike. 

Patients are seeing improved satisfaction and clinical outcomes. Physicians are improving professional satisfaction, economics and time management. Finally, insurers are reducing reimbursement from higher-cost centers to more efficient and less costly ASCs. I view the continued migration to the ASC as the single biggest opportunity for spine surgeons today.

Barrett Woods, MD. Rothman Orthopaedic Institute (Philadelphia): It is becoming increasingly challenging to practice as a spinal surgeon today. Significant challenges exist with insurance approvals, reimbursement and administrative burdens. With that said, opportunities to increase our footprint and improve access in our communities exist. With the COVID-19 pandemic, we have seen increasing utilization of telehealth platforms. Utilization of telehealth has improved office efficiency, decreased patient wait times and improved patient satisfaction. The next advancement will be the utilization of smart phones as most patients, young and old, have access to these devices.  

James Chappuis, MD. SpineCenterAtlanta: There are still significant opportunities for spine surgeons in private practice. Profit margins are much smaller than in the past, so first of all, it's important to make sure your costs are well contained. Secondly, as consumers are more in charge of choosing their surgeons, I think it's very important to focus on excellent patient care and overall service when patients come to your office. They must see value. If so, they will reward you with social media referrals and good ratings on various sites available. 

This, in turn, will welcome many other referrals with which larger, vertically-oriented systems, because of sheer volume, won't be able to compete. Finally, there are other referral sources that are outside of the traditional health insurance plans now becoming available, so keep an open mind and remember to always put excellent patient care first.

Noam Stadlan, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.): The preeminent goal of spine surgery is the preservation/enhancement of the quality of life of our patients. The COVID-19 pandemic starkly illustrated the prominence of social factors in the health of our patients. I think there currently is an opportunity to work for better and more equitable access to quality spine care for both current and potential patients. The pandemic has also illustrated the utility and effectiveness of telehealth, and this can and should be expanded. 

Finally, the growing move toward electronic medical records and large outcome databases should help guide spine surgeons by providing accurate data to improve surgical and nonsurgical decision-making. The data can also help provide better and more accurate benchmarks for quality care, identify areas that require improvement and supply recommendations to achieve the needed improvement. 

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: I think more surgeons need to be involved in advocacy. Instead of complaining about how things are, or "going with the flow," let your congresspeople and senators know how things are going. So many folks in advocacy have no idea why so many doctors are not more involved. Whether it's through American Association of Neurological Surgeons/Congress of Neurological Surgeons, the North American Spine Society, or American Academy of Orthopaedic Surgeons, or other organizations, only by creating a voice for your concerns will things get better. The largest opportunity by far, is affecting our collective destiny and patient outcomes in a positive way.

Todd Lanman, MD. Lanman Spinal Neurosurgery (Beverly Hills, Calif.): The biggest opportunities will be in providing advanced surgical therapies, reducing the patient's pain and blood loss with minimally invasive techniques. Those that augment and improve the placement of hardware or implants necessary for the surgery, such as image-guided robotic-assisted spinal surgery, are becoming more prevalent. There are new companies emerging with newer technologies that are more cost effective and help with precise screw placement, reducing incision size and decreasing the need for reoperation and repositioning.

Secondarily, image-guided surgery can be done with neuronavigation techniques, as well as augmented reality technology. Not only will this benefit fusion surgeries, but also disc replacement. Patients who want to have motion preservation surgery want to avoid fusions and these technologies will assist with lumbar and cervical artificial disc replacement to preserve patients' motions and reduce their pain.

Approximately 10 years ago, there were 4,500 spine surgeons practicing in the U.S. Now there are approximately 3,600. As the number of surgeons is reduced, the demands and time are increased for seeing patients and delivering proper care. Being familiar with these technologies broadens the opportunities for spine surgeons today.

Grant Shifflett, MD. DISC Sports & Spine Center (Newport Beach, Calif.): I think there are two great growth opportunities for surgeons in the years to come: motion preservation technology and outpatient spine surgery. Motion preservation technology will likely be the standard of care in years to come as more and more data comes out supporting the clinical effectiveness of these procedures and as patients become more educated about their options and push for these procedures over fusions. The COVID-19 pandemic has highlighted the fact that outpatient spine surgery is safe, effective and here to stay. Medicare has done away with many of their "inpatient-only" codes. A great way to grow a practice is by getting on board with these trends now.

Andrew Hecht, MD. Mount Sinai Health System (New York City): The biggest opportunities for the future in spine surgery rest in biologic treatment of disc degeneration and annular repair. These disc repair technologies will represent the new frontier of spine care over the next five to 10 years.  

Burak Ozgur, MD. Hoag Neurosciences Institute (Newport Beach, Calif.): I feel the biggest opportunities for spine surgeons today is to participate and collaborate in comprehensive multidisciplinary teams for improved accurate diagnoses and effective treatment of spine patients. I believe being a part of an effective team enables continued learning and enhancing effective patient outcomes.

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