Where spine innovation is needed most: 11 surgeons weigh in


From multilevel disc replacements to artificial intelligence-based technologies and patient education initiatives, 10 spine surgeons from health systems and private practices across the country discussed the areas they believe would benefit most from innovation in spine care.

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.

Next week's question: What tips do you have for spine surgeons beginning practice this year?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, April 13.

Editor's note: The following responses were lightly edited for style and clarity.

Question: In which area of spine care is there the biggest need for innovation? Why?

Isador Lieberman, MD. Texas Back Institute (Plano): Today, artificial intelligence has impacted every aspect of decision-making outside of medicine. In spine surgery, we rely far too heavily on the art of surgery. As spine surgeons, we absolutely need an objective scientific way to decide upon whom we should operate, and what would be the most appropriate and least invasive method, with the highest likelihood of success. The combination of demographic data, radiographic assessment, objective biomechanical measures and the use of patient-reported outcomes, all integrated into a population-wide database, with the ability to create a comprehensive "neural network," will define the way we do surgery in the future.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: We need more innovation in the lumbar disc arthroplasty space. Soon, I hope to see lumbar disc choices increase, but also being able to place a lumbar disc from a lateral, retroperitoneal approach. Being able to safely place lumbar disc replacements in the upper lumbar segments (e.g. L2-3, L3-4) without vascular retraction is incredibly exciting. Right now, we are somewhat limited to upper lumbar access. I am very fortunate to work with an amazing approach surgeon. Not all of my colleagues around the country are as lucky, and it would be a quantum leap in patient outcome and safety if we would place a lumbar disc replacement through a safe lateral corridor.  

Neel P. Shah, MD. DISC Sports and Spine Center (Newport Beach, Calif.): The technological advancements in orthopedics and spine surgery have been exponential over the last couple of decades. One segment of spine care that needs more innovation and engagement is patient education. When looking at outcomes, I do believe that patients who are truly engaged and understand their condition, along with the possible outcomes of surgery, will recover better and faster than patients who are not engaged. Physician and surgical knowledge has grown exponentially; we should now use that effort to teach and empower our patients as well.

Navin Sethi, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): As spine surgeries are increasingly performed in the outpatient setting with patients looking for quicker recoveries, the focus of innovation and growth will be on minimally invasive techniques. This includes developments in image guidance, disc replacements and multilevel disc replacements, in addition to robotics, which I anticipate will become more sophisticated in the coming years. I also predict we will see innovation in the area of regenerative therapies, specifically the use of stem cells or [platelet-rich plasma] as treatment options for patients.

Emeka Nwodim, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): First and foremost, we should focus on communication between everyone involved in patient care, including the physician, the patient and third parties such as payers and hospitals. An innovative, multifaceted approach to communication is key to ensuring everyone is on the same page to manage expectations. In the clinical setting, I often find patients don't have a full understanding of their pathology or treatment options, such as surgical and nonsurgical treatments. By emphasizing communication between the physician and patient, we can likely improve outcomes.

From a surgical perspective, further innovation is needed to manage certain degenerative spine pathologies that may need stabilization. Spinal fusion techniques that exist can minimize complications, but the industry must find more innovative approaches to improve accuracy within the operating room, such as spine navigation, instrumentation and bone graft products.

Richard Kube, MD. Prairie Spine & Pain Institute (Peoria, Ill.): Revenue cycle management is in desperate need of change. Payers continue to squeeze. Overhead continues to rise. More staff is needed to collect the same or less. Creating large consortiums of providers who understand their businesses and the ability to create a bundled cash model can provide direct access to many self-insured businesses. Not only does this model provide a path to improved revenue streams, but it also creates a provider and consumer-driven market. This effectively acts as a hedge against hospital manipulation of surgeons' referral base. When combining direct patient access with lean overhead, a smaller practice can remain nimble and thrive in today's market.

Noam Stadlan, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.): The greatest need in spine care innovation is advances in being able to identify the etiology of back and neck pain and then finding efficient ways to treat it. We are too dependent on the paradigm of fusing or replacing painful joints. The rate of clinical failure in the treatment of mechanical back and neck pain is unacceptably high. We still lack reliable methods to diagnose and treat spine problems that are not due to compression of neural structures. 

Peter Newton, MD. Rady Children's Hospital (San Diego): As a pediatric orthopedic spinal deformity surgeon, one of our greatest treatment dilemmas is the treatment of progressive, early-onset scoliosis. The need to control the spinal deformity while maintaining/optimizing continued spine and trunk growth in these young patients requires additional innovation. There has been substantial progress with early casting as well as implant systems designed to allow or even drive additional spinal growth. Posterior-based spine and rib-based anchoring systems have added options for fixation and provided methods to address the often-accompanying chest wall deformity. Externally-driven magnetic motors to power rod-lengthening, ratcheting-distraction mechanisms and components designed to slide along a rod have all brought some new proposed advantages to the treatment paradigm. The fact remains that posterior systems have been associated with little spinal motion and frequent early auto-fusion of the spine.

Preserving motion and preventing early fusion must be a goal for future innovative approaches. Some of this may involve future iterations of vertebral body tethering or posterior dynamic distraction, two methods that are evolving in the juvenile and adolescent idiopathic scoliosis space. Current options for the management of kyphotic deformities, particularly in the upper thoracic spine of young children, also remains an unsolved problem. Early-onset scoliosis can be life-threatening, and current methods often fail to control the spinal curvature progression, leading to severe trunk shortening, deformity, imbalance, pain and cardiopulmonary compromise. The "final" definitive fusion surgeries once growth has been completed are some of the most complicated procedures we perform. Innovative solutions that promote both motion and spinal growth, yet with the power to correct scoliosis and kyphosis in small children is an area of need these children deserve. 

John Koerner, MD. Rothman Orthopaedic Institute (Philadelphia): One of the biggest needs for innovation in spine care is intraoperative imaging. Surgeons and patients are exposed to radiation with current techniques, which can cause problems over time. Imaging modalities that can reduce or eliminate radiation would be beneficial to both the surgeon and patient.

 Pawel Jankowski, MD. Hoag (Newport Beach, Calif.): Three areas:

1. Preoperative planning resources to minimize mechanical and instrumentation failures post-op that avoid further surgeries.

2. Artificial intelligence-assisted technologies that help surgeons account for changes in the non-treated segments of the spine, whether this be after instrumented fusion procedures or decompression.

3. Preoperative functional assessment tests that are quantitative to help discern which patients will be able to successfully undergo and recover from surgery. These tests also will help prepare patients to have successful outcomes if they have failed, so that they can be placed in the operative cohorts to achieve a successful outcome. 

John Burleson, MD. Hughston Clinic Orthopaedics (Nashville, Tenn.): I still think we have a lot of room to go. We have a lot of really exciting potential technologies: navigation, robotics, augmented reality, endoscopic surgery, machine learning and artificial intelligence have all helped the way that we perform surgery. Over the next five, 10 and 20 years, I expect the biggest advances will actually be the seamless integration of these technologies. If we are able to do that, we will really do something special that should dramatically improve the outcomes of our patients.

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