10 surgeons on the most controversial trends in spine

Spine

From medically unnecessary spine surgeries to non-surgeons performing endoscopic spine procedures to the duration and rigor of residency and fellowship programs, 10 spine leaders share what they believe are the most controversial trends in their specialty 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. Becker's invites all spine surgeon and specialist responses.

Next week's question: What advice do you have for spine surgeons graduating from residencies and fellowships next year?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, Nov. 9

Editor's note: Responses were lightly edited for clarity and length.

Question: What’s the most controversial trend in spine surgery today?

Andrew Sama MD. Hospital for Special Surgery (New York City): One of the more controversial trends in spine surgery today is the current duration of most fellowship training programs in the U.S. For residents who finish either orthopedic surgery (five to six years) or neurosurgery (six to seven years) residency programs, the typical spine surgery fellowship lasts just 12 months.

According to the North American Spine Society, the number of spine fellowship spots has grown to over 100 programs in the U.S. We therefore need to consider not only the number of surgeons we are training, but the duration and rigor of how they are trained. Given the increasing scope and breath of the practice of spine surgery, the growth of our aging population, the complex pathologies that these patients seek treatment for, and the evolution of technically demanding surgical procedures with steep learning curves, we may need to consider revamping and lengthening the duration of fellowship programs to allow better mastery.

One potential option may be to have a dedicated longitudinal spine surgery training program that incorporates training modules in the fields of orthopedic surgery, neurosurgery, radiology, neurology, rehabilitation medicine, metabolic bone health, computer science and robotics. Perhaps this can start with a comprehensive pre-spine surgery fellowship curriculum that could be incorporated into the last year of orthopedic and neurosurgical residency programs as electives to lay the groundwork for concentrated spine surgical study during a two-year fellowship program that would follow.

Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Unnecessary surgery and procedures continues to be the pressing controversy in spine care today. Becker's published an article earlier this year that over 13,000 unnecessary lumbar fusions were performed in the first year of the pandemic and over 16,000 unnecessary vertebroplasties were performed in the same year. Recent studies have suggested that more than 50 percent of spine surgeries that are performed in the U.S. are potentially avoidable through the more prudent use of less invasive treatments like physical therapy. The onus is on us as surgeons to define in the coming years what constitutes appropriate and inappropriate surgery and to define clear criteria within our field for when patients should undergo surgery or other interventions. Without this, we will continue to face expanding external barriers from payer groups that will prevent us from delivering necessary care to patients and increase the burden upon surgeons trying to do the right thing. This is the biggest challenge for spine surgeons today. 

Vik Mehta, MD. Hoag Hospital (Newport Beach, Calif.): Evidence for the optimal treatment of chronic low back pain remains sparse. A variety of treatment options ranging from fusions, neuromodulation and conservative treatment such as pain management and physical therapy are all in practice with highly variable selection largely based on surgeons' preference. We need better quality data to show how these treatment options compare head to head and make recommendations to patients that are backed by better quality data. 

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Ostensibly, the most recognized and discussed controversy in spinal surgery has to be MIS versus open procedure approaches for spinal diagnosis. Whilst the recognized complication rate for tubular approaches may be slightly less, the rate of fusion for MIS procedures remains less as well. Minimally invasive procedures for epidural pathology are associated with a similar incidence of complications and reoperation but seemingly have lower estimated blood loss, shorter operative time, hospital stay and expedited return to work time. Tubular microscopic spinal procedures also have the lowest reoperation rate of MIS procedures. Yet patient outcomes and satisfaction scores remain parallel. Albeit the current usage seems to be a training bias and choice, the assurance and confidence of its use is much more accepted and mainstay among surgical strategies.

Issada Thongtrangan, MD. Spine Surgeon at Microspine (Scottsdale, Ariz.): The most controversial issue in my opinion is if the interventionalist should perform spine surgery, especially fusion surgery. There are pros, cons, risks, benefits, expected outcomes, potential complications, etc. The bottom line is "do no harm." Patient safety and best interest are the utmost priorities. The other aspect is the training and skills of these "surgeons." This will remain controversial. My hope is that we can work as a team to get the patients what they deserve.

Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): I think the trend for increasing deformity surgery is controversial because the outcomes may not be supported by the cost and complications of the procedures.

Ali H. Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Motion preservation and robotic applications to spine surgery remain two areas of persistent controversy within our specialty. From a purely rational standpoint, there is no question that movement in the spine is normal, natural and generally superior to any fusion. The controversy arises in why so many surgeons have not adopted cervical disc replacements — and to a much lesser extent — lumbar disc replacements over anterior fusions. At this point, the published data for cervical disc replacements is superior to that of fusion in virtually every aspect. While this is less true for the lumbar spine, one would expect that artificial disc technology should be superior to fusion technology in its ability to restore and preserve movement, and prevent adjacent level disease.

Some of the controversy stems from reimbursement; others in insurance approval and the ability to do these cases in a cost-effective manner. For anterior lumbar surgery, a co-surgeon (vascular or general) is normally required in most areas of the U.S. In Europe, the standard of care involves the spine surgeon doing the exposure. The lack of availability of additional specialists can oftentimes mean that anterior lumbar surgery is not offered in a clinical setting.

Robotics is an area of controversy that is less well-defined. Certainly, the ability to decrease radiation exposure, improve the accuracy of instrumentation placement, and enhance reproducibility of results are all aspects that surgeons can agree on. The controversy arises in the cost of bringing robotics to the operating room, especially ambulatory surgery centers. In addition, there is no way to capture this cost from a sensible reimbursement standpoint. Efficiency has also not been improved with robotics, and for efficient spine surgeons who have many years of experience doing deformity surgery, robotics may not produce superior results.

One would assume that as technology improves and robots become less cumbersome, they'll become more widely adopted. The same holds true in every aspect of medicine, consumer technology and industry.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: By far, the participation of non surgeons in spine surgery remains a for controversial topic.  Both the AAOS, NASS, and AANS/CNS joint section on Spine and Peripheral Nerves have put out statements discouraging nonsurgeon colleagues from performing fusions.  It is unfortunate some will operate on patients, creating abnormal motion segments, causing iatrogenic deformity, fractures, or even serious infections and then refer the patients to surgeons, sometimes without warning, and avoiding accountability.  The main thing to remember in surgery is that if you cannot fix the complication, do not do the operation.  We need partners in caring that are not engaging in questionable or even dangerous operations that can harm patients in the name of revenue generation.  

Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): Endoscopic spine surgery is a controversial trend in spine surgery today. Some spine surgeons are advocating for endoscopic techniques as the next generation of minimally invasive spine surgery. Some fellowships are being designed to optimize exposure to these techniques. Other spine surgeons remain unconvinced. While some literature exists describing the outcomes compared to more traditional techniques or conventional minimally invasive spine surgery, unanimous acceptance has not occurred and will likely not occur. Many spine surgeons believe the learning curve is not worth, what they believe to be, equivocal results.

Chester Donnally, MD. Texas Spine Consultants (Addison): Multiple level disc replacements in the lumbar spine and primary sacroiliac joint fusions. Some top training programs don't even teach it while others live by it. Fortunately, we have leaders doing high impact research to help educate us further. It will be great when there is more consensus.

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