The outdated ideas in spine that still persist


While spine surgery has evolved significantly in recent decades, there are still some old ideas that stick in the industry. Eight spine surgeons discuss the outdated practices that remain today.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.

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

Question: What's an outdated idea or technique in spine surgery that still persists today?

Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (West Bloomfield, Mich.): An outdated spine surgery technique is iliac crest autologous bone graft harvesting. There are a number of complications related with harvesting iliac crest bone graft, including "donor site pain." I have not seen any people performing this today, but if it is then reconsideration should be given.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Performing in-situ fusions is still done occasionally. I rarely see this in any second opinions I have done — I do occasionally see patients who are more recently post-op. I am fairly certain the practice is done in vanishingly small numbers and really hope folks who do still do it will switch over to using instrumentation, or refer the patients out.

Chester Donnally, MD. Texas Spine Consultants (Dallas): I will often send patients to pain management outside of my group, closer to their home, only to learn that they were offered surgery with an interspinous clamp. I think these have a very very limited role in 2023 spine surgery.

Mohammed Khan, MD. New Jersey Brain and Spine (Hackensack): Spine surgery still clings to an outdated idea that extensive spinal fusion is often necessary, despite evidence supporting the effectiveness of non-fusion alternatives with fewer risks. Some medical practices continue to hold onto the traditional mindset of defaulting to fusion as the primary treatment option.

Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): I am still surprised to encounter patients who have been treated by other spine surgeons who do not believe in sacro-iliac joint pain. While that was more common ten years or more ago, there is such a wealth of literature today that it is hard to justify that thought. To those surgeons, the SIJ must be that one magical joint in the body that cannot cause pain. While treatment recommendations may differ, on face value, it makes no sense to deny the diagnosis exists.

Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): There are a lot of spine surgeons that still perform traditional open posterior lumbar fusions through a large midline incision with significant soft tissue dissection. The minimally invasive lumbar fusion techniques, tools and equipment have been improved significantly over the past 20 years. Minimally invasive spine surgery is technically more demanding and requires additional training, but it offers significant benefits to the patients over the traditional techniques including much lower blood loss, lower risk of infections, shorter hospital stay, less postoperative pain, and quicker recovery.  

Noam Stadlan, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.): Prior to the development of instrumentation, spinal bony fusion was the only way to assure stability. The initial hardware was developed to assist in fusion.  Surgical success was defined and dependent on fusion. Fusion can have unwanted side effects, specifically loss of motion and adjacent level disease. Motion preservation devices are a step towards addressing these issues. But putting those devices aside, our current fixation hardware may have the potential to provide adequate fixation even without solid fusion. In other words, perhaps a stable pseudoarthrosis can be an acceptable or even desired outcome in some (certainly not all) cases. Our fixation (pun intended) on fusion as the only desired outcome in all instrumentation cases may be an outdated idea, or at least one that we should revisit.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): One of the constantly discussed issues in complex spinal disorders and its past evaded definition is the concept of adjacent segment failure/disease and its accelerated degenerative processes following fusion of the lumbar spine. It is author acknowledged at approximately 10 percent to 14 percent, whereby this locking of the spine's segmental forces compensatory changes to the adjacent proximate levels. The stressors and loads to these upper/lower vertebrae force the intervertebral disc to degenerate and lead to the ASD condition. Many biomedical implants have been designed and marketed to address this phenomena, with little success and in most experienced practitioners. 

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