'Spine surgery seems to be in a golden age': The trends generating the most buzz


From motion-preserving techniques to advanced navigation technologies, there are multiple emerging trends in spine surgery.

Several spine surgeons shared the trends that have their attention.

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: Where are the biggest opportunities for spine surgeons to reduce costs?

Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Wednesday, Oct. 4.

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

Question: What trends in spine surgery excite you most?

Chester Donnally, MD. Texas Spine Consultants (Dallas): I like expandable cage technology. It allows for the obvious — a small portal and working window — yet a large impact. The next generation of these will be able to feature either PEEK, titanium coated PEEK, as well as medial to lateral expansion. Some of these already exist of course, but more and more are coming out. The possible issue with the expandable cages is a likely higher risk of subsidence. So, I look forward to seeing more information about how to reduce this risk in terms of the Newtons associated with the expansion, larger medial-lateral footprints, and patient selection!

Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (West Bloomfield, Mich.): 

1. Minimally invasive techniques: Advancements in minimally invasive spine surgery have revolutionized the field, allowing for smaller incisions, reduced risk of infection and faster recovery times.

2. Robotic-assisted surgeries: Robotics and artificial intelligence are increasingly being used in spine surgeries to enhance precision, improve outcomes and reduce the risk of complications.

3. 3D printing: Customized implants and instruments created through 3D printing technology are enabling surgeons to provide personalized solutions for complex spinal conditions.

4. Motion-preserving techniques: Rather than fusing vertebrae together, surgeons are now exploring motion-preserving techniques that allow for greater flexibility and preservation of natural movement in the spine.

5. Non-fusion alternatives: Non-fusion technologies, such as artificial disc replacements and dynamic stabilization systems, are gaining popularity as alternatives to traditional fusion surgeries.

6. Regenerative medicine: The use of stem cells and other regenerative therapies in spine surgery holds great promise for repairing damaged spinal tissues and promoting healing.

7. Navigation systems: Advanced navigation systems using real-time imaging and computerized guidance help surgeons navigate the complex anatomy of the spine more accurately, improving surgical precision.

8. Virtual reality and augmented reality: Surgeons can now use virtual reality and augmented reality techniques to visualize the patient's anatomy before and during surgery, assisting in planning and execution.

9. Biologics and tissue engineering: Innovative biologic materials, such as bioactive bone grafts and engineered tissues, are being developed to enhance spinal fusion and promote better outcomes.

10. Patient-specific care: With advancements in imaging technology and computer modeling, surgeons are able to provide individualized treatment plans tailored to each patient's unique anatomical and functional needs. 

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Right now I see a lot of troubling trends. To stay positive, I see patients who understand their conditions better thanks to the internet. An educated patient asks great questions and I think so much better in terms of recovery, as they start ahead of the game, and we can focus on what to expect after surgery. They feel much more focused and relaxed as they get better.  

Arun Hariharan, MD. Paley Orthopedic and Spine Institute (West Palm Beach, Fla.): As a pediatric orthopedic and spine surgeon, I've been following two particular trends with great interest: the integration of augmented reality technology and the collaboration between AI and patient-specific technologies. These developments are adding a new dimension to how we approach surgeries and patient care, and I'm excited to see their potential unfold.

Augmented reality: Imagine being in the operating room and having the ability to superimpose detailed 3D models of a patient's spine onto their actual body. AR allows us to do just that. Navigation has been a game-changer in safety and efficacy, but AR will take it one step further.

This real-time visualization is a significant step forward in surgical planning and execution. It assists us in placing implants accurately, planning corrective actions, and maintaining focus on the patient throughout the procedure. For pediatric patients, whose growth patterns are unique and dynamic and often have distortion of "normal" anatomy, AR offers a valuable tool that can adapt as they grow, contributing to personalized and precise treatment plans.

AI and personalized care: AI has become a game-changer in many fields, including healthcare. In spine surgery, AI's ability to analyze extensive patient data enables us to create tailored treatment approaches. This includes customized surgical strategies, implant choices, and postoperative care plans that suit each child's individual needs. AI's predictive capabilities are particularly valuable, since they allow us to anticipate potential complications and address them proactively. The integration of AI into patient care also helps with personalized and evidence-based approaches. For example, we already take advantage of the power of this by using AI and models to generate rod contours for our scoliosis patients based on a large database of "normal" and based on parameters of correction we aim for.

While these trends highlight technological advancements, AR and AI enhance our ability to work closely with patients and their families, offering a clearer understanding of the surgical process and potential outcomes. I see these trends as valuable tools that can enhance the care we provide to our young patients.

Sohaib Hashmi, MD. UCI Health (Orange, Calif): Navigated/ image guided and robotic decompression procedures are forthcoming, potentially leading to more accurate and effective patient outcomes.

Artificial intelligence and pre-planning of instrumented spine surgery is allowing for better understanding of normative and corrective sagittal and coronal alignment parameters.

Endoscopic spine surgery continues to have a larger role in minimally invasive surgical techniques. Advances in technology allow larger footprint interbody cages.

Prone lateral surgery has advanced to allow thoracic and lumbar corpectomy solutions in challenging trauma and tumor settings.

Sanjay Khurana, MD. orthopedic spine surgeon with Hoag Orthopedic Institute in Southern California (Marina del Rey): There are five trends which interest me most in spine surgery: image navigation, endoscopy, robotics, regenerative biologics and disc arthroplasty.

We presently use the Nuvasive/Globus Medical Pulse navigation for our instrumented cases in our ASC. This affords near 100 percent fidelity for hardware and interbody placement. I have used the Globus Excelsior robot at our hospital and have found benefits of this tool as well. I think for the more complex deformities, the robot will be exponentially more helpful for pre-determined screw placement and predictive spine corrections. 

Endoscopy excites me as an ultra-minimally invasive tool for decompressions and discectomies. The optics and technology has come a long way since I saw the earliest iteration nearly 20 years ago. I am tiptoeing cautiously into this technique, but my early experience suggests a rapid learning curve and promising patient outcomes.

Regenerative biologics, whether stem cells, PRP or other peptides, seem to be gaining traction in the peripheral joints like shoulders, knees and hips. Hopefully, it's a matter of time before we can influence and lengthen the durability of discs and minimize recurrent disc ruptures.

Finally, disc arthroplasty has clearly been the most tangible disruptive technology in the spine, which is improving the outcomes for patients. I believe the technology will continue to improve and I would surmise this will become the mainstay of primary lumbar and cervical surgical treatment in the coming decades.

Intersecting all these technologies and knitting them together as a platform, I would imagine the ultimate suite of tools to offer patients bespoke, highly accurate, and reproducible outcomes for our spine patients.

Daniel Kim, MD. Andrews Sports Medicine & Orthopaedic Center (Birmingham, Ala.): Endoscopic spine surgery: Minimally invasive spine surgeons are constantly seeking to minimize the dysfunction and pain associated with surgery, while keeping true to intraoperative goals, which are irrespective of method. Endoscopic surgery presents an opportunity to decompress the spine, and in certain situations, even include instrumentation, with the least muscular, ligamentous or osseous collateral damage of any technique that exists in spine surgery today. Indications, complication management, techniques and training are rapidly advancing in this field, which is evident in the increased adoption rates in the United States. Although not for every situation, endoscopic spine surgery will likely be a very important tool in the arsenal of the future spine surgeon. 

Personalized implants: Current economics of spine surgery are not sustainable. A facet of this involves the spine implant market, which in its current state is inefficient, expensive and in many ways wasteful. The advances in technology with respect to preoperative planning, machining and production will likely lead to more efficient and cost-friendly implants, surgical trays and other instrumentation. Modern imaging technologies, artificial intelligence and other enabling tech like navigation and robotics can help determine the appropriate implants for each patient at each level, while reducing intraoperative second guessing. The ability for local manufacturing and more streamlined distribution combined with enhanced, efficient planning will lead to reductions in cost for the system, less stress on the operative staff and potential increases in patient outcomes.

Robotics: The current iteration of the spine robot, regardless of platform, is a great tool for safety and planning, but not a game changer in terms of operative efficiency and ability. Newer generation robots will greatly alter workflows, with the ability for faster and accurate registration, segmental registration with live tracking, enhanced planning software, and the ability to perform powerful surgical tasks such as facet decortication, retractor placement, amongst others. Enhanced speed, accuracy and ability will result in significantly enhanced adoption.

Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): I believe that spine surgery, like much of healthcare, is reaching a tipping point. Costs are out of control. The nature of the current model for the [large payer companies] necessitates that costs rise for profit to rise. I saw a statistic that average millennials will spend 50 percent of their gross lifetime earnings on healthcare.That is not tenable. Free market options are beginning to gain traction. Healthcare purchasers are becoming more educated. I believe that freedom is generally a good idea. Nothing will drive value in healthcare better than a direct interface between willing buyers and sellers. The notion that we cannot pay for care and the solution is to add mountains of regulation is absurd. (Cost of care) < (cost of care + administrative behemoth).

Todd Lanman, MD. ADR Spinal Restoration Center (Beverly Hills, Calif.): Spine surgery seems to be in a golden age right now, especially with advancements in artificial discs and expanded indications for ADR. Revising a fusion with an artificial disc was unheard of ten years ago, and now we are seeing them all the time. Same with three- and four-level artificial disc. Restoring a patient's spinal mobility or keeping them from living a life with a four-level fusion is an exciting trend that I believe will become the new normal.

Bjorn Lobo, MD. DISC Sports and Spine Center (Newport Beach, Calif.): The movement away from spinal fusion surgery toward motion preserving surgery is a trend I find quite exciting. The positive results surgeons have had with total disc replacements for single- or two-level pathologies resulting in radiculopathy are encouraging them to try TDR on other pathologies. I have noticed more reports of results with TDR for pathologies typically treated with fusions, such as degenerative disc disease resulting in multilevel stenosis or causing myelopathy. In my region, I have seen an uptake in TDR to salvage adjacent segment disease in previously fused patients, as well as hybrid TDR and fusion models to manage multilevel degenerative disc disease that includes segments that are too far gone to undergo disc replacements. So far, these results have seemed favorable, but — as with many things in spine surgery — long-term studies will be needed to validate this trend.  

Another exciting trend I have noticed is the increasing utilization of full-spine/body imaging to inform surgical decisions in single- or two-level degenerative disc disease. As more studies show the importance of maintaining or restoring good spinal alignment in terms of patient function, longevity of a spinal construct, and prevention of adjacent segment disease, spinal surgeons are ordering more comprehensive spinal imaging before deciding the optimal surgical approach for patients with more focal degenerative disc disease. In my practice, I find myself more often ordering full-length "scoliosis"' plain films when considering any thoracic or lumbar fusion. Additionally, the standing whole-body skeletal radiographs provided by EOS imaging systems give spine surgeons greater insight into a patient's baseline deformity as well as helping us choose specific interbody grafts to restore a more physiologic alignment.  

Both of these trends are significant in that they demonstrate the overall trend in our community of employing techniques with the goal of maintaining patients' long-term function while preventing additional future operations.

Anthony Russo, MD. Billings (Mont.) Clinic: One of the most promising trends in spine surgery is the integration of advanced technologies into the operating room. Whether it's navigation, robotics or AR, these technologies enhance accuracy and reduce invasiveness in complex procedures. This leads to increased safety, reproducibility, efficacy and patient satisfaction.

Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): Further adoption and refinement of minimally invasive techniques in spine surgery has been very beneficial to our patients. Smaller incisions (while maintaining surgical effectiveness) lead to lower risk of complications, less blood loss, quicker recovery, and less pain. MIS techniques also allow us to safely perform spine surgeries on patients that would be very poor candidates for traditional open surgeries. There is still more work to be done on improving surgical techniques, instrumentation, and training more surgeons to make MIS spine surgery the standard of care for our patients. It is an exciting time to be a spine surgeon!

Bo Zhang, MD. The Centers For Advanced Orthopaedics (Bethesda, Md.): In spine surgery, it is most gratifying to see the increasing adoption of minimally invasive techniques with tubular and endoscopic surgery at the forefront, assisted by percutaneous instrumentation with fluoroscopy, navigation, robotics and a variety of technology in development. As more academic centers are emphasizing MIS over traditional open techniques, many new surgeons are coming into practice with this skill set.

While techniques are evolving, the goals and principles of spine surgery remain the same: decompression, stabilization, and fusion with appropriate alignment. However, access to accomplish these goals varies tremendously, with tissue trauma and physiologic burden being exponentially higher in an open surgery compared to MIS. For appropriate cases, minimally invasive surgery can lead to improved short-term outcomes and postoperative recovery, including less pain, less blood loss, quicker discharge, and faster return to activities.

While long-term outcomes and costs remain central points of debate for widespread adoption of MIS-enabling technology, I believe it will be inevitable that increasing literature on favorable outcomes, evolving technology, patient preferences, and the transition to outpatient surgery will all continue to push the evolution to MIS spine surgery forward. 

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): AI in spinal surgery management is trending in a number of areas, as we carefully explore its utility and use. A number of trends have been forerunners for a number of years, including the minimally invasive surgery designation and consolidation of surgical services in a collective effort towards efficiency and cost containment. The conceptual acceptance surrounding three-dimensional printing and construction will be forthcoming as orthobiologics and health systems seek additional methods to further costs and spending. 

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