As spine programs expand, the conversation often defaults to scale: more surgeons, more volume, more complexity and a constant pressure to keep up with fast-moving technology.
David Skaggs, MD, co-director of Los Angeles-based Cedars-Sinai Spine and director of pediatric orthopedics at Cedars-Sinai Guerin Children’s, doesn’t dismiss any of those realities.
Cedars-Sinai Spine is now among the largest spine programs in the country, and he’s seen how growth can unlock resources, access and operational leverage.
But he’s also blunt about what can quietly slip when programs get bigger: the habits that keep teams sharp, aligned and relentlessly focused on patients.
“The danger is, can we all be better than the 50th percentile?” Dr. Skaggs told Becker’s. “It’s kind of a joke that most surgeons think they’re better than the average surgeon. So how do we actually make that true for a large center?”
For him, the answer isn’t simply adopting the newest tool or adding more capacity. It’s protecting something less visible and far more fragile.
“One of the most important things, hands down, is culture,” he said.
Building a team that stays honest as volume rises
As spine programs scale, outcomes rarely deteriorate overnight. They drift, through small breakdowns in communication, repetition, accountability and follow-through. Dr. Skaggs believes the best defense is creating a culture that treats improvement as a shared responsibility, not a critique.
“Do we have a culture where we’re open to continual improvement?” he said. “That means being open to the fact that maybe we’re not doing everything perfectly right now.”
In surgery, that kind of openness can be difficult to sustain. Confidence matters, and so do egos. Dr. Skaggs said what makes continuous improvement real is building routines where everyone is expected to reflect, including the surgeon leading the room.
He drew that model from an unexpected source: the U.S. Navy Blue Angels.
“I learned this from the leader of the Blue Angels,” Dr. Skaggs said. “After every show, they do about a 45-minute debrief, and the leader starts by asking, ‘What could I have done better?’ Then every person shares.”
He brought that same approach into the operating room.
“As I take off my gloves and scrub out, I say, ‘OK, everybody, here’s what I could have done better,’” he said.
It might be a planning detail. It might be a small issue that could be missed in the rush of a busy schedule. The point, he said, is to create a space where learning is safe enough to happen in real time.
“By saying what I could do better, everyone else feels comfortable,” he said. “People speak up.”
Dr. Skaggs frames the practice as a way to keep the team centered on its real purpose.
“It sets the tone that the patient’s welfare comes first,” he said.
And he said the most effective spine care is never a solo performance.
“As a surgeon, I’m almost useless by myself,” Dr. Skaggs said. “I’m only useful when I’m part of a good surgical team.”
Why “elite” spine care should look the same in the clinic as it does in the OR
Dr. Skaggs believes programs can lose patient confidence long before a procedure happens. The patient experience, he said, isn’t a separate initiative, it’s part of clinical quality, which starts in the office.
“How many times have we all been to a doctor’s office where we feel like nobody cares about our time and we’re disrespected?” he said.
At Cedars-Sinai, he said one operational focus has been designing a more consistent care journey, especially for patients traveling from out of state. The goal is to make care feel coordinated rather than fragmented.
“One of the differentiators is nurse navigators,” Dr. Skaggs said. “We created a new position and title.”
Nurse navigators, he explained, often make the first contact with patients, collect imaging and history and help coordinate telehealth and planning before patients arrive in Los Angeles.
“By the time they come here, surgery may already be scheduled,” he said. “The family has already met the nurse navigator. They’ve met the surgeon through telehealth. The same nurse navigator sees the patient in clinic, sees them postoperatively in the hospital and follows up with telehealth afterward.”
He believes that kind of continuity changes how patients experience a high-volume program.
“The nurse and I give both of our cell phone numbers to every patient’s family,” Dr. Skaggs said, “so they feel they’re cared for beyond being just a number, and help is available when needed.”
New technology demands transparency, not marketing
Few specialties feel the pull of technology like spine surgery. Robotics, navigation and minimally invasive platforms have accelerated rapidly, and adoption decisions can quickly become entangled with competition and branding.
Dr. Skaggs said programs have to be cautious about the assumption that newer is always better.
“Robots are probably between $1.5 million and $2 million a shot,” he said. “Everybody wants to market that they have robotic minimally invasive surgery. But there are studies showing it’s not always necessarily better.”
For him, the bigger risk is what happens when the marketing runs ahead of the data, and when organizations don’t publicly acknowledge learning curves or complications.
“It’s easy when new technology comes out to shout, ‘We have the newest technology, it is wonderful, come here,’” Dr. Skaggs said. “But when things don’t go well, people don’t tend to put it on websites.”
In his view, credibility depends on a willingness to publish what didn’t go well in peer-reviewed journals and respond with measurable improvement.
“One of the ways we maintain credibility is to publish what doesn’t work so well,” he said.
Dr. Skaggs pointed to a Cedars-Sinai study published in The Journal of Bone and Joint Surgery on robotic spine surgery outcomes.
“A paper was just published … showing that robotic surgery at Cedars-Sinai had a 2.3% rate of complications,” he said. “Screws were being put in the wrong place.”
Instead of downplaying the results, he said the organization responded by tightening the process. Cedars-Sinai partnered with industry and created formal requirements for robotic spine cases, standards that were mandatory, not optional.
“We partnered with industry,” Dr. Skaggs said. “We put industry in a room and surgeons in a room and came up with 10 points that became mandatory.”
The protocol itself focused on workflow safeguards, including best practices for reference-frame placement, intraoperative trajectory checks, depth limits while drilling, neuromonitoring for thoracic screws and imaging confirmation before leaving the operating room.
When surgeons asked what would happen if they didn’t want to follow the requirements, he said the answer was straightforward. “‘Don’t operate at Cedars,’” Dr. Skaggs said.
The shift, he added, was immediate in the data. “In the next 300 cases, there wasn’t a single robot-related complication,” he said.
What top spine programs do differently
When asked what the best spine programs consistently do that others don’t, Dr. Skaggs didn’t point first to technology, recruitment or size. He pointed to something that requires humility and structural commitment.
“If I had to pick one thing, it’s open and honest peer review,” he said.
The strongest programs, he said, build routine forums where surgeons review cases before and after procedures and are willing to surface mistakes and near-misses, not to punish, but to improve.
“They show what went wrong,” he said, “and they give each other honest criticism about what could have been done better.”
But peer review, he noted, is also shaped by incentives. If an institution values production above all else, peer review can become an afterthought, despite its role in quality.
“This depends on incentives,” he said. “There’s a quote: ‘Show me the incentive, I’ll show you the behavior.’ If the incentive is purely dollars per [relative value unit], there may not be incentive, at least in the short term, to sit in a room and show your cases to each other.”
For Dr. Skaggs, the “long play” for spine programs is investing in practices that sustain quality at scale: time for review, space for learning and infrastructure that supports patients beyond surgery.
The next evolution of spine care could be nonoperative
Even in an environment where spine surgery continues to grow, Dr. Skaggs sees a preventable gap across the industry: too many patients aren’t receiving fully integrated conservative care before surgery becomes part of the conversation.
“The next evolution in spine care is that spine centers have nonoperative or conservative physicians and programs,” he said. “Most people with back pain don’t need spine surgery.”
His vision is to rebalance the model.
“I’d love for us to have two nonoperative specialists for every operative specialist,” he said.
But, he emphasized that conservative care must be aligned within the system, not siloed or structured as a separate business competing with surgeons and physical therapy.
“You can’t have the non-ops versus the surgeons,” Dr. Skaggs said. “I’m afraid that’s how it’s incentivized at many centers. The truly elite centers will have everyone incentivized together.”
The hallmark of an elite spine program: ortho and neurosurgery working as one
Dr. Skaggs also believes elite spine programs require a level of specialty collaboration that some systems still struggle to achieve. In many markets, orthopedic surgery and neurosurgery operate with tension and competition, which can undermine both culture and outcomes.
“At some centers, they fight so much they’re physically put in different buildings because there’s competition,” he said.
The strongest programs, he argued, intentionally bring the specialties together through shared review, shared accountability and a shared commitment to patients over internal politics.
“The truly elite programs are together,” he said. “It takes energy. It takes beating down egos and putting patients ahead of surgeons’ egos.”
If programs want scale without slippage, they have to build trust across specialties and be unafraid of honest review.
“Peer review and neurosurgery and orthopedic surgery truly working together are the two hallmarks of an elite spine program these days,” Dr. Skaggs said.
