Spine surgery has never lacked data. It has lacked alignment.
For years, surgeons have reported outcomes using different metrics, definitions and thresholds, complicating efforts to compare and benchmark results. Now, as multipayer alignment pushes toward standardized quality measures, many see an opportunity to bring order to the field.
David Weiner, MD, assistant professor of orthopedic surgery at Georgetown University School of Medicine in Washington, D.C., however, foresees a challenge.
His perspective is this: Standardization has the potential to either elevate spine care or quietly constrain it. The difference will depend on how the data is used.
The promise of 1 language
In today’s landscape, quality is measured everywhere, but not always in the same way.
“In many systems, we’re obligated to have some element of quality metrics that help define our quality as a provider and allow us to be benchmarked against a standardized measure,” Dr. Weiner said. “When there are multiple different ways that’s done, it’s really hard when nobody’s saying, ‘This is how we’re actually going to measure that,’ especially when it comes to patient-reported outcomes (PROs).”
Without shared definitions, comparisons can mislead.
Academic and tertiary referral centers often treat sicker, more complex patients. Their outcomes, on paper, may appear worse than outpatient-focused practices performing lower-risk procedures.
“There’s always this conversation about our outcomes, that at the academic, tertiary referral centers, they may not be as good,” he said. “And we say, ‘Well, yeah, our patients are sicker. We’re doing bigger surgeries on more complicated problems.’”
Standardization, done correctly, could allow surgeons to allocate themselves appropriately — not siloed, but compared against peers treating similar risk profiles.
“We can sort of allocate ourselves to different pods and be really sure that our metrics are stacking up appropriately against the appropriate benchmark,” he said.
In that sense, alignment is not about a broad ranking. It is about context.
The decision-making shift
The most transformative opportunity Dr. Weiner sees is in surgical decision-making itself.
“I think that’s the end goal, right? To say, are we practicing evidence-based medicine, not just evidence-based by our fusion rates, but by the PROs and by the actual nationwide available information.”
He describes a future wherein spine-specific databases power real-time risk stratification with which surgeons can more precisely counsel patients.
“Being able to have access to data like that — whether it’s through an insurance company or because we’re all measuring things the same way — would allow me to quickly pull information and use it in a one-to-one conversation with a patient,” he said.
Instead of relying on generalized readmission rates across all specialties, surgeons could plug in age, comorbidities, surgical levels and anticipated course to estimate individualized risk.
“I can say, ‘Based on your specific metrics, you have a high percentage chance of a good outcome, for example, 80% of patients like you have meaningful improvement,’” he said. “That’s a very attractive tool to have when it’s used responsibly.”
That last word carries weight because the same calculator that empowers a surgeon can empower a payer.
The line between guidance and restriction
Dr. Weiner’s concern is not with measurement itself. It is with authority.
“As we move toward standardization, it’s easy to lose the individuality that a patient presents with,” he said.
He worries that insurers may eventually use standardized outcomes data to deny procedures for higher-risk patients, even when surgery is clinically necessary.
“If I have a patient with cervical myelopathy or severe stenosis and new weakness,” he said, “an insurance company could say, ‘Based on our data, we don’t think this is an acceptable surgical candidate.’”
Because insurers do not assume operative risk, he believes the incentives differ.
“They don’t accept any of the medical risks that we accept when we do these cases that do need to be done,” he said.“We need to be proactive about preventing that utilization instead of reacting after it starts,” he said. “Because once it starts, it won’t be easy to push back.”
A David versus Goliath reality
Even if outcomes alignment strengthens evidence-based care, Dr. Weiner expects the administrative burden to fall unevenly.
“I think it unfortunately is going to come down to the David versus Goliath argument,” he said.
Large health systems have centralized prior authorization teams, integrated intake systems and the resources to automate data collection. Smaller private practices may not.
“If you’re a small private practice and you don’t have access to those types of outcome forms, or you want to automate them within your intake system and have to purchase additional tools to do that, that may not be feasible,” he said.
He has seen insurers revisit authorizations and withhold payment over documentation discrepancies.
“They may deny a surgery, delay authorization or delay payment,” he said. “And in some cases, they’ll review a case after approving it and withdraw the prior authorization. That does happen.”
Practices without infrastructure to defend themselves may be most exposed.
“I think that it’s going to be the private practice folks that are the most vulnerable,” he said.
Measuring what matters to patients
Outcomes alignment ultimately centers on patients, but Dr. Weiner cautions against mistaking standardization for satisfaction.
“[Patients] deserve a voice,” he said. “Making sure that they are able to express themselves in a way that is standardizable.”
Still, surveys and scores cannot fully capture recovery: “We can try and make everything as standard as possible, but that strips away a lot of the human side of delivering care.”
Patient-centered care, he said, is rooted in responsiveness and advocacy.
“It’s ultimately our job as physicians to advocate for our patients, closely monitor their recovery, stay attentive to how they’re doing and respond appropriately to both good and bad outcomes,” he said.
That nuance can be difficult to quantify, making it necessary to calibrate outcome expectations accordingly for patients.
“Some were never going to have a great improvement because they had a spinal cord injury,” he said. “It’s a function of the severity of their problem.”
The research upside
Right now, spine outcomes reporting can feel, in Dr. Weiner’s words, like “acronym salad” (e.g., SF-36, SF-12, ODI, mJOA), layered across studies without uniformity.
“It’s so hard to follow,” he said. “I don’t know what these numbers mean half the time.”
A shared framework could simplify research, education and policy advocacy. When surgeons, trainees and insurers align definitions, decision-making crystallizes, not just for authorization, but for teaching and long-term outcomes tracking too.
“It helps us to be patient-centric and make sure that we are collecting the right data at the right time to deliver care,” he said.
Spine surgery is entering an era where data may carry as much influence as surgical technique. The question on the mind of Dr. Weiner and other forward-thinking physicians is not whether standardization will happen. It is whether it will strengthen surgical judgment or quietly narrow it.
