For most of my career, the spine patients I saw all told a similar story: pain for a prolonged period of time, multiple primary care visits and too many over-the-counter remedies. Out of options, they would finally come to my office, but their time spent seeking alternative solutions meant surgery was an inevitability. Frustration, both on my part and the part of the patient, is palpable in many of these evaluations. If only I had intervened earlier, they might have had more options. But the system was not set up for early intervention.
Making the shift to proactive spine care is a fundamentally different way of structuring the patient journey. I’ve spent the last several years redesigning how my own practice engages patients, and its impact on the medicine we practice and the outcomes we see have been nothing short of eye opening. I’ve watched how simple changes to our processes impact not just who ends up on my operating table, but also how much better prepared the patients who do need surgery become.
Not every patient needs surgery, but that’s the point
I want to be direct about something that often gets lost in most surgical innovation conversations, and that is the majority of spine patients I see do not need an operation. My job, and I’d argue the job of any spine surgeon operating in good faith, is to be the most credible voice for conservative care when conservative care is the right answer. There are three questions that should be asked in sequence to determine if a patient truly requires urgent surgical intervention:
- Is there a structural problem serious enough that surgery is the responsible recommendation regardless of how early we caught it? Those cases are a minority, but they are unambiguous, and early identification is what prevents permanent deficit. Additional considerations for urgent surgical intervention include patients at risk of neurological decline from significant nerve or spinal cord compression and those who have severe, intractable pain that limits their quality of life.
- For everyone else, is there a well-defined, time-bound conservative or multidisciplinary pathway that has a reasonable chance of resolving or substantially improving the problem? That’s where physical therapy, pain management, mental health support for chronic pain and metabolic health interventions become primary solutions. They are not stall tactics before the “real” treatment, and quite often are the only intervention needed for a large share of patients.
- Finally, does the patient understand the tradeoffs well enough to be a genuine partner in the decision, rather than someone who has been steered, in either direction, by a system that wasn’t built for their specific case? This is the puzzle piece that took me longest to fully internalize in my own practice, and it is where earlier engagement pays the largest dividend. A patient who has had time to try conservative measures, to understand their own response to treatment, and to have an honest conversation about goals and risk tolerance makes a fundamentally better surgical candidate when surgery is ultimately the right call.
I also believe there is real value in normalizing second opinions earlier in the evaluation process, not as a sign that something went wrong, but as a routine part of a well-functioning system. A patient who has heard a consistent assessment from more than one credible source trusts the recommendation more.
Proactive healthcare relies on a continuum, not a linear process
In practical terms, proactive spine care means engaging patients at the first meaningful sign of a problem rather than at the point of crisis. That sounds simple, but it requires rebuilding our infrastructure around a patient’s first contact with the healthcare ecosystem. In a traditional system, patients often try over-the-counter medications first, then see their primary care physician who prescribes stronger pain medication. If medication doesn’t work, it’s back to the primary care physician for a referral to physical therapy. As pain worsens, patients must go back to the beginning each time to try another option. Surgeons often are treated as an endpoint.
When we implement a true continuum of care, all specialties are treated as part of the patient’s consortium of providers. Think of a practice, patient-centered model more like a wheel: where the patient is the axle, and surgeons, pain management specialists, physical therapists, imaging and others serve as spokes on the wheel. Patients have a clear, fast pathway to spine-specific evaluation at the first point of entry, whether that’s during a primary care visit or therapy session. When these entry points use simple tools such as intake forms, they can identify risk factors and activate the consortium.
If there are any red flags during those first visits or on the intake forms, surgeons can help guide triage rather than inheriting its consequences. That distinction matters when so much of what determines a good outcome are the decisions made long before we pick up a scalpel.
Collaborative care and earlier evaluations change what surgeons can offer patients. For example, a patient who presents six weeks into a disc-related radiculopathy still has a full menu of conservative options available because their condition hasn’t yet progressed. In later stages, the chronic pain sensitization and deconditioned muscles around a compensatory posture can impair imaging, making diagnosis less precise and treatment planning harder. Those patients have a much shorter list of therapies available and risk permanent nerve pain.
The tools available to us now make this kind of individualized decision-making far more achievable than it was even a decade ago. Patient-reported outcome measures, collected systematically rather than anecdotally, give us objective ways to track whether conservative treatment is working before we let months slip by on hope alone. Wearable activity and movement data can flag functional decline earlier than a patient’s own subjective report, and telehealth triage can shorten the time between a patient’s first symptom and a spine-specific opinion from weeks to days.
But technology is only beneficial when complemented by a genuine multidisciplinary team of spine surgeons, physiatrists, physical therapists, pain psychologists, and primary care who communicate as a coordinated unit rather than a chain of independent referrals. When those teams share data and treatment philosophy, that consistency becomes the real definition of personalized care.
Adoption will require faith before dividends materialize
There’s also a business reality to address: delayed diagnosis often results in unnecessary imaging, redundant specialist visits, and higher rates of chronic opioid use. In fact, I believe the single biggest obstacle to scaling proactive spine care is not clinical, it’s incentive design. Our reimbursement systems still reward volume and procedure far more reliably than they reward the upstream coordination, navigation, and early conservative management that produce better outcomes. Practices and health systems must also be willing to invest in infrastructure, care navigators, integrated data systems, and standardized early-evaluation protocols well before the financial models hit the black. And yet, I’m convinced the surgeons and systems willing to make that investment now will be the ones setting the standard for spine care in the decade to come.
Since I was in medical school, the measure of a good spine surgeon was predicated on our technical skill in the operating room. This shift asks us to measure our own success not solely by surgical volume or complexity, but by how well we’ve matched each patient to the right level of care at the right time. Increasingly, it must now include the good judgment to know when surgery isn’t the answer and the discipline to build a practice that arrives at that decision earlier. Ultimately, proactive spine care gives surgeons a chance to rebuild patient trust in a specialty that has, fairly or not, earned a reputation for reaching for the scalpel too quickly.
Dr. Norton is an orthopaedic spine surgeon and founding partner of Florida Spine Associates in Boca Raton.
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