Spine surgeons have more ways than ever to avoid a fusion. Farah Musharbash, MD, also sees what happens when they try too hard.
In his revision practice, Dr. Musharbash encounters patients whose earlier operations were designed to preserve motion or limit the extent of surgery, but ultimately failed to solve the underlying problem. Sometimes, the next operation is bigger as a result.
That experience has complicated a philosophy he otherwise embraces.
“To me, a fusion is sort of the last resort,” Dr. Musharbash told Becker’s. “But many times, it’s the right thing to do.”
Dr. Musharbash, a spine surgeon at Morristown, N.J.-based Atlantic Brain and Spine, performs endoscopic and minimally invasive procedures, artificial disc replacements and complex deformity surgery. He sees those options along a spectrum, with fusion reserved for cases in which preserving motion can no longer adequately address the pathology.
As endoscopy, disc replacement, navigation and other advances expand that spectrum, the question is no longer simply whether surgeons can do less. It is how they know when they should.
A growing spectrum before fusion
When possible, Dr. Musharbash starts with procedures that are both minimally invasive and motion-preserving. Some patients may need a larger exposure while still avoiding fusion. Others may be candidates for motion-preserving implants such as artificial discs. Farther along the spectrum are minimally invasive fusions, followed by open fusion for conditions such as complex deformity.
That shift is particularly evident in the cervical spine. Dr. Musharbash pointed to expanding indications for cervical disc replacement, including select patients with myelopathy or more advanced degeneration. Navigation has also made it possible to perform minimally invasive decompressions with greater precision while limiting the amount of bone removed and the risk of creating instability.
“I’m doing less and less fusions than I was in training,” he said.
The same shift is taking hold in the lumbar spine. For select patients with severe foraminal stenosis, endoscopy can provide the angle needed to decompress the foramen without fusion. And some patients referred to Dr. Musharbash for lumbar fusion because of axial back pain may instead be candidates for lumbar disc replacement.
Endoscopy can also allow surgeons to address certain thoracic disc herniations without adding a fusion. More options, however, do not always make the choice easier.
“If you talk to 10 different spine surgeons, you may get like 10 different answers,” Dr. Musharbash said.
When doing less becomes doing too little
Motion preservation carries an intuitive appeal: preserve anatomy and mobility, avoid unnecessary hardware and limit the magnitude of surgery when possible. But Dr. Musharbash’s revision practice has also shown him the risks of doing too little.
“I do a lot of revision surgery,” he said. “Sometimes people try to do less, but it potentially makes things worse and makes it harder for the revision surgery.”
Scoliosis is one example. A patient may undergo a short-segment fusion in an effort to limit the operation, only to decompensate later and require a substantially larger procedure. In those cases, doing less initially can ultimately lead to more surgery.
Dr. Musharbash sees other pathologies where fusion remains the better operation. Unstable spondylolisthesis can create dynamic nerve compression that requires stabilization. Severe vertical foraminal collapse from disc degeneration may require reconstruction rather than decompression alone.
He also leans more toward fusion when patients have significant facet arthritis and disc degeneration and are as troubled by axial back pain as they are by radicular symptoms. But those findings do not make the decision on their own.
“You don’t want to treat the MRI,” Dr. Musharbash said. “You really want to treat the patient, what their expectations are and what they’re looking to get out of the surgery.”
The question, then, is not whether fusion is becoming obsolete. It is whether surgeons can become more precise about which patients actually need it.
Patient first. Pathology second. Technique third.
That judgment becomes even more important as the spine surgeon’s toolbox expands. Dr. Musharbash cautions against becoming so committed to one approach that the technique begins to dictate the operation rather than the patient’s pathology.
“The techniques exist for a reason, and some are better at addressing certain pathologies than others,” he said.
For Dr. Musharbash, the order matters: “First, it’s the patient and their symptoms that should be the primary driver. Then it’s the pathology, and then it’s the technique.”
Dr. Musharbash completed an orthopedic surgery residency at Baltimore-based Johns Hopkins Hospital before a combined orthopedic and neurosurgery spine fellowship at Hospital for Special Surgery, Weill Cornell Medicine and Memorial Sloan Kettering Cancer Center in New York City. He credits that training with exposing him to a broad range of techniques, implants and technologies.
The advantage, he said, is not having more tools for their own sake. It is being able to adapt the operation to the patient rather than the patient to the operation.
Maintaining that flexibility gets harder as surgeons become comfortable with techniques that have worked throughout their careers. That is why Dr. Musharbash sees humility as part of the job.
“There’s something that’s going to come up in the future that’s going to be better than what I’m doing right now,” he said.
A surgical career can span 30 or 40 years. Over that time, he said, surgeons have to remain willing to scrutinize new research, examine their own outcomes and learn new approaches when the evidence warrants it. Otherwise, yesterday’s expertise can become tomorrow’s limitation.
Where fusion may lose more ground
There are already patients for whom Dr. Musharbash believes motion preservation should play a larger role.
He pointed to young, otherwise healthy patients with cervical radiculopathy from a soft disc herniation and no significant arthritis, degeneration, deformity or instability. For appropriate patients, cervical disc replacement or discectomy can preserve motion without fusion.
Beyond those cases, however, he is reluctant to predict a broad retreat from fusion. Spine pathology is too nuanced, and the consequences of doing too little can be significant.
That may be where the pendulum ultimately settles. The future of spine surgery may be less about fusing less and more about choosing more precisely, knowing when fusion can be avoided and when preserving motion is no longer the right goal.
“If your solution or technique doesn’t fix the patient’s problem because you didn’t want to do a fusion, then you haven’t solved the problem,” Dr. Musharbash said.
For all the new options available to surgeons, his standard remains straightforward: “You’ve got to fix the problem.”
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