The reputation of spine surgery was built in another era. Patients still imagine a long incision down the back, muscles stripped from the spine and months spent recovering in a brace. For decades, that fear was not irrational. Some fusion patients once remained on bed rest for months while waiting for the spine to heal.
The operation has changed faster than its reputation.
Today, some patients can walk hours after a fusion and leave the hospital the same day. Surgeons can reach the spine through muscle-sparing incisions, plan implants on a CT scan and guide them with navigation or robotics. Regional anesthesia and improved pain protocols have shortened recoveries that once defined the procedure.
Stéphane Owusu-Sarpong, MD, spends a significant portion of his clinic visits explaining that difference.
“It’s not like even 10 to 15 years ago,” Dr. Owusu-Sarpong, an orthopedic spine surgeon at Hospital for Special Surgery in New York City, told Becker’s.
The transformation has made spine surgery less invasive, more precise and, in many cases, eased recovery. However, it has also made the decisions more complicated.
A smaller incision is not automatically the better operation. Preserving motion is not always preferable to eliminating it. A robot can place an implant accurately, but it cannot decide whether the patient should receive that implant in the first place. As the technology improves, the central task of the spine surgeon remains the same: Choosing the right operation for the right anatomy.
The operation moved around the muscle
Traditional open spine surgery generally required an incision along the middle of the back and extensive dissection of the muscles attached to the spine.
That exposure gave surgeons room to see the anatomy and perform complex reconstruction. It also created pain and muscle injury that could prolong recovery.
Minimally invasive approaches changed the route. Instead of dissecting directly through the muscles from the center, surgeons can use smaller paramedian incisions and reach the spine through muscle-sparing corridors. Navigation and robotic assistance help them place implants through those more limited exposures.
Research has associated those approaches with less muscle damage, lower postoperative pain and faster recovery, Dr. Owusu-Sarpong said. The shift is especially significant for common degenerative conditions. A patient undergoing a short lumbar fusion may now receive surgery through several small incisions, begin walking the same day and, depending on the case, recover at home rather than in the hospital.
That experience is far removed from the procedure many patients still fear. But Dr. Owusu-Sarpong is careful not to describe every spine operation as becoming minimally invasive.
A severe spinal deformity still requires surgeons to place multiple anchor points, release stiff portions of the spine and use rods to correct alignment. The work cannot always be compressed into several small openings without compromising what the operation must accomplish.
Certain procedures remain large because the disease is large. Progress does not mean pretending otherwise.
Fusion became the word patients fear
The growth of motion-preserving surgery has created a second change in patient expectations. Many patients now arrive asking for a disc replacement before the surgeon has determined whether they are candidates for one.
Dr. Owusu-Sarpong understands the appeal. A cervical disc replacement removes a damaged disc while preserving movement at that spinal level. It eliminates the risk of a failed fusion at that segment and may reduce the likelihood of future surgery at an adjacent level.
For a younger patient with a soft-disc herniation, limited arthritis and preserved movement, Dr. Owusu-Sarpong said he would generally favor disc replacement over fusion.
The clinical evidence supporting cervical disc replacement has become difficult to dismiss. The technology was originally studied against anterior cervical discectomy and fusion through noninferiority trials, but Dr. Owusu-Sarpong said some long-term findings have favored arthroplasty on measures such as reoperation.
That does not make fusion obsolete.
“Fusion eliminates painful motion,” he said. For a patient with severe arthritis, significant bone spurs or degeneration in the facet joints behind the disc, preserving motion may also preserve the source of the pain.
A disc replacement addresses the damaged disc at the front of the spine. It does not stop arthritic facet joints from continuing to move. The surgery can successfully relieve arm pain caused by nerve compression and still fail to resolve the patient’s neck pain. In those cases, fusion may provide the more durable result because it stabilizes the entire motion segment.
The problem is not the operation. It is applying a promising operation to a patient whose anatomy does not support it.
The scan that changes the choice
Dr. Owusu-Sarpong relies heavily on CT imaging when evaluating patients for cervical surgery. An MRI shows the nerves, spinal cord and damaged disc. X-rays show alignment and movement. The CT scan offers a more detailed view of the bone, including the arthritis within the facet joints. He considers those data essential when choosing between disc replacement and fusion.
“I’m sort of baffled that, in today’s age, you wouldn’t get as many data points as possible,” he said. He compares the decision with boarding an airplane. A passenger would not want the pilot working from an incomplete or hazy map. The patient should not want a surgeon making a permanent decision with incomplete information either.
There is no absolute age cutoff for cervical disc replacement, but Dr. Owusu-Sarpong said many of his candidates are younger than 55 because they are less likely to have advanced arthritis.
Age alone does not make the decision. The condition of the joint does. That becomes even more important when a patient has disease at multiple levels. One level may be severely arthritic and better suited for fusion. The level above it may have a softer herniation and preserved joints.
Rather than forcing the entire neck into one philosophy, the surgeon can perform a hybrid operation: fusion at the arthritic level and disc replacement where preserving motion remains reasonable. The approach reflects a broader evolution in spine surgery. The future may not be fusion or motion preservation. It may be knowing where each belongs in the same patient.
The robot changes what a surgeon is willing to attempt
Robotics has changed another part of the operation: the confidence with which surgeons place implants. The system does not independently perform the surgery. The surgeon creates a preoperative plan, activates the robotic arm and physically inserts the screw along the planned trajectory. That distinction matters because patients sometimes imagine a machine operating without a physician. “It’s robotic-assisted,” Dr. Owusu-Sarpong said. “I press a pedal. The robot, based on my pre-op plan, says the screw goes here.”
The benefit is precision. When placing a screw with traditional anatomic landmarks, a surgeon may choose a shorter or narrower implant to avoid approaching a nerve or another vulnerable structure. With reliable navigation and a planned robotic trajectory, the surgeon can often use a longer or thicker screw with greater confidence. That can improve fixation in the bone and create a stronger environment for fusion.
The technology also changes surgical education. Dr. Owusu-Sarpong can allow a resident to place a screw while watching the trajectory on the navigation platform. He can guide the trainee’s hand and intervene before the implant deviates into danger.
Without that visualization, he may be less comfortable giving an early trainee the same degree of independence.
Robotics can also reduce mental fatigue. The surgeon is not repeatedly questioning the implant’s trajectory during a long operation. Dr. Owusu-Sarpong said he has used robotic technology for more than five years and has rarely seen it deviate from the plan.
The result is not merely a better-looking X-ray. It is a surgeon who can place stronger implants, teach more safely and spend less mental energy on a task the technology performs reliably.
Not every hospital can buy the future
Dr. Owusu-Sarpong expects image-guided implant placement to become increasingly common. He is less certain robotics itself will become the universal standard.
A robotic platform may cost an institution roughly $1 million, depending on purchasing agreements and rebates. That price limits access, particularly among smaller hospitals and practices.
Navigation may offer a more attainable path toward the same broader objective: knowing in real time where the implant is traveling. Dr. Owusu-Sarpong believes some form of technology-assisted placement will eventually become difficult to avoid.
“If you could bet 99%, why would you go back to 80% or 60% or 70%?” he said. The exact percentages were illustrative rather than a comparison from a specific trial. His point was about the direction of the field. Once surgeons become accustomed to greater certainty, returning to a less precise method becomes difficult to justify.
There will continue to be late adopters. Some surgeons have operated successfully for decades using techniques they know intimately and see little reason to change. Dr. Owusu-Sarpong believes resistance will become harder to sustain as the technology matures.
“If you don’t adopt, you will get lost in the dust,” he said. Adoption, however, cannot mean surrendering judgment to the machine. Robotics can improve the execution of the plan. It cannot make a poor plan appropriate.
The smallest incision can still be the wrong operation
No area illustrates that distinction better than endoscopic spine surgery. Patients are increasingly asking for it because the incisions are extremely small and the procedure is marketed as minimally invasive.
Dr. Owusu-Sarpong performs more tubular spine surgery, using a narrow working channel that may be only a few millimeters larger than an endoscope. For him, the additional reduction in incision size does not necessarily justify the longer operating time required while climbing the endoscopic learning curve.
“If I used an endoscope, it would take me a lot longer than it would if I used a tube,” he said. That calculation exposes the weakness in defining minimally invasive surgery only by the skin incision. A patient undergoing a technically small procedure may remain under anesthesia for five or six hours because the surgeon performs it infrequently. Another patient may receive a slightly larger incision but leave the operating room after one or two hours.
Which operation is less invasive? Dr. Owusu-Sarpong believes the answer must account for the entire episode: anesthesia time, muscle damage, pain, complications, recovery and the surgeon’s ability to perform the procedure efficiently. “It shouldn’t just be about the size of the cut,” he said. “It should be about the entire patient experience.”
Endoscopic surgery can be highly effective in the hands of surgeons who perform it frequently. The danger is treating the word “endoscopic” as proof that the procedure is inherently superior. Minimally invasive surgery is not a measurement. It is an outcome.
The spine patient five years from now
For many common degenerative conditions, Dr. Owusu-Sarpong expects the typical patient experience to continue moving closer to modern joint replacement.
Hip and knee replacements once required prolonged hospital stays. Today, selected patients regularly leave within hours. Spine surgery is following that path. Five years from now, Dr. Owusu-Sarpong expects more patients to receive surgery through small muscle-sparing incisions, with navigation or robotic assistance, enhanced pain control and same-day discharge.
Regional blocks are already helping patients tolerate the early postoperative period with fewer pain medications. ASCs and hospital outpatient departments will handle a greater share of appropriately selected cases. Patients may walk out of the facility hours after an operation they once expected would keep them hospitalized for days.
That future will not apply to every diagnosis. Complex deformity, major trauma and medically fragile patients will continue to require larger operations and hospital resources. But the average patient with a degenerative cervical or lumbar condition may encounter a version of spine surgery that bears little resemblance to its reputation.
The incision will be smaller. The implant will be more precise. The recovery will be faster.
None of those advances will relieve the surgeon of the hardest part of the job. Knowing when motion should be preserved, when it should be stopped and when the newest operation is not the right one.
Spine surgery is becoming less invasive. Its judgment cannot.
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