Rising endoscopic, outpatient surgeries & less fusions: 8 spine surgeons predict the future of spinal fusion

Alan Condon -  

Eight spine and neurosurgeons predict how spinal fusion will develop in the next five years.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: If you didn't pursue a career in spine, what medical specialty would you have chosen, and why?

Please send responses to Alan Condon at acondon@beckershealthcare.com by Wednesday, Nov. 27, 5 p.m. CST.

Note: The following responses were edited for length and clarity.

Question: What trends will we see in spinal fusions over the next five years?

Issada Thongtrangan, MD. Microspine (Phoenix): Spinal fusion has been on the rise in the past decades and will continue to grow. The more advanced technologies and techniques are still evolving through better surface technology, 3D printing, biologics and expandable technology. My prediction is that the future of fusion surgery — when indicated — will be done through the least invasive approach utilizing endoscopic, robotic and artificial intelligence.

James Chappuis, MD. Spine Center Atlanta: I predict that in the next 10 to 15 years we will be performing less fusion surgery due to the evolution of endoscopic-assisted surgery, artificial disc replacement, and even stem cells and biologics for degenerative disc disease.

First, especially as it relates to the adult degenerative spine, we are going to see a fewer number of fusions than we did in the past, which is what is happening in our practice. Secondly, if a patient does need a fusion, I think we will see a dramatic increase in these being done endoscopically. Not so much a minimally invasive procedure, but endoscopic. Over the next three to five years, we are going to see fusions completed with interbody graphics — all endoscopic. 

Mark Mikhael, MD. NorthShore Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): Trends are pointing to more outpatient spinal fusion procedures in the coming years, but we need to be selective in the patients best suited for same-day surgeries, patients who are healthy and motivated to recover at home. Robotics also is making its way into spinal fusion procedures. Spinal robotics show promise for better precision, quicker procedures and less blood loss. The goal is to program the robot to put screws and implants into the spine more precisely. We are on the first generation in spinal robotics. The technology will likely be perfected over the next five years. There is still much work needed in efficiency, workflow and the learning curve with robotics. 

Brian R. Gantwerker, MD. Craniospinal Center of Los Angeles: You will see more single-position surgery being done with newer systems offering oblique, lateral and posterior options without the purchase of a lot of hardware. The denial rate of fusion surgery will continue to increase as more patients are being swept into Medicare Advantage plans. The offset will be fusions will be safer with an increase in frameless stereotactic guidance and surgical robots. Endoscopic spine is now more mainstream than ever, and some cases will be shunted to minimally invasive spine cases initially. I think that will lead to an overall decrease in the rate of spinal fusions.

William Taylor, MD. University of California San Diego Health System: We continue to believe that what we consider to be routine indications for fusion will continue to be a question and will demand high-level data for justification. The financial benefit will continue to decrease as instrumentation becomes commoditized and outcome data will be mandatory for participation in many insurance plans.

Scott Russo, MD. Orthopaedic Associates of Michigan (Grand Rapids): I believe spinal fusions will continue to develop as it relates to new improved biological agents that facilitate the fusion process. I also think we will go more old school and attempt to save costs by using more iliac crest autograft harvesting. Also, as it relates to the fusion bed, creating a more robust bed of bone for healing using gouges and avoid bone burring and thermal necrosis. 

Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Minimally invasive spinal fusions will become more common and hopefully the standard of care for most adult degenerative spine conditions. This will allow patients to have surgery done in an outpatient setting with less pain, disability and complications as well as quicker recovery. Computer navigation and robotic technology will continue making minimally invasive hardware placement more precise and efficient with less radiation exposure to the patient, OR staff and surgeons.

Synthetic bone graft substitutes will be better tested, safer and more effective for minimally invasive fusions. This will eliminate the need to harvest patient's own bone or risk possible disease transmission with cadaveric bone graft products. All these advances will lead to better patient outcomes and more value for spinal fusions.

All the above assumes normal market forces driving innovation. There is another possible future with further insurance rules and government regulations designed to deny or ration medical care without sound scientific reason. In such a future there will be no innovation and possible regression of spine surgery to the old days, where 50 percent success rates and high complication rates for spine surgery were deemed acceptable.

Nitin Bhatia, MD. UCI Health (Orange, Calif.): Spinal fusions will continue to be used widely for appropriate indications. Over the next five years, however, we will see improvements in how these surgeries are performed and how well our patients do after surgery. Improvement in surgical technique, anesthesiology, navigation systems and other technological developments will allow surgeries to be performed on an outpatient basis and with less risk for surgical complications. Furthermore, advancements in biologics will provide more consistent bony healing even in less optimal patients. Finally, as outcome measurements of surgical success are used and followed in a more widespread basis, our understanding of who will really benefit from fusions will be further improved.

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