The future of minimally invasive spine surgery: 13 surgeon insights

Alan Condon -   Print  |

From the rising adoption of endoscopic techniques to motion preservation technologies and robotic surgery, the biggest trends in minimally invasive spine surgery are discussed by 13 surgeons.

Note: Responses are lightly edited for style and clarity.

Mick Perez-Cruet, MD. Michigan Head & Spine Institute (Southfield, Mich.): I expect to see continued growth in the spine field in 2021. Increasingly, patients suffering from spinal disorders are recognizing the benefits of outstanding spine care in achieving a better quality of life and getting them back to an active lifestyle. This is being achieved through advancements in minimally invasive spine surgery and a better understanding of spinal disorders. Large collaborative spine surgery patient-generated data pools, such as the Michigan Spine Surgery Improvement Collaborative, a Blue Cross Blue Shield-initiated program, are showing us the true benefits of spine surgery care in improving the lives of our patients. 

Alexander Vaccaro, MD, PhD, and Bryce Basques, MD. Rothman Orthopaedic Institute (Philadelphia): Today, robotics and various minimally invasive techniques have high potential, yet [we] would caution surgeons, especially those early in practice, from broadly adopting these techniques without scrutiny. Especially in saturated markets, spine surgeons may think that these newer technologies are an opportunity to differentiate or market themselves. However, if adoption of these techniques leads to inefficiency, complications and poor outcomes, your reputation will suffer, and any potential marketing benefit will be lost. In the current financial climate, surgeons will be expected to justify the cost of this technology to payers as well. I would encourage surgeons to be highly discerning in the technologies or advancements they adopt and pursue patient care avenues that demonstrate high value.

Jeremy Smith, MD. Hoag Orthopedic Institute (Irvine, Calif.): The most fascinating and applicable technology that will be welcomed in 2021 will center around minimally invasive techniques. With COVID-19 limiting hospital beds and resources, the drive toward outpatient surgery will accelerate. Techniques involving single-position surgery (lateral or prone) will continue to improve and allow 360-degree fusions with minimal blood loss and perioperative morbidity. Endoscopic spine surgery continues to grow, and as surgeons continue to refine their skills, indications will become broader. Industry competition has allowed for multiple navigation and robotic technologies that continue to maximize accuracy and minimize invasiveness.

John Liu, MD. USC Spine Center (Los Angeles): Minimally invasive surgery has come a long way since I started practice in 1999. However, there currently are still very few cervical MIS options for decompression and fusions that are reliable and consistent. I would like to see the use of robotics or advanced imaging and navigational systems to help us tackle these cases to provide more options and quality of life for patients.   

Peter Derman, MD. Texas Back Institute (Plano): I hope that we will look back 10 years from now and think that the surgery we were doing in 2020 was archaic. In the future, I think that far fewer fusions will be performed as disc replacement and other motion-preserving technologies continue to improve. I am also excited about endoscopic spine surgery, which is becoming an increasingly large part of my practice. It is a true paradigm shift in the field, which allows surgeons to access and address spinal pathology without the morbidity associated with traditional techniques. In many cases, it allows me to perform an ultra-minimally invasive decompression when a fusion might otherwise have been necessary. Patients are comfortably home within hours of surgery and often only take Tylenol for postoperative pain control in the days after the procedure.

Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Minimally invasive surgery and technologies that enable MIS procedures will continue gaining popularity. There is more scientific evidence on the benefits of minimally invasive surgery, and patients demand it. These technologies also make it easier to do more advanced spine surgery, such as lumbar fusions, at an ASC. That will drive better outcomes, cost savings and avoid the need to take elective spine surgery patients to the already overwhelmed acute care hospitals. Robotic-assisted spine surgery will continue gaining popularity as newer capabilities (beyond placing pedicles screws) become more available and accessible.

K. Samer Shamieh, MD. Avala (Covington, La.): There are two major categories of possible advancement in minimally invasive spine surgery. Strides in disc and cartilage regeneration in the facet joints seem to be a hot topic these days. But the next big advancement is joint and replacement surgery, which has exploded with the aging population. I would like to see facet joint replacement become a real option for surgeons. Advancement in the quality of lumbar disc replacement is going to be the next great step, as joint replacement is the future of spine surgery.

Christopher Blanchard, DO. Resurgens Orthopaedics (Atlanta): Robotics in spine surgery is still in its infancy compared to robotics in general surgery. Currently, the largest utility of a robot is with screw placement. This is rapidly changing with software and hardware updates. In the next five years, I think robotics will continue to evolve, allowing surgeons to perform surgery in a less invasive way to allow for quicker recovery. I believe as robotics develops, it may completely change how we think about and perform spinal procedures.

Srdjan Mirkovic, MD. Northshore Orthopaedic & Spine Institute (Chicago): I see two big minimally invasive spine surgery innovations in spine care. First, robots have advanced in spine surgery. Robotic and free-hand spine surgical procedures are proving to insert screws with great precision and accuracy for surgeons. Secondly, we are managing pain much better through more aggressive, nonoperative steroid injection protocols.

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: The increasing minimization of surgical techniques and the development of great expandable devices piques my interest. I am finding myself using expandable cages more and more as they really help avoid making more "flat back" patients. It is reassuring when instead of doing five-level fusions, you can focus on one level, correlate with the patient's symptoms and films, do a great job and give them lasting relief.

Daniel Lieberman, MD, Phoenix Spine & Joint: Over the last five years we've seen real energy pulling away from deformity correction and multilevel fusion surgery, and the entire field of spine surgery moving into much more focused interventions based on structure. I think the next horizon is focused interventions based on symptoms. What patients really are concerned about is their pain. Our surgery centers offer endoscopic dorsal rhizotomy, so ultra-minimally invasive surgeries that eliminate pain are really the next horizon. It's almost like we're going to see spine surgery absorb and move into more of a pain management approach, rather than a structural correction approach. 

Neel Shah, MD. DISC Sports & Spine Center (Newport Beach, Calif.): The spine field is ever-evolving. Some emerging technologies include artificial intelligence and robotic surgery as well as the push toward motion restoration and preservation over fusion. These innovations that have been evolving over the last decade seem to be coming to fruition and are accepted and widely used.

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