Spinal fusion has long been “the gold standard” in spine surgery, but motion-preserving techniques have become more attractive to physicians and patients in recent years.
Spine surgeons discuss how they balance the nuances behind the traditional and newer options available to them.
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. Becker’s invites all spine surgeon and specialist responses.
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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Tuesday, Nov. 25.
Editor’s note: Responses were lightly edited for clarity.
Question: How do you balance the push toward motion preservation with the reliability of traditional fusion techniques?
Jordan Iordanou, MD, PhD. McHugh Neurosurgery (West Islip, N.Y.): Balancing motion preservation and fusion techniques involves assessing patient-specific factors like age, pathology, and lifestyle. Motion-preserving technologies, like disc replacement, offer promising alternatives but lack the long-term data of fusions. I use a tailored approach, reserving motion preservation for younger, active patients while relying on fusion for complex cases.
Philip Louie, MD. Virginia Mason Franciscan Health (Seattle): I think the most important first step is avoiding broad classifications and dogma. This conversation often gets oversimplified into motion preservation versus fusion, when in reality it’s far more nuanced. I also think it’s important to be open minded to the growing body of evidence and the advancement in the technology/implants themselves that may be safely expanding the indications beyond the original IDE trials.
I lean towards motion preservation when there is no evidence of instability, severe facet joint arthropathy, poor bone mineral density. Also in the cervical spine, I often will lean toward a fusion when there is myelopathy in the setting of congenital stenosis.
In multi-level pathology (not tumor, infection, trauma), I do think that hybrid procedures can address different types of pathology at different levels; allowing us to accomplish multiple goals.
Noam Stadlan, MD. Endeavor Health Neurosciences Institute (Skokie and Highland Park, Ill.): I think that there are reasonably well-established pros and cons for both fusion and motion preservation techniques. It is the obligation of the surgeon to discuss these with the patient and help come to a mutually acceptable surgical solution. Sometimes the best option will be abundantly clear. Sometimes it will depend on which set of risks/benefits are most attractive to the patient. It is important to make sure that motion preservation, just like fusion or any other technology, be used for the proper purposes. I was one of the investigators who participated in the study that led to the approval of a lumbar artificial disc that treats degenerative disc disease. In the months after FDA approval, many patients came in requesting the disc, even though all they needed was a microdiscectomy. Frequently, the most difficult part of the visit was convincing them that they did not need the artificial disc. But that is a very important part of our obligation to the patient.
Kushagra Verma, MD. Hoag Orthopedic Institute (Los Alamitos, Calif.): With regards to the advancements in spine surgery, we have motion preservation surgery in the form of disk replacement, both in the cervical and lumbar spine, and gradually surgeons are expanding our indications for this technology.
However, we also have innovations in minimally invasive fusion techniques, both through anterior and lateral approaches. Both surgeries offer a comparable recovery, and so surgeons and patients will often spend time looking at the imaging carefully. If a level does not have significant facet, joint arthritis, then that’s a level that we may consider disc arthroplasty. If, however, the level has significant arthritis, then it’s a bit of a judgment call, whether to pursue a fusion or a disk replacement.
At the current time, we often will discuss both treatment options with patients, review the imaging, and make an individual custom-tailored decision to help patients choose between motion preservation and minimally invasive fusion.
In our practice, we pursue both surgical options with patients and debate them and allow the patients to make the decision that is best for them. When we do fusions, we do them in a way so that the recovery times are minimized. We use all minimally invasive techniques and modify our techniques so that if there is a problem at an adjacent level, the future revision surgeries can also be minimally invasive.
This is an innovation that our practice has pursued over the last five years, and it’s proved to have a profound impact on our practice. We’re able to do either disc replacement or fusions in an outpatient setting, use smaller incisions, have shorter recovery times and provide patients peace of mind, knowing that should a problem develop in the future at an adjacent level, any revision surgery will also be minimally invasive.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: The tension between motion preservation technologies (artificial disc replacement, dynamic stabilization systems) and fusion stems from mixed long-term data. While motion preservation theoretically prevents adjacent segment disease, clinical studies show variable results. Recent systematic reviews suggest that while artificial discs may reduce adjacent segment pathology in some patients, the clinical significance isn’t always clear, and patient selection criteria remain poorly defined. Fusion techniques continue to show predictable outcomes with established long-term data, though they carry known risks of adjacent level degeneration. The decision often comes down to patient age, activity level, anatomy, and surgeon experience with the technologies.
Jacky Yeung, MD. Yale School of Medicine (New Haven, Conn.): It really comes down to patient selection. Motion preservation is exciting technology, and for the right patient it can provide excellent outcomes but it’s not the answer for everyone. The key is matching the treatment to the patient’s goals, lifestyle, health status, and imaging findings. For example, a younger, active patient with isolated disc pathology may benefit from a motion-preserving approach, while someone with multi-level degeneration, instability, or deformity is often better served with a fusion. If a patient is at baseline sedentary, then we have to have a discussion on how they can maximize recovery if we pursue motion-preservation surgeries. The decision isn’t about which technique is newer or trendier — it’s about which approach offers the safest, most durable result for that individual.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): This harkens back and the resounding overuse of PEEK instrumentation and current artificial disc usage in contrast to the trustworthy, standard fusion procedures of the lumbar and cervical spine. Both procedures have their significant advantages and have been shown to relieve pain, yet options are derived from individual patient needs and surgeon preference. The extent of degenerative presentation and patient goals and lifestyle must also be factored. Reliability is the highest form of safety, which is paramount to outcomes and experience. That level of comfort is administered to patients and family members.
