When Jonathan Baskin, MD, began his neurosurgical career nearly 25 years ago, spinal fusion was used more selectively for degenerative conditions. Today, increasingly sophisticated technology has made spinal instrumentation more precise, less invasive and more commonplace.
For Dr. Baskin, that progress raises an uncomfortable question: Has making spine surgery easier to perform also made it easier to recommend?
Dr. Baskin, a neurosurgeon at Morristown, N.J.-based Atlantic Brain and Spine, has watched navigation systems, robotics and motion-preserving procedures transform what surgeons can accomplish. He considers many of those advances extraordinary. But he also sees a growing tension between technical capability and clinical judgment.
“Just because you can do something safely and accurately, is it the right thing to do?” he told Becker’s.
It is a question that runs through nearly every major change in spine care, from the expanding use of fusion and the migration of procedures to ASCs to AI’s emerging role in the operating room. For Dr. Baskin, the challenge is no longer simply how to perform increasingly sophisticated operations. It is knowing which ones are worth performing in the first place.
When greater precision changes the decision to operate
Of all the innovations introduced during his career, Dr. Baskin considers frameless stereotactic navigation one of the most consequential. The technology acts as an intraoperative GPS, allowing surgeons to place instrumentation with greater accuracy while limiting the tissue dissection traditionally needed to identify anatomical landmarks.
Beyond improving precision, navigation has made complex instrumentation more accessible, a shift Dr. Baskin describes as a democratization of surgical capability.
Operations that once required more extensive exposure and technical effort have become more accessible to a broader range of surgeons. But greater familiarity can also change practice patterns.
“When people are more familiar and comfortable doing things, there’s a momentum to do more of those procedures,” he said.
Earlier in his career, fusion was not routinely applied to many degenerative spine conditions. As instrumentation became safer and more predictable, he observed what he describes as a lowering of the threshold for considering it. That shift is particularly consequential for patients whose conditions fall between clear surgical indications and cases that can be managed without stabilization.
Dr. Baskin sees a clear distinction between patients who need fusion and those who do not. The challenge lies in the gray area, where either approach may be clinically justified. Within that gray area, a surgeon’s experience, training and clinical philosophy can influence which path is chosen.
Dr. Baskin’s own approach begins before any discussion of surgical technique: Determine whether an operation is necessary at all. If it is, make it as large as necessary, but as small as possible.
Why preserving motion isn’t always the answer
That philosophy also shapes how he approaches the growing range of alternatives to traditional fusion. Artificial cervical disc replacement has given appropriately selected patients an opportunity to maintain motion while addressing degenerative pathology. When both fusion and replacement are reasonable options, Dr. Baskin generally prefers the latter.
Preserving more natural spinal biomechanics may reduce the risk of complications associated with fusion, including adjacent-level degeneration that can eventually require additional surgery. But the appeal of motion preservation can obscure an important distinction: Not all movement is healthy.
In patients with abnormal cervical hypermobility or significant facet joint degeneration, continued movement may contribute to the symptoms that brought them to surgery. An artificial disc in those circumstances could aggravate the underlying problem rather than solve it.
“It’s not always appropriate to preserve all motion if the motion is part of the problem,” Dr. Baskin said.
The same reasoning applies to minimally invasive surgery more broadly. Dr. Baskin does not consider incision size a meaningful measure of success on its own. What matters is whether the surgeon can adequately address the pathology while minimizing unnecessary disruption to surrounding tissues.
“For me, it’s just trying to find the most elegant and least traumatic way of getting to the pathology and performing the surgery,” he said. A smaller incision is not necessarily a better operation if it compromises the surgical objective. The least invasive approach, in his view, is the least traumatic one capable of accomplishing what the patient actually needs.
The danger of letting the surgery center dictate the surgery
Few changes illustrate the industry’s evolving definition of appropriate care as clearly as the shift toward outpatient spine surgery. When Dr. Baskin began practicing, patients undergoing anterior cervical discectomy and fusion typically spent two or three days in the hospital. Today, many appropriately selected patients can return home the same day.
That transition has created opportunities for greater convenience, scheduling flexibility and lower facility costs. It has also introduced financial incentives that deserve scrutiny.
ASCs can offer surgeons more predictable operating schedules without the disruptions of hospital emergency cases. Physician ownership creates another economic consideration, while hospital-ASC partnerships increasingly bring both settings into the same business model. Dr. Baskin does not dispute the benefits of outpatient care. His concern is whether the desire to perform more procedures in surgery centers could eventually influence clinical decisions.
“If you’re not comfortable discharging a patient after a procedure the same day from the hospital, you obviously shouldn’t be doing that procedure at a surgery center,” he said.
He has observed circumstances in which he believes the boundaries of outpatient surgery are being pushed, particularly given the pain and recovery needs that can follow some spinal procedures. He acknowledges that other surgeons may have different experiences and capabilities.
“The procedure should determine where surgery takes place, not the setting dictate which procedures are performed,” he said.
AI may make surgery smarter. It won’t make the hardest decision.
Artificial intelligence is already changing spine care, beginning before patients enter the operating room.
Dr. Baskin said patients increasingly arrive with AI-generated diagnoses and treatment recommendations, sometimes convinced they need surgery. When his clinical assessment differs, explaining why an operation may not be appropriate can take longer than obtaining consent for one.
“Not every problem can be necessarily remedied by surgery,” he said.
Meanwhile, AI is entering surgical planning, building on navigation and robotics to help surgeons optimize instrumentation placement, particularly in complex spinal constructs. Dr. Baskin sees opportunities for greater precision, efficiency and less invasive approaches as AI becomes more integrated into surgical planning.
Even as technology assumes a greater role in surgical planning, Dr. Baskin believes the decision to operate must remain grounded in clinical judgment.
After nearly 25 years in neurosurgery, he sees little reason to doubt that the next generation of surgeons will be capable of more than ever before. The defining challenge for spine surgery may no longer be what surgeons can do, but what they are willing to leave undone.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
