The most divisive topics in spine surgery include regenerative medicine, hybrid constructs and who performs some minimally invasive procedures.
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, June 24.
Editor’s note: Responses were lightly edited for clarity and length.
Question: What’s the most controversial trend in spine surgery today?
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: There are some surgeons who advocate for large-scale hybrid constructs. I think this field is very controversial. There are some peer-reviewed journals that support smaller, 2-level hybrid surgeries. We need more study of these and a better way to qualify or disqualify patients in these instances. Especially in re-do surgeries, they might really help people. There will be instances where they will not be, and it’s important we are honest with ourselves and get some data to better qualify complex approaches.
Mohammed Khan, MD. New Jersey Brain and Spine (Paramus): One of the most controversial trends in spine surgery today is the increasing use of spinal implants and instrumentation, especially in cases of degenerative disease where conservative management might suffice. Critics argue that financial incentives and aggressive marketing by device companies may be driving overuse, leading to unnecessary fusion surgeries with limited benefit over decompression alone. This is particularly debated in lumbar spine care, where outcomes do not always correlate with the complexity or invasiveness of the procedure.
Robert Masson, MD. Masson Spine Institute (Orlando): I have a sports spine surgery practice and get asked all the time my thoughts on Stem cell injections for their spine problems.
Stem cell injections are controversial in spine care because the problem they target, “back pain,” is an umbrella diagnosis that often masks very different pathologies with massive variation in features. Disc degeneration without neural compression might plausibly benefit from a biologic meant to nourish or rehydrate the disc, but how do we know that the pain is discogenic and which one? The same injection does nothing for radiculopathy or myelopathy caused by a herniated fragment or a stenotic canal, where mechanical decompression is the proven solution. Lacking reliable imaging or molecular markers to predict who will respond, most candidates are treated on conjecture, and the handful of phase 2 and phase 3 trials under FDA oversight have yet to show durable clinical advantage over placebo or surgery beyond two years.
That evidentiary gap collides with aggressive, cash-only marketing. Because the FDA classifies these preparations as drugs, commercial clinics that process and reinject “point-of-care” stem cells without approval now face injunctions and have lost key court battles that confirmed the agency’s authority to shut them down in the United States. Yet patients still pay $5,000 to $25,000 per injection for treatments that regulators warn are unproven and may carry serious risks, including infection, ectopic tissue growth, and progression of neurological deterioration when used for the wrong reason.
Until randomized evidence links a specific stem-cell product to a clearly defined spine indication, and insurers adopt transparent coverage criteria, responsible use “starts” inside tightly regulated trials with new focus on diagnostic targeting and clarity and should “stop” at any retail offer that cannot document safety, efficacy, and a fallback plan when structural compression demands surgery.
I do not recommend stem cell injections for a spine health crisis of any kind as direct treatment. I have historically used them in reconstruction procedures, when I felt that the patient needed as much assistance as possible because of systemic issues and osteopenia, poor nutritional state. But the evidence thereto remains controversial.
Noam Stadlan, MD. Endeavor Health Neurosciences Institute (Skokie and Highland Park, Ill.): I think the most controversial trend in spine surgery is the situation where non-surgeons are performing surgeries. There are an increasing number of minimally invasive surgical procedures – many to treat lumbar spinal stenosis and another to relieve pain from sacroiliac joint dysfunction – being performed by an increasing number of non-surgeons. Those who are not trained as spine surgeons/clinicians may not be as adept in correctly diagnosing spine pathology and correlating it to the imaging findings. Non-surgical specialists may also not be trained to address the complications that they may encounter when performing these procedures. And finally, the effectiveness and duration of action of most of these procedures have been compared not to definitive surgical solutions, but to interventions that are known to provide only temporary relief such as epidural steroid injections.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The most controversial trend in spinal surgery is non-surgeons performing decompressive operations on the nervous system with dubious symptoms and collectively, less than marginal outcomes. The most common complaint recorded in our interactions are the continuance of pain and claudicatory symptoms and a less than satisfying relief of presenting signs. Couple those defining contexts with an astonishing and unexpected invoice, and the cumulative result is predictable. Most if not all radiologic, post-operative surveillance demonstrates little or no change in the original pathophysiological segment(s). These procedures and their solicitors harken back to the ‘Kyphoplasty’ grift, which fell out of favor expeditiously, and rightly so.
