Spine surgery has no shortage of innovation. New implants appear, new navigation systems gain traction and AI keeps inching closer to daily practice. But J. Patrick Johnson, MD, believes the long-term health of a spine program depends less on technology than on something much harder to standardize: alignment.
Dr. Johnson is founding director of the neurosurgery and orthopedic spine fellowship program at Los Angeles-based Cedars-Sinai Medical Center. He also serves as vice chair of the spine program in the department of neurosurgery and co-director emeritus of the Cedars-Sinai Spine Center
Over a career spanning at the University of California in Los Angeles and at Cedars-Sinai, Dr. Johnson has watched programs expand, fracture, rebuild and mature. When he talks about what separates the centers that endure from the ones that stall, he doesn’t start with volume targets or growth curves.
He starts with conditions.
“Sometimes it takes a little bit of luck and a lot of hard work,” he said. “And the environment has to be right. Things have to line up.”
In other words: success isn’t accidental, but timing matters. And leaders who pretend otherwise usually build on sand.
The earliest move that shapes everything later
When Dr. Johnson mentors younger surgeons, he tells them the foundation of a strong career, and a strong program, is choosing the right place to build.
“I tell them, ‘The key to success as a practicing surgeon is finding a place where there’s a need,’” he said. “Or a relative vacuum.”
That “vacuum,” he explained, doesn’t always mean geography. It can be institutional, a market where spine exists, but no one has truly assembled it into a unified service line with shared standards, shared investment and shared identity.
He saw that contrast clearly over the years. Some regions, he said, make it easier to become indispensable quickly. Others require an entirely different kind of patience.
“It’s like somebody who moves to rural Illinois, they’re going to do really well if there’s a need,” he said. “In Chicago, I’ll bet it’s a pretty competitive place.”
Integration starts as a people problem, not a structure problem
At UCLA, Dr. Johnson said the earliest spine-building work wasn’t about creating new marketing or new branding. It was about getting physicians to stop functioning as separate camps long enough to build something shared.
He remembers those dynamics sharply.
“Orthopedics and neurosurgery didn’t talk to each other,” he said. “The spine surgeons did, and then they clashed heads.”
That friction, orthopedics versus neurosurgery, is not unique to any one institution. It’s a structural tension inside spine programs across the country, and Dr. Johnson believes the winners are the programs that refuse to let it become the operating system.
“You need to have the right people,” he said. “That’s really what it comes down to.”
Cedars-Sinai had an opening — and he knew what to do with it
When Dr. Johnson arrived at Cedars-Sinai in the early 2000s, he said he wasn’t stepping into a mature academic spine juggernaut. What he found instead was opportunity: room to build.
“Cedars-Sinai, it was a vacuum. It really was,” he said.
He described the institution at that time as having strong physicians, but a different reputation than what it holds now.
“It was not a well-known academic research and high-profile clinical place,” he said. “I hate saying this, but it really was mostly a hospital for the movie stars.”
What he saw, and what mattered more, was trajectory. He believed Cedars-Sinai was about to become something bigger, and he wanted to build with it.
“It has exploded into the big gorilla in Los Angeles,” he said.
That growth, he emphasized, wasn’t magic. It was leadership appetite paired with long-term investment, even when the payoff was years away.
What slows spine programs down inside large systems
Dr. Johnson said programs don’t typically stall because surgeons lack skill. They stall because the institution can’t fully commit, or commits in a way that fades when budgets tighten or leadership shifts.
“Things that slow down are just not having the vision and committing to it,” he said. “They need to have the commitment.”
Commitment, in practice, is concrete. It’s resourcing. It’s recruiting. It’s building around the surgeons rather than expecting the surgeons to generate the infrastructure on their own.
“Resources usually means money, and money means recruiting the right people,” he said.
Then he used a comparison that felt more like a strategy memo than a metaphor: a spine program is built the way teams are built, intentionally.
“It’s putting together a coach and the right team,” he said. “It really is.”
At Cedars-Sinai, he said early recruiting moved quickly and made a visible impact.
“We got one orthopedic and another neurosurgery guy,” he said. “Those two guys came here with the existing team, and then another surgeon came after that. That put us on the map within a year. It’s recruiting the right team, going out and spending your draft picks.”
The culture wasn’t effortless — it was protected
Dr. Johnson doesn’t describe Cedars-Sinai’s culture as a naturally harmonious ecosystem. He describes it as something built under pressure, and defended repeatedly.
“Believe me, there were plenty,” he said, referring to obstacles. “I have incredibly thick skin.”
Some of the earliest recruits moved on, he said, not because the mission wasn’t real, but because the environment was intense and still forming.
“It’s a difficult place to work in this big environment,” he said. “It was evolving and growing … it was a hard place for people to come in and exist.”
His response, he said, was to keep recruiting and keep pushing toward one non-negotiable standard.
“I want to build the biggest, and it has to be the best,” he said. “Don’t compromise on quality of care, when it comes right down to every individual patient. It can’t be just orthopedics and neurosurgery. You need pain medicine, physical medicine and rehab, radiology, vascular surgeons who help with exposures, and thoracic surgeons who work with us. When you get them all on board, you can feel the energy.”
The operational decision that made integration real
When asked what it takes for orthopedics and neurosurgery to function as one spine team, Dr. Johnson didn’t give a leadership cliché. He gave a design choice.
“Here’s the real fundamental answer,” he said. “We made them all exist in the same space.”
Then he made it even clearer: “We live together, literally,” he said.
He pointed to physical proximity as a lever many systems underestimate. Integration becomes far easier when it’s built into daily movement and daily relationships.
“The next door over … there’s a neurosurgeon,” he said. “Twenty feet down the hallway … is an orthopedic surgeon.”
As the program expanded, the footprint expanded with it.
“The program grew so big … we’ve occupied a second floor to accommodate all of them,” he said.
For Dr. Johnson, this wasn’t symbolic. It was operational discipline: shared space, shared teaching and shared responsibility.
“It’s not that we are neurosurgeons or orthopedic surgeons,” he said. “It’s spine surgery.”
