Spine surgery has become increasingly capable of correcting severe deformities. Kristen Jones, MD, is interested in a different measure of progress: whether surgeons can keep more patients from ever needing those operations.
Dr. Jones, an associate professor of neurosurgery and orthopedic surgery at Durham, N.C.-based Duke University Health System, treats complex spinal deformity in adults and children, including patients referred after previous treatment has failed.
Seeing patients at that end of the spectrum has sharpened her focus on what happens much earlier, sometimes during the first operation.
“The smallest thing we can do to make the biggest positive impact isn’t always a big surgery,” Dr. Jones told Becker’s. “Sometimes a bigger surgery can lead to more problems.”
Her argument is not simply for earlier surgery. It is for earlier recognition: understanding which patients are deteriorating, protecting alignment when surgery is necessary and addressing risks that can compound over time. That could eventually change the trajectory of spinal deformity care from increasingly sophisticated reconstruction toward preventing the need for it.
The first surgery can shape the next decade
A patient does not have to be undergoing a major deformity correction for alignment to matter. Dr. Jones said even a single-level fusion can have consequences years later if the spine is fixed in a position that is not physiologic.
There is now substantial evidence, she said, that poor alignment can accelerate degeneration at adjacent levels. If those levels eventually require fusion and are also fixed in a nonphysiologic position, the problem can compound.
“Even for a one-level surgery, you need to think about the alignment that you put the spine in,” she said. “You can really accelerate problems for patients down the road.”
That reframes what can appear to be a relatively small operation. The immediate goal may be treating one symptomatic level. But the surgeon is also making a decision about the architecture the rest of the spine will have to accommodate for years afterward.
For Dr. Jones, getting that decision right is one way to intervene earlier without necessarily operating more aggressively.
When waiting becomes its own risk
Knowing when to operate presents a harder problem. There is good reason not to intervene simply because a deformity might worsen. But waiting until a patient is severely disabled can carry consequences that a technically successful reconstruction cannot always reverse.
“I don’t think there’s an absolute number or guideline that will ever work for every patient,” Dr. Jones said. Instead, she said surgeons have to consider whether the condition is progressing and what it is doing to the patient’s function and quality of life.
“If a patient is having progressive problems, we want to intervene while they’re still functionally able to recover as well as possible,” she said.
Waiting too long can change what surgery is capable of delivering. “Even if we make the spine look better on X-rays, patients may not get the full benefit if they’ve already spent years disabled by their condition,” she said.
The challenge is therefore not finding an earlier universal threshold for surgery. It is getting better at recognizing which patients are moving toward a point from which recovery becomes harder. Increasingly, some of those signals may come from beyond the deformity itself.
The warning signs surgeons can see earlier
Bone quality is one of them. Dr. Jones said surgeons are gaining more ways to identify osteoporosis beyond a traditional DEXA scan. CT and MRI can provide indirect measures of bone quality, and newer approaches can use computer algorithms to estimate bone density from X-rays.
That could give surgeons a broader view of bone health before deterioration contributes to larger problems.
Muscle quality may provide another clue. Dr. Jones pointed to the muscles surrounding the spine, what patients might broadly think of as their core, as another factor increasingly relevant to understanding deformity. Loss of muscle mass and spinal deformity often occur together, she said, even if determining which initiated the decline can be difficult.
“When they go hand in hand, affecting both of them is important,” she said.
That same philosophy runs through Dr. Jones’s research, which focuses in part on complication avoidance and steps that can be taken before surgery to improve outcomes. “We’re starting to understand more about how to improve people’s risk factors for surgery,” she said.
Taken together, those advances could give surgeons more opportunities to act before a patient’s options narrow.
The push beyond fusion
Earlier detection is only part of the equation. The operation itself may also change. When fusion is necessary, Dr. Jones said surgeons are still refining their understanding of precisely how the spine should be aligned. She expects that work to continue.
At the same time, technologies that preserve motion could give selected patients alternatives to fusion. Disc replacement has been used for years with strong outcomes in specific indications, Dr. Jones said. She also pointed to facet joint replacement as a newer option that may offer another motion-preserving solution for some patients.
But the arrival of another technology does not mean every fusion should be replaced.
“The trouble that we have is when we try to take one solution and apply it to every patient,” she said. “Each patient has somewhat of a unique situation and will benefit from different things.”
That distinction is central to the future Dr. Jones describes. Progress does not necessarily mean operating earlier, operating less or replacing fusion with a particular technology. It means becoming more precise about which patients are deteriorating, which risks can be modified and how much surgery each patient actually needs.
Over the next decade, Dr. Jones expects both sides of deformity surgery to advance: better reconstruction for patients who need it and more ways to keep others from reaching that point.
For a field that has spent years expanding what surgeons can reconstruct, its next achievement may be measured partly by something less visible: how often it no longer has to.
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