For years, spine surgery has been judged by what happens early. How long was the hospital stay? Were there complications? Did the patient need another operation? Did pain improve in the first year? Praveen Mummaneni, MD, believes those questions miss the larger story.
As the Joan O’Reilly distinguished professor in spine surgery, co-director of the UCSF Spine Center and vice chair of neurosurgery at the University of California San Francisco, Dr. Mummaneni has helped build one of the clearest long-term views the field has ever had into what happens after spine surgery.
Through the Quality Outcomes Database and related spine registries, surgeons are now following thousands of patients for five years, long enough to evaluate not only whether surgery works, but whether its benefits last.
The findings, he said, challenge some of the most persistent assumptions about spine surgery. “I think the key lasting impact is that, in the appropriately selected patient, if you do surgery, not only do you benefit them for a year or two, you’re benefiting them for more than half a decade,” Dr. Mummaneni told Becker’s.
That matters because spine surgery remains one of medicine’s most scrutinized specialties. It is often described as costly, overused and vulnerable to inconsistent outcomes. Dr. Mummaneni does not dismiss the need for accountability. But he believes the five-year data shows a more nuanced reality. For many appropriately selected patients, spine surgery is not a short-term intervention. It is a durable one.
The myth patients bring into the exam room
Patients often arrive in Dr. Mummaneni’s clinic already afraid of what surgery will mean. They worry they will never work again. They worry they will never golf, bike, swim or return to the activities that matter to them. They worry spine surgery will leave them worse, not better.
For years, surgeons had limited long-term data to counter those fears. Now, Dr. Mummaneni said, the conversation is different.
“I tell them, actually, what you’re telling me is not factually correct,” he said. “We followed patients who have your problem for five years, and those patients are actually able to do a lot of activities and go back to work, and they get off their narcotics.”
That may be one of the most important shifts the database has enabled. It gives surgeons evidence to reset expectations before the operation ever happens.
“The expectation should be that you’re going to have surgery, that you’re going to resume an active and healthy lifestyle, and that you’re going to go back to work, and you’re going to get off the opiates,” Dr. Mummaneni said.
For him, that is not optimism. It is data. The QOD findings show patients returning to work, reducing opioid use, maintaining improvements and avoiding high rates of reoperation years after surgery. Those outcomes, he argues, should change how patients, physicians, payers and policymakers understand the value of spine care.
The patients many policies might leave behind
The five-year data has also challenged Dr. Mummaneni’s assumptions about patient selection. Like many surgeons, he once expected patients with obesity, smoking histories or significant medical comorbidities to experience limited improvement after surgery.
The registry told a different story. “Even patients who have a high BMI and obesity are making measurable gains,” he said. “Even smokers are making measurable gains.” Those gains are not identical to those of younger, healthier patients. A 35-year-old nonsmoker in good health may experience a larger improvement than a medically complex patient with obesity or tobacco use. But that does not mean higher-risk patients fail to benefit.
That distinction is critical as healthcare systems and payers increasingly use risk factors to determine surgical eligibility. Blanket restrictions may appear responsible from a population-health perspective. But Dr. Mummaneni believes they can become dangerous when applied too rigidly.
“What do you do if you’re one of those people and you have myelopathy and you can’t walk?” he said. For him, the lesson is not that every patient should have surgery. It is that patients should not be reduced to a risk factor.
Minimally invasive surgery’s real advantage
Dr. Mummaneni has spent much of his career advancing minimally invasive spine surgery. The QOD data has helped clarify what those procedures do, and do not, change over time.
In patients undergoing transforaminal lumbar interbody fusion for grade-1 spondylolisthesis, minimally invasive surgery offered clear early advantages compared with open surgery. Patients left the hospital sooner and required fewer blood transfusions.
The longer-term findings were equally important. “The minimally invasive surgery patients got out of the hospital faster, had less blood transfusions, and in the long term, the outcomes of open and minimally invasive surgery were essentially equivalent,” he said. In other words, minimally invasive surgery produced short-term recovery benefits without sacrificing durability.
At one year, two years and five years, the patient-reported outcomes and reoperation rates were similar between open and minimally invasive approaches.
For health systems, that kind of finding is valuable because it separates marketing from measurable benefit. Minimally invasive surgery may not necessarily produce superior long-term outcomes in every case, but when applied appropriately, it can improve the early recovery experience while preserving long-term results. That is the kind of distinction large registries are built to detect.
The preoperative diagnosis surgeons cannot ignore
Some of the most important changes in Dr. Mummaneni’s practice now happen before surgery. If a woman over age 65 comes to his clinic, one of his first steps is to evaluate bone density.
“I never used to do that,” he said. The reason is straightforward. Undiagnosed osteoporosis can undermine even a technically sound fusion. Poor bone quality can increase the risk of implant failure, nonunion and revision surgery. “The number of people with osteoporosis is tremendously high,” Dr. Mummaneni said. “If you don’t treat it, they’re going to fail their fusion.”
That has changed his sequencing of care. “The No. 1 maneuver is to treat it, not rush off to surgery,” he said. “And then maneuver No. 2 is to do the operation.”
That shift reflects a broader evolution in spine surgery. The operation still matters. But increasingly, outcomes depend on what happens before the incision: optimizing bone health, selecting the right patient, setting realistic expectations and addressing risks that were once underrecognized.
Innovation has to be judged over years, not months
Dr. Mummaneni also believes the five-year data should shape how the field evaluates technology. Spine surgery has seen major advances in biomaterials, implant design and fixation. Three-dimensional printed cages, improved screw designs and better fusion technologies have changed what surgeons can achieve compared with 10 or 20 years ago. He believes those advances are contributing to fewer revisions.
That is especially important as patients live longer after complex spine surgery, including those with spinal tumors and metastatic disease. In the past, surgeons might not have expected some oncology patients to live long enough for fusion durability to matter. Today, many are surviving five to seven years or longer. That changes the responsibility.
“You have to pay attention, is the bone going to heal?” Dr. Mummaneni said. “Otherwise, the implant will fail over time.”
For him, innovation should not be judged only by whether it improves a postoperative X-ray or shortens a hospital stay. It should be judged by whether it prevents failure years later. That is why long-term registries matter. They reveal whether technology delivers value beyond the immediate episode of care.
The policy problem
The stakes of outcomes measurement are rising. CMS and other payers are increasingly moving toward models that shift risk onto surgeons and evaluate performance using standardized metrics. Dr. Mummaneni is concerned some of those measures may not reflect the outcomes spine surgeons actually use or understand.
He pointed to FOTO, focus on therapeutic outcomes, an outcome measure he said many spine surgeons do not routinely use.
He believes health systems and policymakers should focus on validated measures already used widely in spine research and clinical practice: EQ-5D, Oswestry Disability Index, Neck Disability Index, numeric pain scores, return to work and patient satisfaction.
“These are the ones that actually patients will show the true benefits on,” he said. “These are the ones that spine surgeons use frequently. These are the ones we’re familiar with.”
The wrong metrics could have real consequences. If surgeons are judged by unfamiliar or poorly understood measures that follow them across hospitals, some may stop taking Medicare patients or avoid operations perceived as risky under the model.
“I think surgeons are going to drop out of Medicare, and I think that would be a disaster,” Dr. Mummaneni said.
He is especially concerned about policies built around the belief that spine surgery is expensive, ineffective or short-lived in its benefits. The five-year data, he said, shows the opposite for many properly selected patients.
What value looks like five years later
The Quality Outcomes Database was created to establish risk-adjusted benchmarks, measure safety and effectiveness, demonstrate comparative value and help identify which patients are most likely to benefit from specific neurosurgical and spine procedures. Over time, its spine modules evolved into some of the largest North American spine registries, with longitudinal patient-reported outcomes that allow surgeons and health systems to evaluate durability rather than relying only on short-term results.
That long-term view is now producing evidence across multiple conditions, including cervical myelopathy, cervical radiculopathy, grade-1 spondylolisthesis and high-grade spondylolisthesis.
Across 14 sites, Dr. Mummaneni said researchers now have roughly 6,000 to 7,000 patients with five-year follow-up in major spine datasets. One forthcoming cervical radiculopathy dataset alone includes about 4,400 patients with five-year follow-up at roughly 80%.
The size matters. So does the follow-up. Spine surgery has often been judged by cost, complication rates and isolated short-term outcomes. The QOD allows researchers to examine return to work, opioid discontinuation, pain, disability, quality of life and patient satisfaction over years.
That provides a more complete definition of value. For example, if surgery helps a patient return to work and remain functional for years, the value cannot be measured only by the initial price of the operation.
Dr. Mummaneni said researchers are now using measures such as EQ-5D to calculate quality-adjusted life years, incremental cost-effectiveness ratios and other analyses designed to show the long-term economic value of spine care.
The conclusion, he believes, is clear. Spine surgery is not simply expensive. In properly selected patients, it can be cost-effective.
The next era of spine data
The registry is still teaching surgeons things they did not know. That is the point.
Dr. Mummaneni said the data has already changed how he talks to patients, how he evaluates risk factors, how he thinks about minimally invasive surgery and how he prepares patients with osteoporosis before fusion.
He believes the next wave of publications will continue reshaping the field.
“Every year that goes by, you can see 20, 30 articles coming out of this,” he said. “It’s going to change the way that we view healthcare.”
For decades, spine surgery has had to defend itself against a familiar critique: expensive operations, uncertain benefit, too many revisions and insufficient proof.
The five-year data does not suggest every patient should have surgery. It suggests the specialty can finally answer with evidence. In the right patient, the benefits can last. Patients can return to work. They can reduce opioids. They can regain function. They can remain satisfied even when improvement is incomplete.
And health systems can evaluate spine care by what happens not only at discharge or one year later, but half a decade after the operation.
That may be the most important shift. Spine surgery finally has a long-term report card. And according to Dr. Mummaneni, it tells a more hopeful story than many people have been led to believe.
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