For decades, spine surgery has largely operated on a straightforward premise: identify the problem and fix it.
If an MRI showed spinal stenosis, instability, deformity and degeneration, the goal was often to address as much of the pathology as possible. The assumption was simple. The more completely a problem was corrected, the better the outcome.
Saqib Hasan, MD, a spine surgeon at San Francisco-based Golden State Orthopedics & Spine, believes that mindset is beginning to change. Not because surgeons have become less capable, but because patients have become more informed.
“Patients are more empowered, and they are going to ask more questions about different kinds of treatments,” Dr. Hasan said. “It allows them to be empowered to make a choice for a procedure that fits more with what their goals are, and less so about what the doctor feels comfortable with or is in their wheelhouse.”
The shift, he argues, is forcing spine surgery to confront a question it has not always prioritized: How much treatment does a patient actually need?
Dr. Hasan describes the concept as “dosing” surgery, tailoring treatment not only to anatomy, but also to a patient’s priorities, lifestyle, risk tolerance and long-term goals.
The idea borrows from modern medicine’s broader movement toward personalization. The difference is that instead of adjusting a medication dose, surgeons may increasingly be adjusting the size and scope of the operation itself.
The MRI problem
One of the most persistent challenges in spine care is that imaging often reveals far more abnormalities than symptoms. A patient may arrive with severe leg pain caused by a single compressed nerve root. An MRI may reveal degeneration at multiple levels, mild deformity, arthritis and other age-related changes.
The temptation can be to address everything visible.
Patients, however, are often focused on something much simpler. Relieving pain. Returning to work. Playing golf again. Picking up grandchildren. Getting back on a bicycle.
“Many times when people look at spinal problems, they want to fix everything they see on an MRI,” Dr. Hasan said. “I don’t think that’s always what patients want.”
That distinction has become increasingly important as spine surgery has evolved.
“When we fix everything in the spine, it can end up being a very large surgery,” he said. “Sixteen screws. Pelvic fixation. Massive reconstructions. The question is whether every patient actually needs that dose of treatment.” The answer, he believes, is often more nuanced than the MRI alone would suggest.
Why patients are changing the conversation
Historically, patients relied on search engines, online forums and word-of-mouth recommendations to learn about treatment options.
Today, many arrive with something far more powerful. AI. “AI is way better than Google,” Dr. Hasan said. Patients can now compare procedures, review scientific literature, understand surgical risks and identify specialists with expertise in specific techniques before they ever enter an exam room.
The result is a different type of conversation. Rather than accepting a single recommendation, patients increasingly want to understand why one surgeon recommends a fusion while another recommends a motion-preservation procedure. They want to know why one physician performs endoscopic surgery and another does not. For Dr. Hasan, the implications extend beyond patient education.
“It’s revealing what surgeons are capable of and what they’re not capable of,” he said.
In the past, treatment recommendations were often shaped by the procedures available within a surgeon’s skill set. Increasingly, patients can see beyond those boundaries. That transparency is creating pressure for physicians to explain not only what they recommend, but why.
The rise of surgical choice
For much of spine surgery’s history, treatment decisions were constrained by available options. Many patients faced a binary choice: continue living with symptoms or undergo a major operation.
Today, the landscape looks different. Endoscopic surgery, motion-preservation procedures and increasingly specialized surgical techniques have created a wider spectrum of interventions between conservative care and large reconstructive operations. Dr. Hasan views that evolution as one of the most important developments in modern spine care.
Patients are no longer choosing simply between surgery and no surgery. They are increasingly choosing between different doses of surgery. Some may prioritize durability and accept a larger operation. Others may prioritize recovery time and select a less invasive approach that addresses only the symptoms affecting their quality of life.
Neither choice is inherently right or wrong. The goal is alignment. “The goals of the patient’s treatment decision should be understood very early in the process,” Dr. Hasan said.
The incentives problem
Personalized care sounds straightforward in theory. In practice, healthcare economics can complicate the discussion.
Larger operations often generate greater reimbursement. Hospitals, physicians and payers all operate within financial structures that can influence treatment decisions. Dr. Hasan is careful not to frame fusion surgery as the problem. Many patients benefit enormously from fusion procedures, and extensive reconstructive operations can be life-changing when appropriately applied. The question, he said, is whether every patient receiving a large operation actually needs one.
“We know these surgeries work,” he said. “The question isn’t whether they help. The question is whether they’re the right dose.”
That distinction becomes particularly important because spine surgery is rarely a short-term decision. “The problem is, it’s not a one-time thing. This is a forever thing,” Dr. Hasan said.
Hardware implanted today may influence a patient’s life for decades. Adjacent segments may change. Future operations may become more complex. Decisions made in a patient’s 50s can still shape outcomes in their 70s. For Dr. Hasan, that long-term perspective is often missing from treatment discussions.
Where the field may be overdosing
If there is one area where Dr. Hasan believes overtreatment remains a legitimate concern, it is complex deformity surgery performed outside highly specialized environments.
Major deformity corrections can dramatically improve quality of life. The evidence supporting these procedures is substantial. The concern arises when highly complex operations are performed without the safeguards that often exist at major academic centers.
“I think that’s when the overdosing happens,” he said. Large deformity programs frequently involve multiple surgeons reviewing cases, challenging assumptions and debating treatment plans before patients ever enter the operating room.
That process creates a layer of protection against unnecessary intervention. For Dr. Hasan, the lesson is not that deformity surgery is overused. It is that complexity benefits from specialization.
What the best spine programs may look like
The future of spine surgery, Dr. Hasan believes, will be defined by increasing specialization. Historically, many spine programs were built around individual surgeons capable of treating a broad range of conditions. The next generation may look very different.
“We’re entering super-specialized realms,” Dr. Hasan said. “The more specialized people become, the better outcomes they tend to have and the fewer complications they tend to see.”
In that environment, the first question may no longer be which procedure to perform. The first question may be who should be evaluating the patient. An endoscopic specialist. A motion-preservation surgeon. A deformity expert. A tumor surgeon. Each bringing a different perspective and set of tools to the same problem.
For patients, that specialization may create something medicine has historically struggled to provide: meaningful choice.
The future of spine surgery
Dr. Hasan often returns to a simple observation. The most minimally invasive surgery is no surgery at all. Not because surgery lacks value. Because the goal is not to perform an operation. The goal is to improve a patient’s life.
Traditionally, spine surgery has measured success through radiographs, alignment parameters and patient-reported outcome scores. Those metrics remain important, but Dr. Hasan believes they no longer tell the entire story.
“It’s not just about the statistics anymore,” he said. “It’s about the impact on a patient’s life.”
For much of modern spine surgery, the central question was whether a problem could be fixed. Dr. Hasan believes the next era will be defined by a different challenge: determining how much treatment a patient actually needs,and recognizing that the answer may be different for every person who walks through the door.
In a field long defined by technical innovation, the most significant shift may not be a new device or a new procedure. It may be giving patients more control over the decision itself.
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.
