Spine surgeons can operate on patients today who might not have been considered surgical candidates years ago. The harder question is determining which of them should be.
As patients live longer with diabetes, osteoporosis, cardiovascular disease and other chronic conditions, Alekos Theologis, MD, a clinical professor and orthopedic spine surgeon at University of California San Francisco Health, is seeing complexity rise on two fronts. Operations have become more sophisticated, but so have the patients arriving for them.
“There has been a steady increase in complexity, both from the medical side and from the surgical side,” Dr. Theologis told Becker’s.
Advances in surgical planning, deformity correction, blood-loss management and perioperative care have expanded what surgeons can attempt. Yet one of the most consequential questions remains difficult to answer: Which patient has enough physiologic reserve to recover?
For Dr. Theologis, that uncertainty increasingly comes down to frailty, and it creates a paradox in complex spine care.
“The patients who are most disabled potentially have the greatest benefit from surgery,” he said. They can also be among the hardest patients to predict.
The patient-selection problem spine hasn’t solved
Age is easy to measure. Dr. Theologis does not believe it tells surgeons enough. “Age is an easy concept. It’s linear, but it definitely is not reflective of patients’ physiologic state,” he said.
Spine programs have gotten better at assessing disability and identifying patients who could benefit from surgery. What remains less certain is how frailty and other medical conditions will affect an individual patient’s recovery.
“We do still get it wrong,” Dr. Theologis said. “Sometimes patients do really well, and it’s a home run, but others struggle and they languish,” he said.
Frailty itself remains difficult to assess, he said, despite its importance in determining how patients fare after surgery. The calculation can extend beyond a patient’s medical conditions. Social isolation and a lack of support may also contribute to poorer outcomes.
Dr. Theologis sees an opportunity for more personalized approaches to close that predictive gap. He pointed to genetic phenotyping and, eventually, digital twins that could help simulate a patient’s situation before surgery.
“There’s a lot of homework that we still have to do,” he said.
As surgery advances, the threshold keeps moving
The challenge is complicated by another tension: Surgeons have become more selective even as advances in spine surgery have expanded what they can do.
Negative outcomes have pushed the threshold for surgery higher, Dr. Theologis said. At the same time, advances in surgical techniques, deformity correction, blood-loss management, resuscitation and preoperative planning have given surgeons a better understanding of how to approach difficult cases.
That can push the threshold in the other direction. “I think it’s iterative,” he said.
The goal, then, is not simply to exclude more high-risk patients. Better preoperative optimization could move some patients who once would have been considered too high risk into a group that can reasonably undergo surgery.
“We may be able to better optimize patients before surgery,” Dr. Theologis said, allowing more people to become eligible for surgery who may not have been in the past.
That is an important distinction as spine patients become more complex: Better selection does not necessarily mean fewer operations. It can also mean getting better at preparing the right patients for them.
Complex spine can’t operate in a silo
That preparation increasingly depends on what exists around the surgeon.
“You have to have a full team, and it starts in the clinic before surgery,” Dr. Theologis said.
For complex patients, that can include nurses and advanced practice providers helping navigate the preoperative process; primary care physicians and endocrinologists managing underlying conditions; pain specialists; and physical therapists working on prehabilitation.
The network extends into the operating room, where Dr. Theologis pointed to experienced anesthesiology and neuromonitoring teams, along with vascular and plastic surgeons for cases that require their expertise.
After surgery, patients may need intensive care, pain management, physical therapy, bracing and physiatry before transitioning to rehabilitation or home. Psychological health can be another part of preparation, including addressing depression, psychiatric distress and catastrophizing.
“You can’t operate in a silo,” Dr. Theologis said. “This is a team effort.”
The model spine programs may have to leave behind
Having those specialists available, however, is different from having them function as one system.
That is the gap Dr. Theologis believes complex spine programs will have to close. Many of the most complex spine patients are already treated at tertiary academic centers, he said, but their care can still be fragmented.
His vision for the next decade is an integrated network built around these patients, with a consistent group of physicians and other providers involved throughout their care.
“Almost like a one-stop shop,” he said. Instead of finding an available endocrinologist, plastic surgeon or other specialist as each need arises, the infrastructure would already exist around the patient.
“I think it has to be integrated from top down,” Dr. Theologis said. “That will improve the patient experience, and I do think that’s going to ultimately improve outcomes.”
Dr. Theologis is preparing to put that model into practice. He told Becker’s that he and several other UCSF surgeons are moving to Sutter Health in San Francisco, where they plan to establish an Advanced Spine Institute. Dr. Theologis said his final day at UCSF is expected to be in mid-October.
For him, the move also reflects where he believes the specialty is heading.
“This is the talk of the town,” Dr. Theologis said of integrated teams in adult deformity. “We’re all trying to move in this direction.”
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.
