Todd Albert, MD, makes his living in the operating room. He also spends a good part of his clinic day telling patients they don’t belong there.
“I’m a spine surgeon. I make a living doing surgery. I’m telling you, you don’t need surgery,” Dr. Albert said he tells some patients. “Does that not mean anything to you?”
Back and neck pain rank among the most common reasons people see a physician, and spine surgery volumes have climbed for years. But a different message is gaining ground among surgeons: Many patients who walk into a spine surgeon’s office don’t need an operation. Physical therapy, time, targeted injections and lifestyle changes can resolve or manage many conditions.
The harder questions are practical ones. How do surgeons separate the patients who need surgery from those who don’t? How do they keep a patient’s trust when the answer is “not yet” or “not ever”? And in a system that pays for procedures, what makes “no surgery” the default when it’s the right call?
Dr. Albert, surgeon-in-chief emeritus at New York City-based Hospital for Special Surgery and professor of orthopedic surgery at Weill Cornell Medical College, has spent more than three decades in spine surgery. He has held leadership roles at both HSS and Rothman Institute and serves on the board of the National Spine Health Foundation, a patient-centered nonprofit that helps people make informed decisions about their spine care. He joined the Becker’s Spine and Orthopedic Podcast to discuss how surgeons should prioritize conservative care — and when they shouldn’t.
Some cases are a hard stop. Many aren’t.
For Dr. Albert, the decision is not all-or-nothing. Some diagnoses call for surgery with little debate. He pointed to cervical myelopathy, or spinal cord compression in the neck.
“When somebody has signs and symptoms of spinal cord compression, meaning their hands don’t work, their balance is off, and there are physical signs when we examine them … we know the natural history of that is incredibly unfavorable, and the patient’s going to progress,” he said.
Back pain without leg pain sits at the other end. Absent an infection, tumor or other red flag, those patients should be treated with exercise, core and back strengthening, an organized physical therapy program and healthy lifestyle changes before surgery enters the conversation.
“Those are patients that we would take to the wall trying to avoid surgery for them because our results aren’t as reliable,” he said.
A disc herniation with leg pain or weakness is a surgical problem, he said, but only if the patient can’t get better without an operation. “It’s not all of spine surgery or none of spine surgery,” Dr. Albert said.
Telling patients no — and keeping their trust.
Dr. Albert said patient understanding and communication around treatment options can be tricky part of delivering conservative care. Many patients arrive in pain and in their mind, already diagnosed. They tell him they’re there for “an L4-L5 problem” because an MRI showed degeneration or a disc bulge.
Dr. Albert’s response: Imaging studies of people who have never had back pain show the same findings. Among pain-free 45-year-olds, he said, roughly 35% to 45% would have disc bulges and similar changes.
“It’s part of the aging process,” he said, comparing the findings to gray hair. “Because they have those changes does not mean they have a severe diagnosis. It means they’re a normal aging person, and we’re going to try to get them better without surgery.”
How patients take that news depends on who they are. Some are so afraid of surgery that they thank him, even while in pain. Others have been suffering for weeks or months and came in expecting a fix. Those conversations are harder.
“The worst interaction is when you look and go, ‘I can’t help them as a surgeon,'” he said. “And then you tell this patient who’s been feeling horrible, ‘You shouldn’t have surgery.’ What are you going to do for me? The answer can’t be, ‘Well, I’m not going to do anything for you.'”
At HSS, he can hand patients off to nonoperative specialists and pain management physicians. But he also said the U.S. overuses treatment, and that some patients carry risk factors such as smoking, inactivity or excess weight that worsen their symptoms while expecting care that isn’t well-proven for them. In those cases, he said, surgeons have to be direct about what will actually help.
He acknowledged that a patient set on surgery can usually find a surgeon willing to operate. He doesn’t think that’s a reason to give in.
“When it doesn’t have success, now you have a patient who has surgery,” he said. “You own that patient forever, and you’re responsible for the bad result.”
What good conservative care looks like
Dr. Albert said that he isn’t surprised when patients are disappointed by physical therapy, or say therapy “didn’t work.”
Dr. Albert often wants to know what kind of therapy they had. He has little patience for high-volume clinics where patients rotate through unsupervised stations or receive hot packs and massage.
“That is not the right therapy for me,” he said.
Instead, he supports a supervised and diligent physical therapy program that is built on strengthening rather than stretching alone: the core, the back extensors and the neck musculature. After a reasonable stretch of supervised therapy, patients should move to their own routine, such as Pilates, swimming or running.
“People who are in good shape have less incidences of back pain, and when they have it, they’re less severe,” he said.
He uses injections often, but with a purpose. He makes a specific nerve root diagnosis from the history and physical exam, then orders a targeted injection, such as a selective nerve root block at L5, to confirm it. If the pain lifts during the anesthetic window and later returns, the diagnosis holds. If it doesn’t lift, he stops injecting.
Pay for outcomes, not for operating or not operating
Dr. Albert doesn’t believe surgeons should be paid for declining to operate. He believes good indications pay off on their own.
“Patients seem to like me better when I get them better without surgery,” he said. Surgeons who choose patients wisely, he added, “are going to be so busy you don’t have to worry about the incentives because you’re going to make a lot of money practicing correct medicine.”
As care moves toward value-based models, he wants groups judged on results across the patients they serve. “Measure us on the population’s outcome,” he said.
He sees payers’ prior authorization requirements as both helpful and harmful. Some criteria make sense, but many are not evidence-based, and the burden often falls on documentation, a problem he expects AI-assisted notes to ease. In general, he said, patients with sound indications aren’t blocked from surgery, though rigid rules still frustrate him.
He pointed to required physical therapy timelines of six weeks or three months as one example. For a patient in severe pain with a clear surgical problem, “we should allow a little bit of leeway there,” he said.
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.
