Christopher Shaffrey, MD, has seen spine care evolve through rapid innovation.
But as outcomes and complication rates face greater scrutiny, the chief of the spine division at Durham, N.C.-based Duke University said the biggest gains are coming from a simpler shift: preparing patients more effectively before surgery.
For complex procedures, the difference between a smooth recovery and a major complication often starts well before the operating room.
“One of the biggest focuses is on all of the different modifiable risk factors,” Dr. Shaffrey said.
Frailty reshaping surgical risk
Dr. Shaffrey said spine surgery has become more precise about identifying which patients are at higher risk.
“What has been shown is that there’s probably a measure of what’s called frailty, and the more frail the patient is, the more likely they’re going to have either a major complication or a poor outcome,” he said.
He pointed to research tracking adult spinal deformity surgery over the last decade showing meaningful improvement, including better outcomes and significantly lower complication rates. Dr. Shaffrey attributed much of that progress to optimization as opposed to technology.
“It’s not a new widget, or a new rod or a new coating,” he said. “These are things that are making people’s health better so that they can tolerate spine surgery better.”
That work includes improving bone health, blood glucose and nutrition, along with structured prehabilitation.
“One of the biggest things we’ve found is that vigorous prehabilitation and preoperative exercise can markedly reduce complications,” he said.
Benefits of restraint
Even with expanding surgical capabilities, Dr. Shaffrey said high-quality spine care often starts with restraint.
“I’m a believer that you should do the least invasive or the least involved treatment that gives people the quality of life that they desire,” he said.
That approach depends on counseling and realistic goal setting, especially when patients are initially expecting to need major surgery.
He acknowledged complex surgery is sometimes unavoidable in severe scoliosis, sagittal malalignment or spinal slippage, but added that major intervention should rarely be the default.
Leading with nonoperative care
Dr. Shaffrey acknowledged that restraint can be difficult in a system in which surgical procedures drive revenue.
At Duke, he said patients often begin with a nonoperative program called Spine Health, which includes physical therapy and chiropractic care alongside broader interventions aimed at improving function.
“Spine Health goes beyond just strictly physical therapy,” he said. “It also does a lot of different things like mindfulness, yoga, pilates and other treatments to maximize physical overall improvement before they may be forwarded.”
Even when nonoperative care is not enough to resolve symptoms, Dr. Shaffrey said it improves conditioning, making an eventual procedure safer.
He added that Duke also relies on an aggressive optimization pathway for complex surgery, including bone health improvement and structured medical clearance.
“Most of our patients undergoing complex surgery have a very aggressive, multi-stage process to improve their health before we engage in surgical intervention,” he said.
What should guide innovation
Dr. Shaffrey said new technology can play a meaningful role, but only if it is evaluated responsibly and delivers measurable improvement. Through national and international research collaborations, he said teams are studying newer approaches designed to reduce the need for deformity surgery, including technologies aimed at improving the health and conditioning of paraspinal muscles.
“We’re just about to start a study that is going to look into this muscle stimulation technique called multiplicative stimulation, to see if that can be a less involved way to go and to treat milder adult scoliosis,” he said.
He emphasized promising tools should not be scaled without evidence.
Cost is also part of the equation.
“Most new technologies, or many new technologies, cost more,” he said. “We need to make sure if we’re embracing a new technology, that it gives a meaningful improvement in patients’ outcomes.”
At the same time, he said some of the most effective interventions are still the simplest.
“If we can do something that is not particularly costly, that improves their global health, that’s absolutely the best course of action,” he said.
A new tool for optimization
Dr. Shaffrey said some of the most important shifts affecting spine care may come from outside the specialty, including metabolic therapies that make weight loss and risk reduction more achievable for patients with severe degeneration.
“There’s some literature showing that if you have a body mass index higher than 35 that your complication rates for many spine surgeries are higher,” he said.
He said GLP-1 medications have helped some patients lose weight, regain function and sometimes avoid surgery entirely.
“Two patients, for example, were placed on GLP drugs, and they’ve lost weight, they are better,” Dr. Shaffrey said. “Both of them came back today and said, ‘I’m so much better that I don’t think I need my back surgery anymore.’”
His focus is on improving the patient’s health, regardless of whether that leads to surgery.
Some conditions still require urgent intervention, such as a major disc herniation with foot drop or cervical myelopathy. But for most patients, he said optimization is still worth the time because it reduces risk even when surgery remains necessary.
Looking ahead, he expects outcomes to keep improving through better risk stratification, better preparation and more targeted innovation.
“We are doing things really 50% better than 10 years ago,” Dr. Shaffrey said. “We’re going to continue to do things that are going to be safer and better.”
