William Richardson, MD, is a spine surgeon with Duke Spine Center in Durham, N.C.
He has spent time as chief of the spine division at Duke and recently shared his thoughts on the big trends in spine care delivery today.
Question: What do you think about robotic technology in the spine field?
Dr. William Richardson: Robotics is in its infancy and currently serves as a drill guide to assist with screw placement. It is as accurate as 3D navigated screw placement but not clearly better. Like spinal navigation it helps protect the surgeon and their staff from radiation exposure but has some potential to increase the exposure to the patient. Companies and surgeons need to pay close attention to the protocols they use to obtain the 3D images to use with the robot or other forms of navigation. I am excited to see where robotics takes us. The hope is that it will allow us to perform other parts of the surgical procedure through minimal incisions safely and effectively (decompression, rod bending and placement, and fusion both inter body and posterolateral). Also, with newer software to plan and then analyze what we need can apply AI — or machine learning — to make us better. Until some of these tools are available, we need to focus on surgical flow and process to decrease the learning curve, improve efficiency and demonstrate the value.
I do worry about the impact of these types of technologies on surgical education. It seems that most studies show some percentage of abortion of the procedure due to technical problems and they have to resort to using older approaches. We need to be sure that we train young surgeons in a variety of techniques to effectively care for outpatients when the computer crashes.
Q: Where do you see the biggest need for improvement in spine patient care?
WR: Risk assessment and risk mitigation along with surgical indications. With the aging population we are increasingly being asked about considering complex procedures on an older patient population with many co-morbidities and often unclear prognosis for success. The question is too frequently can we do an operation as opposed should we do the operation. We do not have a very good way of providing good studies about outcomes and risks.
As the population ages we need to do a better job of this risk assessment and mitigation. There should probably be a role for other services in this process including geriatrics (POSH: preoperative optimization of senior health) and Palliative Care to help with these patients who have chronic disease. While there will be great strides in technology and biologics in the future to allow us to do procedures less invasively, our ability to decide 'if we should' versus 'can we do it' is going to be most critical to decrease our morbidity and mortality.
Q: How do you see trends toward price transparency and value-based care affecting spine?
WR: It is going to be a growing trend. We now have insurance companies who offer patients a bonus to have an imaging study at a less costly facility. Data needs to be collected and openly shared. We can no longer sit back and think because we are a great, well-known facility that patients will come or be allowed to come by their insurance company. We need to be collecting data and sharing to get contracts and drive demand for services because of demonstrated value.
Q: What is the smartest thing you've done in the past 12 months to prepare your practice for the future?
WR: We became a combined spine division (orthopedic surgery, neurosurgery and physical medicine and rehabilitation) and recruited Chris Shaffrey, MD, to replace me as the chief of the division. The Cleveland Clinic was the first to [create a combined spine division] and others have tried with varying degrees of success. I think the we have the support of the department chairs, health system leadership and the medical school dean. I believe this should be the future of spine care and allows us to progress as one team without internal competition. The focus is on spine care and not just spine surgery and will allow us to look at new ways of providing spine care to populations with the greatest effectiveness and best value.
To participate in future Becker's Q&As or speak at Becker's events, contact Laura Dyrda at ldyrda@beckershealthcare.com.