Spinal fusion reliance, open procedures and more: Spine trends to phase out


Some spine surgery trends that have prevailed are now reaching the point where they can be phased out.

Five spine surgeons share what they think should be let go.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

Next question: What is an essential read for all spine surgeons? 

Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Wednesday, May 22.

Editor's note: Responses were lightly edited for clarity and length.

Question: What spine surgery trend needs to be phased out in 2024?

Joel Beckett, MD. UCLA Health/DISC Sports and Spine Center in Marina del Rey, Calif.:  

Heavy reliance on spinal fusion: Spinal fusion has been a cornerstone in treating structural spinal deformities and instability for years. However, the over-utilization of fusion surgeries, often for conditions where less invasive options could suffice, needs reassessment. With the rise of motion-preserving surgeries like artificial disc replacement and evidence pointing to the benefits of conservative management for lower back pain, the trend of defaulting to fusion should be phased out.

Prolonged hospital stays and inpatient reliance for spine surgery: Traditionally, spine surgery is conducted in an inpatient setting. With continued technological advancements and the development of minimally invasive techniques coupled with continued changes in reimbursement, this "default inpatient" needs to be phased out. Across the country, forward-thinking spine surgeons and centers are conducting safe and efficient outpatient surgery. Ultimately, this change benefits both individual patients and decreases the cost burden on the health system as a whole.

Routine postoperative opioid prescriptions: The opioid epidemic has necessitated a drastic rethink of pain management strategies post-spine surgery. The trend of prescribing opioids as a first-line postoperative pain solution should be phased out in favor of multimodal pain management techniques that minimize or eliminate the use of opioids, thus mitigating the risk of addiction.

Ignoring patient-reported outcome measures (PROMs): The traditional focus on surgical and radiographic outcomes often overshadows the importance of patient-reported outcomes. In 2024, ignoring PROMs should no longer be tenable. Practices must integrate these measures into their evaluation protocols to ensure that patient perceptions of pain, functionality, and quality of life are considered when determining the success of spinal interventions.

Chester Donnally, MD. Texas Spine Consultants (Dallas): The acceptance of intraoperative fluoro images being shared on social media and the surgeon posting that the surgery was a 'complete success,' this lack of follow up should be phased out. It would be equivalent to showing me the halftime score of a football game and saying the team is going to win, that doesn't usually happen, and there is still more to the story ... Look, I am not against intraoperative images being shared, just wary of surgeons also claiming what this surgery did for the patient, that day. Heck, sometimes the physician is posting the images at 1 p.m. the day of surgery, and the patient possibly hasn't even ambulated yet! I just think we should expect actual follow-up in these case examples such as standing images (for alignment), and comparative ODIs, to then claim how great a certain procedure or product is at helping patients. Follow-up with post op radiographs tells a different story in terms of success!

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The main things spine surgeons need to remember their worth and their value. It is time we stopped letting the beancounters dictate the use of those two things. There is no more space for not being informed and organized. Playing good little pawns is over.

Gurtej Singh, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Open spine surgery and microscopic-assisted spine surgery should be phased out in 2024 when these procedures could otherwise be treated with endoscopic spine surgery. The minimal disruption to native tissues, the demonstrated efficacy, and the reduced infection risks are just some of the many reasons that endoscopic spine surgery should out-favor a comparable open or tubular surgery.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The entire notion of 'black disc disease' and its aggressive surgical approach should be scrutinized and revisited since the treatment is over implemented for the disease process. Surgical rehabilitation from highly invasive procedures (anterior lumbar interbody fusion and extreme lateral interbody fusion) is prolonged and usually marginal at best. Reportage of most outcomes is usually acute versus chronic and most struggle later or even sooner in life, with adjacent level failure and long-term pain syndromes. Insurers seem to be wise to this overreach in diagnosis and treatment, whereby this type of procedure historically was reserved for treatable cancer diagnosis and restabilization procedures.

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