The Future of Spinal Surgery:
A Spinal Neurosurgeon's Perspective
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Spinal surgery in the United States has had excellent contributions from both neurosurgeons and orthopaedic spine surgeons. The fields overlap considerably in that both specialists often take care of similar spinal problems. In the past, the area of spinal deformity was largely treated by orthopaedic surgeons, while intradural pathology was the domain of neurosurgeons. Disc herniations, other degenerative spinal disorders and trauma were treated commonly by both subspecialties.
Orthopaedic surgeons who commonly perform spinal surgery typically participate in a fellowship for one year after the completion of residency training. More and more neurosurgeons are also seeking spine fellowship training. The fields continue to converge with collaboration of the specialties being common in the largest medical centers. In the future, a single spinal surgery discipline may exist with training in the basics of both fields, followed by training in spinal surgery. This may obviate the need for fellowship. There has been resistance to this idea amongst some of the more senior establishment in both fields of medicine. Nevertheless, this trend is being seen in Asia and will likely occur in North America too. Minimally invasive spine surgery has grown substantially as field. Specifically, for certain forms of scoliosis and multilevel degenerative spine disease, minimally invasive approaches can cut down on blood loss, pain and potentially hospital stay. As the procedures become more popular, they will need to demonstrate both durability and equivalent outcomes to traditional open procedures. Imaging continues to advance, allowing the surgeon to make more accurate diagnosis preoperatively and allowing the surgeon to more accurately place spinal instrumentation, especially in complex revision procedures. Neuronavigation improvements will hopefully allow the surgeon to maximize intraoperative awareness and visualization for placing instrumentation and other historically fluoroscopy dependent tasks with less patient and less surgeon radiation. In conjunction with minimally invasive techniques, this may also further allow advancements with robotics in the field. |
 In collaboration with: Eli M. Baron, MD, Clinical Associate Professor of Neurosurgery, Cedars-Sinai Medical Center
Biologics continue to evolve in spinal surgery. The last decade saw the widespread use of rhBMP-2 (Infuse, Medtronic Sofamor Danek, Memphis, TN)) as a biological agent promoting spinal fusion. As a better understanding of the factors involved in promoting and inhibiting fusion is achieved, more materials with biological activity will be available to the surgeon to assist in achieving fusion.
Motion preservation technology became widely available in the last 10 years including artificial cervical and lumbar disc replacement. Disc arthroplasty is a relatively new technology in the United States, and without a doubt, there will be numerous new devices and next generation devices available in the next 10 years. Thus far cervical outcomes data has been excellent. This may result in reduced cervical fusions being performed for disc herniations Finally with the advent of the Affordable Care Act and rapid changes in healthcare delivery systems and payer mixes (such as Accountable Care Organizations), outcomes will be highly scrutinized. Cost effectiveness and health related quality of life outcomes will be important in terms of which procedures are authorized by payers and also in terms of keeping providers contracted with facilities and payer systems. Bundled payments by diagnosis will also likely result in changes in treatment patterns, hopefully resulting in maximizing cost/benefit ratio for patients undergoing surgical intervention. |