Here are eight important spinal technology advances heading into next year.

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1. Artificial discs. Much controversy circles around the future of artificial disc replacements. Lumbar disc replacements have not held up under scrutiny and researchers studying cervical disc replacements are just beginning to gather long term effectiveness data.

"Lumbar disc replacement is dead in the water, but there is a lot we are still excited about with cervical disc replacement," says Andrew Hecht, MD, co-chief of orthopedic spine surgery at Mount Sinai School of Medicine in New York City. "Now we are seeing some evidence that in its current form, cervical artificial discs aren't preventing adjacent segment disease as we had hoped. Cervical fusion is such a successful procedure that the key is really going to be whether disc replacement really does reduce the rates of adjacent segment disease."

At this year's North American Spine Society annual meeting, studies presented compared cervical disc replacement and fusion procedures and showed minimal, if any, difference in adjacent segment disease. However, there are promising developments on the horizon for artificial discs.

"One of the shortcomings of the United States-approved lumbar discs is they do not incorporate shock absorption while some of the European ones do," says Donald Corenman, MD, a spine surgeon with The Steadman Clinic in Vail, Colo. "The currently available ball and cup disc replacements are not mechanically connected so there are no significant stresses created in the interface between the vertebral body bone and the implant itself. With a shock absorption type of disc, there is a strong mechanical connection between the two ingrowth endplates. This creates greater mechanical stress between the host bony endplate and the device. Longevity of the implant comes into question. Nonetheless, I think this will finally yield disc implants that are more acceptable for the lumbar spine."

Regardless of the method, surgeons are looking for ways to preserve motion in the spine and new developments in disc replacements may give patients more normal motion than in the past.

"We continue to get closer to having actual metal and plastic options that really more closely mimic the movements and kinematics of the normal human cervical spine and disc," says Sheeraz Qureshi, MD, associate professor of spine surgery in the department of orthopedics and chief of trauma in at Mount Sinai School of Medicine in New York City. "We are getting longer term results on disc replacement options that are available, which have had excellent outcomes. We continue to improve the type of motion that is occurring and we are getting closer to the point where we can say we will have these devices to protect against adjacent segment disease."

2. Minimally invasive surgery for instrumentation and fusion. Minimally invasive techniques are now the standard of care for simpler procedures like decompressions and are gaining traction among instrumentations and fusions. While maverick surgeons have been performing these procedures for several years, more studies now show their effectiveness and the idea of minimally invasive spinal surgery has gone mainstream.

"Now that we have done this for quite some time, we are seeing a lot more papers discussing how effective minimally invasive surgery is compared to mini open techniques," says Dr. Hecht. "We are trying to figure out where these procedures will fit in and whether the differences are really enduring. For cervical foraminotomy and far lateral discectomies, the minimally invasive techniques are the gold standard; for spinal fusion, the jury is still out on whether it makes a difference."

For some procedures, such as transforaminal lumbar interbody fusions, the minimally invasive technique might shorten hospital stays by a day, but the patient might not achieve fusion as well as the mini open technique would have.

"We need to have a minimally invasive technique that will allow us to achieve as good of a fusion there," says Dr. Hecht.

3. Lateral access procedures. Device companies are increasingly developing instrumentation for lateral access techniques. These techniques allow surgeons to access several different areas of the spine through a minimally invasive approach.

"Initially, minimally invasive surgery was just percutaneous pedicle screw placement, but as things evolved we were able to do more TLIFs and fusions, and now we are seeing the increased popularity of direct lateral surgery," says Dr. Qureshi. "The next thing on the horizon will be the ability to more safely access not only the L4-5 space through a minimally invasive direct lateral approach, but also the L5-S1. Before this area wasn't considered a space that could be accessed through those approaches, but if we are able to do that it would be a major advancement."

The lateral approach has also brought forth several new innovations n image guidance.

"We are very excited in the improvements in image guidance technology that allows us to do these less invasive procedures more safely because when you have an idea of where you are and how close you are to directly accomplishing the goals of surgery, you have better outcomes," says Dr. Qureshi. "We are seeing improved ability to navigate and access levels commonly involved in surgery that weren't possible even through lateral approaches before. In 2013, we will be introducing some new ways to do that."

4. Implant and instrumentation materials. Spinal instrumentation is constantly being refined based on the metal material, shape and technique. Every major manufacturer routinely updates their instrumentation and while the application of the instrumentation hasn't changed much, the metal material has.

"There is a trend, in spinal deformity surgery, to use cobalt chrome for longer constructs. This is an evolution from stainless steel and titanium implants," says Purnendu Gupta, MD, medical director of the Chicago Spine Center at Weiss Memorial Hospital. "Now we can use a combination of titanium screw implants with cobalt chrome rods. The advantage is that you have greater fatigue life than with titanium."

Cobalt chrome also has greater resistance to infection than stainless steel, which is important particularly in long constructs. However, more data should be gathered to really assess theses benefits. Another material on the rise is Amedica's patented Silicon Nitride, which is a heat resistant material that can be manufactured into different forms — either very dense or very porous with a highly polished or texturized surface — to accommodate different implant types.

"Silicon Nitride is certainly one of the most exciting new emerging technologies in the space," says Grant Skidmore, MD, a neurosurgeon at Neurosurgical Specialists in Norfolk, Va. "Silicon Nitride provides surgeons with another option for spinal implants, as it appears to be superior to both titanium and PEEK in its interaction with bone."

Two peer reviewed studies have show the benefits of Silicon Nitride, which also allows for intraoperative visualization.

5. Bone morphogenic protein. Medtronic's Infuse is currently the only FDA-approved bone morphogenic protein product available on the market for spinal fusion, with limited indications. Despite current controversy surrounding its use, many spine surgeons still find the product helpful for complex fusions, and further developments in bone morphogenic protein products could enhance the procedure over the next several years.

"BMP continues to remain useful in spine fusions, particularly in challenging environments where patients have significant comorbidities," says Dr. Gupta. "Perhaps in the future, there will be more research on the use of combinations of BMP — it's already being used with bone graft substitutes — but there are other BMPs beyond what is commercially available and they could be more effective in combination. The basic science research on combinations will continue to emerge over time."

For now, many companies are financially limited in their research and development on bone morphogenic protein material. In the near future, researchers and device companies may take steps to define the appropriate use of BMP material currently on the market.

"I think over the next year, we will see what the best and most appropriate role for BMP is," says Dr. Hecht. "I don't think it will go away and it shouldn't."

6. Biologic treatment and disc regeneration. Some research is being done now on biologic alternatives to BMP that would promote fusion and potentially enhance disc regeneration in the distant future. These solutions include stem cell research and other types of biologic material.

"We are still looking for biologic treatment for both fusion and disc regeneration, and I don't think we are any closer to finding a solution," says Dr. Qureshi. "I don't think there are great things on the horizon for the upcoming year, but that will be the next space where a lot of research and resources will be devoted."

While BMP has powerful bone forming and fusion forming abilities, there are some issues with the substance that are causing surgeons to reach for an alternative that is just as effective. In disc regeneration, no material is pervasive yet.

"We are working for the point where we will have these things that are injectable and promote disc regeneration and healing for the patients so they will avoid the need for surgery," says Dr. Qureshi.

7. Growth tethers. For children with juvenile scoliosis, growing rods have been developed to allow growth and delay spinal fusion procedures. For early onset scoliosis, surgeons can do serial casting with some success as well. However, there is an opportunity to further modulate spinal growth with a device known as a growth tether.

"We are seeing the development of growth modulation in addition to growing rods," says Dr. Gupta. "Growth tethers are still on the horizon and hopefully will emerge as effective adjuncts to growing rods. Several companies are developing growth tethers which are being used in animal research. At the moment, none are commercially available, but they will probably emerge in the near future."

For children needing a fusion for treatment of scoliosis, surgeons are also looking at how the length of fusion may impact residual spinal motion. In some cases, surgeons are ending their fusion at L3 instead of L4 for motion preservation. Dr. Gupta is participating in a study being done in collaboration with Drs. Hammerberg and Harris at Shriners Hospital which currently includes two year data and will be followed up at five years.

"We see there is a dramatic change in the patients' motion if we stop a scoliosis fusion at L2 versus L3 or L4," says Dr. Gupta. "It will be interesting to see the follow-up at five years to know whether the motion is maintained or will change. We'll know the impact of longer fusions at the five-year mark in the pediatric population."

8. Image guidance technology. Enhance imaging technology available with the O-arm is now starting to gain traction among mainstream spine surgeons and could become the standard of care in the near future. An O-arm helps spine surgeons with screw placement and many have found this technology particularly useful during revision surgeries or with patients who have more complex degeneration.

"The O-arm allows for accurate implant placement so we don't have to worry about screw placement issues," says Dr. Corenman. "It allows you to perform procedures that you normally might not contemplate because these procedures were too complex in the past. It also substantially reduces the exposure of surgeons and staff to radiation when compared with standard C-arm technology."

The O-arm has developed into a useful tool for training younger surgeons in their fellowships because the fellows can place screws without viewing the stealth monitor, but the experienced surgeon can watch the monitor to see if the screws are in the right place.

"We've had the ability to make three-dimensional guidance in the operating room for some time but it has never been user-friendly," says Dr. Qureshi. "There were always problems with little movements that threw off the entire navigation in the past. With newer technologies, we overcame that and can navigate very predictably."

Newer technology can also save operating time. "For the navigational surgery, you just take a one-time three dimensional image and you don't have to take an X-ray for the rest of the time," says Dr. Qureshi. "It goes a long way for long term safety. There is also a fatigue factor because surgeons don't have to wear heavy led aprons during surgery."

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1. Coverage denials will continue among many payors. This year more than ever, spine surgeons are reporting coverage denials from insurance companies for surgery as well as other procedures and tests.

"The last two years have been extremely challenging," says Neel Anand, MD, director of spine trauma, minimally invasive spine surgery at Cedars-Sinai Spine Center in Los Angeles. "Seemingly, everything is being denied, including MRIs and CT scans. We spend at least 50 percent of our time, compared to two years ago, getting approval for patients and talking to non-medical personnel. Sometimes even then, we aren't able to get clearance for the surgery."

The inability to treat patients quickly and efficiently could lead to health problems in the future, especially for patients with degenerative conditions.

"It really has become a vicious and ineffective cycle that I think will adversely affect patient care," says Dr. Anand. "It is delaying patient care and it's really sending them backwards. There is a very finite window for treatment, and that's become apparent now. If we are able to tackle the problem right away, patients can go back to work and their regular life. On the flip side, if the back pain digresses and they are unable to work for a year or more, patients don't tend to do as well."

Professional societies are responding to payors and advocating in Washington, DC, so patients can receive the care they need without bankrupting the healthcare system.

"I know the North American Spine Society is trying to start a registry to gather evidence," says Jeffrey C. Wang, MD, vice chair of clinical operations in the UCLA department of orthopedic surgery and chief of the orthopedic spine service at the UCLA Comprehensive Spine Center. "Whenever there is a new code or issue, NASS is there to respond and have an evidence-based approach. When payors announce an inappropriate coverage decision, NASS responds."

2. All surgeons must gather data and practice evidence-based medicine. Insurance companies are increasingly implementing coverage guidelines that exclude patients and services from coverage that traditionally would have been approved in the past. The most glaring example in spine surgery is the Milliman guidelines, which have been adopted by insurance companies across the country.

"It's becoming harder and harder to take care of our patients and deal with the payors," says Dr. Wang. "Because of the Milliman guidelines, when we try to authorize surgery for our patients we are getting push back from our payors. We need to advocate on the behalf of the patients and say these guidelines aren't accepted by the medical community."

The Milliman guidelines recommend continued conservative treatment for patients who were considered candidates for spinal fusion in the past, particularly those presenting with just degenerative disc disease. The guidelines are based on hand-picked, outdated studies that many surgeons reject in favor of new, higher quality studies.

"Payors are adding these guidelines and there is very little evidence that they are appropriate," says Dr. Wang. "We as spine surgeons have to collect evidence and outcomes — whether it is from registries or good prospective studies, to show what works and what doesn't. There are some things we can work on and it's incumbent upon the surgeons themselves to gather the evidence for these things and show what will be successful for our patients."

The implementation of EMR and other healthcare IT may make this process easier in the future. "The one good thing coming out of EMR is that it will gather our data and show our treatments work," says Dr. Wang. "I think that's going to result in better outcomes. I think gathering outcomes and doing the surgeries that work is important. It may be harder for people in private practice to do it, but it's more important because private practices are dwindling and more surgeons are becoming hospital employees."

3. Hospital employment will likely increase. Today's tight regulatory environment, coupled with low reimbursements and rising costs for practice management, mean fewer physicians coming out of medical school are choosing to strike out on their own. Instead, they are becoming hospital employees. Established physicians are also selling their practices to hospitals at an alarming rate in search of more flexible hours and high salaries hospitals are willing to pay.

"The trend of hospital employment of spine surgeons is growing and will continue to grow," says Robert Watkins Jr., MD, co-director of the Marina Spine Center at Marina Del Rey (Calif.) Hospital. "The larger hospital networks are gaining control of masses of patients which will make it more difficult for private practice surgeons. The private practice surgeons need to be able to spend adequate time with their patients and provide outstanding service."

When hospitals begin employing specialists it becomes more difficult for private practice surgeons to drive referrals.

"The opportunities are going to become more constricted as more hospitals hire people to be staff members instead of independent contractors," said Donald Corenman, MD, a spine surgeon with The Steadman Clinic in Vail, Colo. "I think it's going to negatively impact care because doctors will become shift workers and that's going to diminish their quality and continuity of care."

Even when surgeons are not employed by hospitals, hospital executives and leaders are dictating clinical measures, such as which types of implants surgeons can use.  

4. Care will need to become more cost-effective. All providers will be pushed further toward delivering the most cost-effective care possible as the government and payors pursue ways to lower healthcare spending and cut costs. Additionally, more patients with high deductible plans will shop for the best value and expect spine surgeons to deliver.

"Reimbursements are declining and they will continue to decline," says Dr. Watkins. "Patients expect better care and more time with doctors, but most people don't want to pay for it."

This trend also holds true for spine innovations. "One of the biggest challenges in the medical profession is dealing with the decreased reimbursement and moving toward more cost-effective measures," says Matt Chong, MD, a spine specialist at White Memorial Medical Center in Los Angeles. "How do we make safer, more reliable implants and keep innovation going while minimizing the cost of developing and using this new technology.”

Striking that equilibrium for better products with fewer complications while meeting lower reimbursement needs will make it more difficult to innovate. However, some innovations we are likely to see in the future include robotic guidance for spine surgery because it delivers higher quality of care.

"Technology will continue to make spine surgery safer and more effective," says Dr. Watkins. "Robotic computer navigation will continue to evolve."

5. Spine care is becoming more interdisciplinary. Spine care providers are now integrating more than in the past to provide patients with a one-stop location for all their spine and back pain needs. Spine surgeons are partnering with all types of non-surgical specialists, including physical therapists, pain management, physicians, massage therapists, chiropractors and acupuncturists to bridge the gap in care.

"Spine surgery can be an isolating profession but at its core, our patients require a multidisciplinary approach," says Dr. Chong. "We need to reconnect with primary care physicians and pain management specialists on a multi-modal approach to care."

Practices are also incorporating MRI, behavioral specialists and other ancillary services into their practice for convenience; patients can have multiple services in the same visit and specialists are able to coordinate care better.

"I think the model that a lot of people are interested in is the 'one-stop shop' approach, where through a single practice site you can see a non-operative specialist or a spine surgeon, as well as a physical therapist, and have access to advanced imaging facilities," says Dr. Chong. "Consolidating all of that is an advantage from a financial perspective and enhances good communication."

It will take considerable skill to lead these practices of the future. "To be a leader at a major institution, a spine surgeon needs to become fluent in the politics of the field," says Dr. Watkins. "To be a leader in private practice, the surgeon needs a marketable trait and [needs] to provide outstanding service to patients."

6. Regulations and lower reimbursement threaten the patient/physician relationship. As more regulations are passed, and healthcare providers struggle to implement electronic medical records, surgeons are spending more time doing administrative and paper work than ever before. While they are still spending time with patients, it has become more difficult for them to carve time out of busy schedules.

"It's a challenge for surgeons comply with the rules, institute EMRs and improve patient satisfaction scores," says Dr. Wang. "A lot of the reimbursement in the future will be based on patient satisfaction. We need to figure out how to maintain our practices and profitability while having good relationships with patients and complying with more rules and regulations."

According to a Medscape 2012 report, around one quarter of orthopedists spend 30 to 40 hours per week seeing patients, slightly higher than last year. However, 20 percent of orthopedists reported spending 10 to 14 hours per week on paperwork and administrative activity; another 29 percent reported spending five to nine hours weekly on non-patient visit work. With the uncertainty surrounding healthcare reform implementation, more regulations are possible in the future.

"Right now, we know what we have to do and we think we know what will be required next year, but they could change the rules at any time," says Dr. Wang. "They could have new rules and regulations in a few years, so it's almost like a moving target."

Another threat to the patient/physician relationship is lower reimbursements, which prompt some surgeons to see more patients per day and spend less time with each patient.

"One of the biggest challenges facing spine surgeons over the next five years is being able to afford to spend enough time with patients to make a proper diagnosis and to properly inform patients of their conditions and potential treatments," says Dr. Watkins. "Patients desire to know more information than in the past, and they want their doctor to answer many questions. These are reasonable expectations from the patient with spinal disability, but with decreasing reimbursement the doctor will less be able to afford to do this."

7. More surgeons will jump on the minimally invasive bandwagon. Over the past five to 10 years, the biggest trend in spine surgery technological development has been less invasive surgical technique. "Minimally invasive approaches are really revolutionizing the field," says Dr. Chong. "At times in the past, we were often limited to offering a patient a more invasive procedure. The advancements and increased adoption of minimally invasive techniques are resulting in shorter hospital stays, less post-operative pain and a reduction in traditional complications."

While most surgeons were initially skeptical of these developments, solid evidence have shown certain techniques and procedures — performed with the same goal as open surgery — have good outcomes while minimizing comorbidities such as pain and blood loss.

"Minimally invasive spine surgery should play a role in the practice of every spine surgeon," says Dr. Watkins. "Surgeons should perform less invasive surgery when they feel confident that it will treat patients' conditions as safely as more invasive surgery. Surgery may be performed as an outpatient [procedure] if the safety is not compromised."

In time, the procedures that don't show clinical and cost improvements will fall out of favor and those with clear, proven benefits will continue to grow.

"There are some procedures that are good and we know work well, but even among these procedures there will be innovation," says Dr. Chong. "We'll want to reduce the rate of revision surgery and maximize long term patient satisfaction.  We're also looking for new technology that will make us more accurate and expose surgeons to less radiation."

New developments in minimally invasive procedures for more complex surgeries, such as spinal deformities, are on the horizon and pioneers in the field are already using them.

"I think the minimally invasive correction of spinal deformity is a massive move forward," says Dr. Anand. "It represents a huge paradigm shift in performing major spine surgery. I see that continuing in the future because many centers are adopting it, societies are accepting it and courses are teaching it. A big operation being done through minimally invasive techniques is showing equivalent to better outcomes; we have five and seven year outcomes data proving it works."

8. Artificial discs and lateral fusion research is coming due. For years, spine surgeons and medical device companies have collaborated on artificial disc replacements and lateral fusions with mixed results for coverage. Lateral procedures, initially developed by NuVasive with the eXtreme Lateral Interbody Fusion, are now becoming a standard approach from device companies across the board.

"Compared to many other spine procedures, direct lateral interbodies are relatively new," says Dr. Chong, "but within the next decade we will have long-term feedback to help us determine what techniques work and where we need further development."

Insurance companies are covering these procedures more readily than artificial disc replacements, which still have some room for development.

"There are trends right now that are going in the direction that will try to maintain mobility but they haven't been completely successful yet," said Dr. Corenman. "The problem with current artificial discs — and it may be resolved in the next generation — is impact absorption. There are a few discs out of Europe that may show some promise in fixing this problem."

One of the road blocks facing many artificial discs is payor coverage. A few discs have gained 510(k) clearance, but even after that insurance companies often continue to deny coverage, citing lack of evidence for clinical efficacy.

"There are new technologies out there that are being hampered by coding and regulations in that they are put forward as experimental and insurance companies won't pay for it," says Dr. Anand. "These issues will determine whether new technology moves forward and whether it will become more ubiquitous."

Current research in these fields is promising and coverage could be expanded in the future, if cost- and quality-effectiveness are shown.

"One way to influence the decision by insurance companies on whether to provide coverage for this procedure," says Dr. Chong, "is to conduct studies designed for superiority to determine if artificial disc replacements are better than traditional fusion in long term follow up."

9. Online marketing and patient education becomes a must. There is a huge opportunity for spine surgeons to market themselves and their practice to patients online. Beyond the standard practice website, spine surgeons must engage the online community with patient education platforms, videos and blogs related to spine conditions.

"I think the internet is going to be the next wave for spine care," says Dr. Corenman. "Patients are coming into the office having significant fear and not understanding anything about spine surgery, and they are hungry for knowledge. Unfortunately, there is not a lot of education in typical spine offices, and that's where I think the internet is really going to shine."

Dr. Corenman has a website that includes a forum where anyone can ask general questions about spinal conditions and he answers to the best of his ability. One common problem is patients receiving different diagnoses and treatment recommendations from multiple spine surgeons and specialists; he tries to help patients sort through this information and find the right pathway to care.

"There is a significant lack of continuity for different problems," says Dr. Corenman. "When I'm interacting with them online, I'm not practicing medicine, it's purely education. When you can gain accurate and succinct education, it makes patients more confident and empowers them in their own decisions."

Dr. Corenman receives two to seven questions per day on his forum and spends around an hour answer the questions daily. He also writes articles for the website and uploads videos of procedures. He has nearly 40 videos on his YouTube site, which receives about 100,000 hits per month. While the website has gained traction, it takes significant time and effort to maintain.

"It's still uncommon for surgeons to have a vast online presence," says Dr. Corenman. "The problem is that it takes a tremendous amount of time to write these things and an understanding of how patients think so you can write in a way they will understand. Even though there are a lot of plug in sites where you can purchase information and publish it on your webpage, it might not be accurate or accessible to patients. It behooves you to write that information yourself."

10. Physician ratings and online reputation management won't go away. Over the past five years, several physician rating websites have sprung up from various organizations, allowing patients to "rate" their physician and leave comments.

"The most difficult part of the internet will be how to rate doctors," says Dr. Corenman. "Now a patient can go on the internet and there are a number of different rating sites. They can express their opinions and you don't know how accurate it is. That's one of the dangers of the internet, and it's relatively new territory."

While a vast majority of these websites are underutilized, they are gaining traction as patients are continuously encouraged to take more responsibility for their care. Unfortunately, the most avid contributors to these pages are often those with negative experiences.

"It's a double-edged sword," says Dr. Anand. "You can have one disgruntled patient for any reason who could post a very negative review that is an inaccurate misrepresentation of the physician and his clinical skills. On the flip side, you can also have patients posting extremely positive results. At the end of the day, I advise people to look at these comments very carefully, conduct extensive research about the surgeon they are considering, and assess their decision based on more than just one review whether it is positive or negative."

If someone publishes false damaging information, physicians may be able to take action based on libel or slander. However, wrongdoing may be difficult to prove and removing the information could be a time-consuming process. Instead, physicians should work on getting ahead of a negative reputation by creating a positive one.

"The internet is going to make decisions for us," says Dr. Corenman. "If physicians don't take part in the discussions regarding the internet, you are going to have the decisions make for you by the general public."

Beyond using the internet, Dr. Anand suggests connecting patients via phone. With permission, connect a previous patient with a future surgical candidate so they can discuss the process and what to expect in the future. "I think that's the most effective way for patients to be comfortable about who the surgeon is and what the surgeon is capable of clinically and surgically," he says.

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This article is written by John M. Ventura and Donald R. Murphy of Spine Care Partners, LLC.