Nine spine surgeons discuss the technology and techniques that will fade over the next few years, and factors driving the disappearance.
Q: What do you think will fade or disappear from the spine field over the next few years?
Mitchell Levine, MD. Lenox Hill Hospital (New York City): Interventions for focal back pain and neck pain without neurological involvement are going to trend down. Insurance companies are tightening their criteria for approving fusion surgeries and evidence-based care will be standard. This increased scrutiny on efficacy will be brought to bear on all aspects of spine care, including pain management and physical therapy as well. The overuse of epidural steroids and ablative procedures in spinal stenosis treatment is already being evaluated.
Nigel Price, MD. Children's Mercy Kansas City (Mo.): Several value-driven practices are changing the outcomes. We will see fewer infections, less need for transfusions, early mobilization and earlier discharges from the inpatient side. We will hopefully make better decisions in terms of preoperative planning and execution so avoidable complications necessitating revision surgery will be reduced. Collaboration across many institutions will help refine technique through sharing of data. There will be fewer spine fusions for deformity in the younger age group as techniques and technologies for doing guided growth will encourage more fusionless surgery.
Jeffrey Cantor, MD. Cantor Spine Institute (Fort Lauderdale, Fla.): Traditional bone cutting tools are the easiest old technology to replace.
Eugene Koh, MD, PhD. University of Maryland School of Medicine (Baltimore): Currently, insurance companies are collecting data on each individual surgeon, including expense for each individual procedure (for example, the cost for a single-level ACDF). Certain insurance companies are financially incentivizing primary care physicians to refer to the least expensive surgeons. As they accumulate more data, including outcomes data, the insurance companies would dictate the procedure or surgeon with the lowest revision rate. Numerous reports have demonstrated interspinous devices for lumbar spinal stenosis have poor outcomes and a high re-operation rate. Insurance companies will make it more and more difficult for surgeons to justify placing these implants or any devices that have a high revision rate.
Andrew Cordover, MD. Andrews Sorts Medicine & Orthopaedic Center (Birmingham, Ala.): I have a concern with the over-reliance on technology and the disappearance of knowledge of basic, technical surgical principles. The burden will fall on teaching institutions to make sure that doesn't happen as image guidance and new biologics (which may allow for suboptimal surgical technique) gain acceptance.
Avery Jackson, MD. Michigan Neurosurgical Institute (Grand Blanc): I think interbody spinous devices will eventually fade. I think halo fixation will eventually fade.
Michael Goldsmith, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Hopefully revision surgery for pseudarthrosis will be less prevalent in the coming years. As our implants and techniques become better and our adjuncts to bone grafts become more powerful through advancement in biologics, I would expect to see fusion rates rise. Revision surgery is extremely costly and has higher complication rates than index fusions, so the goal is to avoid reoperation to benefit both the patient and health system.
One concern I have, which is a bleak prediction, is that innovation may decrease as well. In an effort to save money, many hospitals, in particular the larger health systems, are moving to one or two vendor systems which drives out smaller companies and may have the downstream effect of diminishing innovation. Oftentimes smaller companies have the ability to be more innovative either because they were created around a new technology or in order to differentiate themselves. We need to continue to encourage true innovation at the ground level by supporting all technology, not just from the big companies.
Robert Jackson, MD. Orange County Neurosurgical Associates (Laguna Hills, Calif.): Narcotic consumption will decrease over the next five years as practitioners and public become more aware of the dangers.
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