How Will the Future Shape the Practice of Spine Surgery? Q&A With Dr. Ziya Gokaslan of Johns Hopkins

Ziya Gokaslan, MD, is the vice chairman of neurosurgery and director of the neurosurgical spine center at Johns Hopkins Medicine in Baltimore. He is also a board-certified neurological surgeon and a professor of neurological surgery, orthopedic surgery and oncology at Johns Hopkins University. Dr. Gokaslan is a prolific researcher and has pioneered several spine surgery techniques for sacrectomy and complex spinal and pelvic reconstruction. He serves on the editorial board of top academic journals such as The Spine Journal, Journal of Neurosurgery, Journal of Spinal Disorders and more.

Throughout Dr. Gokaslan's distinguished career, he has gained in-depth insight into the spine surgery industry. Here he discusses how the field will evolve, including the employment structure, financial challenges and technological trends.

Question: How do you foresee spine surgeon employment evolving?

Dr. Ziya Gokaslan: Hospital employment of spine surgeons is the trend, not only for spine but many other subspecialties as well. From our perspective, it doesn't make much of difference. We work for a hospital system plus a university under one umbrella. One of the advantages to that is the physicians from the university can partner with the hospital and contract for care jointly for significant strength.

Partnering with the hospital has advantages, but in some situations you lose your autonomy. Our situation is structured so we have fiscal responsibility of our unit and a fair amount of autonomy. Anytime you are partnering with a hospital, be careful and make sure your interests are well protected and you are not being taking advantage of for your professional contributions.

Q: What are the most marked changes you've seen in the spine industry since you began practicing?

ZG: There have been two major changes I've observed. One is that there is definitely more emphasis to do procedures with minimally invasive technology that is gaining popularity. The evidence is accumulating in literature supporting it for certain types of procedures. There is a lot left to be done to prove its value in various setting. One of the trends out there is that we will see more application of minimally invasive techniques for a variety of procedures.

The other major change has to do with how the insurance companies are trying to be gatekeepers with a variety of spine procedures with the screening and approval processes. Regulatory challenges are increasing for the spine surgeons and will continue to do so going forward. All of those elements are becoming a daily part of our practice, making the system much less efficient, less user-friendly, and the patient-physician relationship is being affected negatively as result of that.

Q: Do you think the current minimally invasive spine techniques match the hype?

ZG: I would say there are a number of spinal procedures that are being advertised for a minimally invasive application which are done quite well with traditional techniques, such as a microscopic lumbar discectomy done with a small incision and openly with a microscope. This procedure is already by definition minimally tissue destructive, and the results are outstanding with the traditional open technique. In this particular situation, it's hard to demonstrate that a MIS operation does improve patient outcomes.

One procedure where we see the difference, however, is with lumbar fusion procedures, where the open approach tends to be tissue destructive. You can do that less invasively with percutaneous screws and rods. This makes the operation less destructive, which patient outcomes tend to support, and helps the patient return to work more quickly, though the long-term outcomes don't differ much between the two approaches. Under the right circumstances and for the right patient and indication, minimally invasive makes a difference. I think we will see more minimally invasive technologies going forward.

Q: How will increased regulations change the way spine surgeons practice?

ZG: If payers are not paying for the procedures, then physicians will be less enthusiastic about performing the procedure. One such procedure is the artificial disc replacement for cervical spine. There is room for that procedure in young patients with one- or two-level disc disease or a herniated disc, yet many physicians would not offer that to the patient because it's practically impossible to get approval.

It is such a painful process to the physician and the patient to spend hours on the phone to convince a third party provider to cover the procedure. I suspect similar types of situations in the future to disincentivize surgeons to offer an option to the patient.

The government is using some of that strategy for strategically reducing reimbursements for common procedures with the hopes that it will reduce healthcare expenditures in the long-run, but it seems to be backfiring. When reimbursements are reduced, the number of procedures goes up to make up for it.

Q: Can anything be done to combat restricted access to spine surgery?

ZG: The surgeon ought to be a better advocate for maintaining autonomy with decision making and choosing the right option for the patient. Patients need to be better advocates for these matters, as well, through writing their Congressmen. Many people are not affected by these processes until they are afflicted by a disease. We need to educate people, and the burden is on us to produce evidence that what we are offering does make a difference.

Q: How viable is outpatient spine surgery, and will it become more or less prevalent?

ZG: I anticipate it will become more prevalent, but I don't think it will be a very significant portion of spine surgeries. In academic situations, we do more complicated procedures. However, in large private practice groups, outpatient is becoming more important. A lot of procedures we used to do inpatient, such as a disc laminectomy or simple fusion, have turned to outpatient. This is a trend that will continue in private practice but not so much in an academic environment.

Q: What does the future of spine surgery look like? Will physicians be more financially-focused than in the past?

ZG: Under ideal circumstances I would rather not know about insurance or what we are getting for a procedure. I try to differentiate that from the decision-making process and blind myself to it, but it's a reality you are held accountable for your collections. It's also a reality for any physician, particularly those running practices, that you have to produce in order to keep staff and stay in business.

As much as we would like to be divorced from reimbursements, when it comes to caring for your patient, it is a reality of life. Under ideal circumstances it should not be an issue in making decisions, period. The moment you thinking about how much you will get paid for a procedure and that influences your decision making process, then it's time to retire.

I firmly believe spinal surgery is an exciting subspecialty to be in. We are learning an incredible amount every day. Technology is evolving rapidly, and the options for our patients are exponentially increasing. I think the future is very bright for our subspecialty. The population is aging, patients are here to stay and research with advances in technology will have many more options in treating patients.

Q: What topics are you currently researching?

ZG: I'm focusing on various aspects of spinal surgery and outcomes research see how we are doing with our outcomes and how we can improve on them, including cross utility analyses. It's important for us to prove the value of spine surgery to society and to patients, to be honest with our results and hope we will learn from them and improve spine care.

The other area I'm focusing research is on lumbar fusion and fusion in general. We still would like to make sure that surgeons who are fusing the spinal column are achieving excellent fusion rates. We are trying to improve our fusion rates and mitigate affects of drugs that may impede healing. We also have an interest in imaged-guided surgery and robotics to guide screws and hardware more precisely.

Q: Where does spine and neurosurgery research need to be focusing in the next five to 10 years?

ZG: I think given the regulatory scrutiny we are facing and the control that the third party providers have with respect to what we are offering our patients that the outcomes research and cross utility analyses related to procedures and the value of procedures are very important. They are important to be done not only on an institutional level, but in our societies.

More Articles on Spine:
Independent Predictors of Spine Surgery Cost: Where Are Opportunities for Savings?
Forbes Features Dr. Todd Alberts: The Future of Data Sharing, Transparency & Culture Change in Spine Surgery
Patients Afraid to Move After Spine Surgery: The Impact of Fear 6 Months Later