From artificial discs to stem cells and complex deformity surgery, 10 surgeons discuss some of the most controversial trends in spine today.
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. We invite all spine surgeon and specialist responses.
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Note: The following responses were lightly edited for style and clarity.
Question: What is the most controversial trend in spine today?
Alexander Vaccaro, MD, PhD, and Bryce Basques, MD. Rothman Orthopaedic Institute (Philadelphia): The most controversial trend I see in spine surgery is the development of "solutions looking for problems" by the device industry. The core fundamentals of good spine care have remained the same for years, yet there continues to be massive investment and marketing in various spinal technologies that seem to fill a void in untapped intellectual property voids, rather than a demand by patient needs.
Today, robotics and various minimally invasive techniques have high potential, yet I would caution surgeons, especially those early in practice, from broadly adopting these techniques without scrutiny. Especially in saturated markets, spine surgeons may think that these newer technologies are an opportunity to differentiate or market themselves. However, if adoption of these techniques leads to inefficiency, complications and poor outcomes, your reputation will suffer and any potential marketing benefit will be lost. In the current financial climate, surgeons will be expected to justify the cost of this technology to payers as well. I would encourage surgeons to be highly discerning in the technologies or advancements they adopt and pursue patient care avenues that demonstrate high value.
Neel Shah, MD. DISC Sports & Spine Center (Newport Beach, Calif.): One controversial trend in spine is the evidence of more and more invasive procedures, such as endoscopic discectomies or placement of paddle leads for spinal cord stimulators, being undertaken by interventional specialists. This becomes dangerous when these providers cannot adequately address complications that may arise from such procedures. It is especially concerning when invasive procedures are being done within the spinal canal, where they can cause disastrous complications without the right precautions.
Christian Zimmerman, MD. Saint Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): As a regional referral center for complex spinal disorders, our practice has witnessed many more minimally invasive spine surgery cases. Albeit, the conceptions and training emphasis of these surgeries varies among programs and individuals, motives and intent are ill-defined and usually cost expansive. Invariably, the decompressive component of the surgery is lacking/not achieved and nonunions are convention. Corrective surgical methods are usually much more involved because of lateral instrumentation and protracted in recovery.
Hamid Abbasi, MD. PhD. Inspired Spine (Burnsville, Minn.): The artificial disc, as well as unjustly applying the deformity parameter to degenerative spine disease.
Todd Lanman, MD. Lanman Spinal Neurosurgery (Beverly Hills, Calif.): Oddly, it still remains relatively controversial — placing artificial discs, multilevels or adjacent to fusions, and certainly reversing fusions, as off-label indications. I find this odd in the sense that hybrid surgeries, or combinations of artificial discs with fusions, have such a huge body of published experience throughout the world that shows superiority, or at least equivalency, to fusion, while maintaining normal motion of the spine.
Why this controversy still exists escapes me. Similarly, with multilevel cervical disc replacement, many surgeons feel that this type of surgery, because it's off label, means it doesn't work, when it is clear that using devices in an off-label manner is certainly allowed by the FDA and entirely proper if the clinician feels it is in the benefit of the patient.
John Burleson, MD. Hughston Clinic Orthopaedics (Nashville, Tenn.): I find the most controversial issue in spine to be the use of unproven technologies. I get questions from patients all the time about stem cell injections into their spine, or injections into their discs to "heal" them. These newer treatments do not have adequate evidence that they are helpful and could be harmful. They are also extremely costly to desperate patients. It is frustrating to have to tell patients that there is no data for those treatments and that they might need more than an injection to fix their misaligned spine or back/leg pain despite what other doctors have told them.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: Complex deformity surgery I believe is the most controversial trend right now. There is a lot of it being done at this point in time. While I feel there is good work being done, especially in robotics and minimally invasive surgery, as well as artificial intelligence solutions to get the job done, I fear there is a great deal of surgery being done based on films, rather than symptoms. We are starting to see patients being fused from C2-pelvis, and I fear some surgeons have lost their way. Ultimately, the long-term outcome data will need to be shown the light of day, so we can honestly judge if the significant perioperative and postop consequences are worth it for the patients. I hope we, as a specialty, can learn to live with a patient who is functional and off pain meds, rather than one who has perfect films but also has a proximal junctional kyphosis, pseudoarthrosis, or a completely fused spine.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): The most controversial trend is probably stem cells. The hope is that they will become the holy grail of spine surgery, capable of "repairing" injured discs and reversing years of degeneration, thereby reducing pain. The current reality is far from it, and a lot more scientific progress, research and development must happen before any of this becomes true. It should be noted that the stem cells that "built" the discs when the fetus was developing in a uterus did so in the environment of zero gravity, minimal mechanical stress and abundant nutrient and oxygen supply. To enable similar mesenchymal stem cells to do the same work with comparatively minimal nutrient and oxygen supply, in an already degenerative disc full of inflammatory cytokines while constantly being subjected to the mechanical stress of an upright walking adult, will take a lot of work. Despite this logic, many clinics tout stem cell treatments for back pain with minimal to no scientific basis.
I would urge any patient or clinician interested in using stem cells to "cure" back pain and spine injuries to look very carefully at the basic science and outcome studies. I am sure the day when stem cells are used effectively for spine problems will come, but a lot more work and research need to be done before that happens.
Issada Thongtrangan, MD. Microspine (Phoenix): There are so many controversial topics in spine. For example, anterior cervical discectomy and fusion versus cervical total disc replacement for cervical myelopathy in certain age groups. The major controversy is probably in lumbar fusion above L5/S1 in terms of approaches, as there are so many: ALIF, PLIF, TPLIF, XLIF, OLIF, etc. Also, the interbody cage technology: static versus expandable, etc. Now you can find any online studies that support or [contradict] your beliefs. I am trying my best to follow a well-designed paper and not a paper sponsored by a company. At the end of the day, I look at my outcomes and stick with the approaches that give my patients the best outcomes. However, I have an open mind for new technology.