What are the Real Achievements in Spine Surgery?

Two recent publications in North America have again kindled the question of the role of Spine surgery and if it is overutilized. In her opinion piece titled ‘The Spinal Surgeries that didn’t need to happen’ published in the New York magazine Sept 29, 2025 Paula Aceves candidly points out the fear of many – that Spine surgery is widely overused especially in regards to fusion surgery with poor results to show for it. ¹ She also references a Neurosurgical Spine surgeon, Dr Johnathan Choi, who has developed a substantial Social Media following under the pseudonym ‘Dr Goobie’. His posts revolve around his disillusionment with performing Spine surgery and poor results that has led him to leave his career and pursue an outdoor lifestyle in Alaska. ² Such questions of overutilization of Spine surgery arrive periodically in roughly ten-year cycles and have been part of this subspecialty ever since its inception. As humankind around the globe age and live longer and are afflicted with more illnesses the question how we optimally manage diseases such as the Spine with its common set of ailments becomes a critical question.

Any glance at Spine conventions and a quick look at Spine related social media content will suggest unprecedented breakthroughs in Spine care mainly in form of ‘minimally invasive’ Spine surgery (MIS) performed through ever tinier keyhole incisions, delivered through increasingly automated precision robotics aided by stunning augmented, virtual or mixed reality imaging systems. And if there was a poll for patients’ greatest hope in Spine care it would probably not list any form of Spine surgery but rather focus on a magical biological fountain of youth in form of stem cells or platelet rich plasma injections, maybe some laser or other targeted high energy applications for pain control and ultimately some restorative cartilage and muscle growth hormone, regardless of how far-fetched or resource intensive these utopian visions may be. A common denominator of these two medical care spheres, the one focused on decreasing soft tissue disruptions of decompression and fusion surgery and the other sphere, which is cellular and molecular based, is that they are aspirational in their quest for restoration of the decaying human spine and are devoid of a solid scientific foundation. Not surprisingly at all - these newer ‘minimally invasive’ and biologically focused technologies are associated with incrementally higher price tags along their entire care spectrum. The cost explosions for these new technologies are substantial and could be conceivably make any human a candidate for these therapies as we age – the ideal business plan if there ever was one. But to paraphrase the initial question – ‘do these Spine surgeries really need to happen?’ - the value proposition is steep and its actual fulfillment not clear at all.

In the big picture we increasingly rely on highly sensitive diagnostic modalities and we utilize increasingly complex and expensive surgical delivery platforms combined with greater use of disposables, the latter having generally been a financial panacea for the procedural device industries. Coincidentally, Spine surgery is not the only surgical specialty where we have witnessed the emergence of new types of health care workers within the ‘value creation chain’ who function as ‘tech experts’ who can handle anything from image manipulations for robotically guided surgery and actually help operate these highly sophisticated machineries and also serve as biotech specialists dedicated to managing blood and tissue samples for further processing. As technology evolutions occur right in our operating rooms we are also witnessing the evolution of new ‘submarine costs’ that add to the overall cost of healthcare deliveries. These are indirect costs hardly heard of in the prior simpler iron age of metal devices. Such ‘submarine costs’ take the form of subscription-based licensing and/or royalty fees, rental, maintenance, service as well as support charges for high-tech modalities. These hidden costs necessitate whole new financial arrangements in an era of tightening (or absent) profit margins for hospitals and health care systems. New concepts like ‘earn-out’ schemes and long-term leases tied to implant usage and deferred payment plans have emerged to try to fund these increasingly complex and pricey technologies. These examples show how these fascinating new device and technology systems come at a substantial additional unreimbursed cost creating an affordability quagmire that adds to the stifling expense burden of health care systems already under financial duress from the challenges brought on by growing numbers of increasingly older and sicker patients. With such exciting headline-grabbing technical evolutions underway it is reasonable to ask for periodical reality checks such as done in the media to help us all direct precious resource allocations strategically for the greater common good.

A helpful principle in performing a medical reality check is the application of the 3 E’s of medical evidence testing– effectiveness vs efficacy vs efficiency . ³ In our much touted ‘minimally invasive’ era of Spine surgery it bears consideration how many of the heavily touted publications are presented under ‘efficacy’ conditions – meaning procedures are carried out under ideal and highly controlled circumstances by highly trained and motivated surgeons (who may also somewhat conflicted by industry funding)? In contrast, how much evidence exists for results presented under real world conditions (all patients treated in a wide regional distribution by non-conflicted surgeons) which is the ‘ effectiveness ’ paradigm of clinical medical evidence. And ultimately – tied to the clinical market-place – how ‘ efficient ’ are these procedures really in general practice – and over what time frame? In the US with its ambulatory surgery centers (ASC’s), which can be surgeon owned, the efficiency paradigm is put to the ultimate test under real life market-place conditions. It is very telling that very few centers actually perform endoscopic decompression surgeries or use robots for outpatient lumbar fusion surgeries in the United States (Quote 2). With an average total capital equipment cost of about US$ 750.000 for each ambulatory Spine surgery center this leaves very little room for acquisition of such expensive additional new technologies with an unclear efficiency performance. ⁴ The reason for this is that these surgeries usually take far longer in set-up and execution compared to more conventional ‘mini -open’ surgeries, they do seem to incur more dural tears and are also associated with higher disposable costs typically not covered by insurance carriers. An additional concept in the introduction of new technologies is the term ‘learning curves’, which is commonly applied for newer procedures like endoscopy and robotically guided surgeries as if it was a necessary part of any newly introduced surgery technique. To be clear, ‘learning curve’ is a euphemism for expected ‘complications’ but despite this relabeling adverse events should not be exempt from objective scrutiny of outcomes. And as to the ‘outcomes’ perspective, it is still not clear that minimally invasive procedures actually lead to better lasting outcomes for patients. Incomplete realignments, doubtful fusion status and persistent neural entrapment after unsuccessful ‘indirect’ decompressions remain real issues with the increased focus on decreased soft tissue trauma rather than focusing on traditional Spine surgery principles. While perhaps impressive and more ‘sellable’ to an interested public in the short term through its less invasive soft tissue exposures the actual longer-term impact on patients over a longer time period remains elusive at this time and keep shifting (improving?) in the techniques applied. What are the results of these surgeries after 2 or 5 years, how many patients required revision surgeries in the same anatomic region and why?

It is an interesting sign of our times that so much of our clinical attention has been directed towards performing the most lucrative of Spine surgeries - fusion procedures, as stated in the New York editorial and by Dr Goobie on Instagram, through ever smaller approach portals instead of more prominently focusing on the achievements of motion preserving procedures which used more conventional ‘open’ approaches. Ranging from more refined neural decompression surgeries, laminoplasties for comprehensive subaxial cervical spine decompression surgeries, disc arthroplasties not just for the cervical spine but also the lumbar spine and interlaminar spacers for decompression of patients with low grade degenerative lumbar spondylolisthesis are examples of motion preservation techniques which are less invasive than any fusion surgery due its far lower adverse biomechanical effects on the remainder of the spinal column. Recently, several longer term larger follow up studies have become available that underscore the true efficiency of these technologies. In the following is a brief entirely nonscientific review of some of the more long-term follow-up studies on common outcomes of some of these nonfusion surgeries:

Lumbar disc arthroplasty: Following a longer introductory period in Europe formal ‘total lumbar disc arthroplasty’ was brought to the US in 2000 and as a major departure from prior lumbar reconstructive surgery world received the perhaps closest scientific scrutiny of any reconstructive surgical procedure over the next decades. Marnay published their experiences on 1187 patients receiving one or two level lumbar disc arthroplasties with a follow-up of 7 to 21 years after their index surgery with a revision surgery rate of 4.13 % (49/1187 patients) total.. ⁵ Revisions of the index disc replacements were very rare at 0.67% with adjacent segment surgeries very rarely found at 1.85%. The author reported Oswestry Disability Index (ODI) improvements of 24 to 26, which are impressive changes from baseline and actually exceed results referenced for the ‘operation of the century’ – total hip replacements.^6,7

Cervical disc arthroplasty: There are many studies that have shown the safety and efficacy of cervical disc arthroplasty since its introduction in the US. A study that covers the outcomes of patients 20 years after their implantation compared to fusion surgery certainly deserves special attention. With 82% of disc arthroplasty patients (18/22) and 84% (231/25) of fusion patients follow-up radiographic results showed statistically fewer patients with adjacent segment disease in the ADR cohort and preserved superior range of motion compared to fusion patients (47.8 vs 33.4° average total cervical motion). ⁶ In a separate publication on outcomes by the same authors ADR patients had less neck pain development than fusion patients and far fewer reoperations (41.7% for fusion patients compared to 10% in disc replacement patients).^8,9 Remarkably these very impressive results were obtained with an implant that is no longer available through its manufacturer due to their introduction of newer disc replacement devices. ¹⁰ Taken together these types of results – of which there are many more, really call into question why one or two level symptomatic cervical and lumbar disc disease is still preferably treated with fusion as opposed to disc arthroplasty.

Laminoplasty: This posterior based motion preserving subaxial decompression technique, which preserves the continuity of the posterior elements, has been around for over 40 years but for some reason has never become a mainstay in the treatment of multilevel cervical stenosis resulting in myelopathy.^11,12 From concerns about patient selection (kyphosis, instability, inflammatory disease, radiculopathy) to the plethora of technical variations proposed by authors over the years this procedure type has maintained a strong presence over the years in certain regions of the world but has never outranked multilevel anterior and/or posterior fusion surgery in popularity outside of Japan and a few other regions. In recent comparative studies current day laminoplasties, usually performed as open-door technique with stable posterior arch reconstruction have shown superior results compared to fusions or disc replacements. In a formal systematic review and metanalysis following PRISMA guidelines Sarraj et al found laminoplasty to be associated with the lowest reoperation rates of all cervical reconstruction techniques (anterior and posterior decompression with fusion and multilevel anterior cervical disc replacement) while having the same neurologic improvements and patient reported outcomes (Figure 1). ¹³

Figure 1.

From Sarraj et al Showing Survival Curves of the Cervical Reconstruction Techniques With LAMP Representing Laminoplasty. ¹³

In a formal prospective clinical observational trial of 163 patients comparing anterior and posterior surgeries laminoplasty again had the fewest complications (11%) compared to anterior fusion and posterior laminectomy and fusion with similar or better neurologic outcomes. ¹⁴ Again – objective comparison studies resoundingly support cervical laminoplasty in all regards, yet alternatives involving fusion surgery remains the mainstay of most Spine surgeons around the world. Reasons for a more wide-spread adoption of this technique have not been fully understood and may involve lack of training, inconsistent application of laminoplasty techniques, subpar reimbursement compared to fusion surgery and finally a misunderstanding of such posterior surgery being ‘more invasive’ compared to any anterior surgery.

Dynamic Interlaminar Stabilization

Effective decompression of lumbar spinal stenosis under avoidance of a fusion would be a major step forward in avoiding the propagation of ‘fusion disease’ through the gradual progression of adjacent segment degeneration up and down the mobile spine. The lumbar 4-5 motion segment with its propensity to develop instability and some deformity is particularly vulnerable to having some degree of instability as part of its stenosis process. The concept of interlaminar stabilization in the context of performing a meaningful but not fully destabilizing decompression and placement of an interlaminar or interspinous process spacer and thereby avoiding a fusion has been around since around 2005 in the United States and longer than that in Europe with equal or better results than fusions or decompressions alone. ¹⁵ Over time Systematic Reviews point to better outcomes scores, fewer reoperations, shorter hospital stays, lower complication rates, lower adjacent segment disease and higher range of motion that patients treated with decompression and fusion in a formal review of 26 studies published by Li et al in 2023. ¹⁶

The common theme of all of these motion preserving surgeries is that while using conventional exposure techniques they seem to have similar if not superior outcomes and clinical safety results over the long run compared to fusion procedures regardless of the exposure type used. Pretty strong long-standing evidence nonwithstanding why are these motion preserving surgeries not the main procedures we are proudly featuring as accomplishments in our profession and why are they not considered as mainstays of surgical education and practice standards? And so the uncomfortable questions remains unanswered – why is this?

The answer lies in the question of who de we actually serve – our patients, medical device industry, insurance payors or our own ego? As the utilization of Spine surgery will be held to ever closer scrutiny and the longer-term impact of expanded use especially of fusion surgeries applied for degenerative conditions will be a primary target in this era of renewed scrutiny we have critically answer the question of who we are asked to serve and how we can fulfill the task at hand best and for the longest duration regardless of recent fads and promises of ‘high tech’. Fusions definitely change the biomechanics of the affected spinal column permanently regardless of how they are done – if clinically indicated any motion preserving surgery will be bound to be actually less invasive in comparison and potentially serve patients better in the long run. Restoring or preserving biomechanical function of the Spinal column may indeed be a more all around fulfilling and long term beneficial surgical approach for patients with many degenerative indications for Spine surgery than what the current ‘minimally invasive’ exposure and high tech fusion focused market-place pushes for. If the assumption is correct that motion preserving/restoring surgery shows actually better results at lower overall cost – lets be proud of these accomplishments, teach our learners accordingly and promote them to the public while refining these technologies rather than overcomplicating our field with more expensive gadgetry and magical applications.