Spine surgery’s race to go smaller has limits

Spine surgery has spent years getting smaller. David J. Park, MD, is interested in what happens when there is eventually less surgery to perform at all.

Dr. Park, a clinical assistant professor of neurosurgery at Stanford (Calif.) University School of Medicine, uses endoscopic techniques to treat spine patients at the VA Palo Alto (Calif.) Health Care System. His practice also spans neurosurgical oncology and stereotactic radiosurgery, including CyberKnife, a noninvasive robotic system that delivers highly targeted radiation to tumors and lesions.

Working across those modalities has changed the question he asks about minimally invasive spine care. It is not simply how small surgeons can make an incision. It is how much of an operation a patient actually needs.

“Minimally invasive doesn’t mean that it’s always the best,” Dr. Park told Becker’s .

That distinction becomes more important as endoscopic surgeons take on increasingly complex cases. Some patients who once appeared too medically fragile for surgery may now have less invasive options. At the same time, Dr. Park sees circumstances in which making an operation smaller can make it longer, more difficult or potentially riskier.

The next frontier, he believes, will require knowing the difference.

When smaller stops being better

For selected procedures, Dr. Park sees a compelling case for endoscopy. He considers uniportal endoscopy particularly useful for many discectomies. For decompressions, he favors biportal techniques in part because they can provide strong visualization.

“Surgery is all about how much you can see,” he said. “If you can see better, the surgery will be better.”

But he still performs about 10% of his procedures using open techniques. He pointed to multilevel decompression as an example. In some patients, an operation he can complete relatively quickly through an open approach could take hours endoscopically. The smaller approach would not necessarily be the safer one.

He is particularly cautious about endoscopic fusion. Patients who require fusion can have more severe pathology, he said, and the restricted working corridor can make complications involving neural structures or the dura more consequential.

“There are pros and cons,” Dr. Park said. For him, the endpoint is not the smallest possible operation. It is the least invasive operation that can accomplish what the patient needs without compromising the surgery itself.

The patients who become candidates

Endoscopy has nevertheless changed whom Dr. Park is willing to consider for surgery. That became clear at the VA.

Dr. Park arrived with a practice centered largely on brain tumors and cranial surgery. As he began seeing more spine patients, he initially used tubular techniques because an endoscopic system was not available.

Then veterans began asking about endoscopic options themselves.

As the program developed, Dr. Park found his threshold for considering surgery changing. Many of the veterans he treats are older and have multiple medical conditions. In the past, the prospect of a larger incision, deeper muscle dissection and a prolonged operation could weigh heavily against surgery.

With endoscopy, he said, “my threshold got way lower.” That may be one of the more consequential implications of shrinking the surgical footprint. A less invasive technique does not merely change how an existing surgical candidate is treated. In selected cases, it can change who becomes a candidate at all.

But expanding that boundary creates its own risk.

The danger of believing endoscopy can do everything

Dr. Park encountered that limit during what he expected to be a straightforward endoscopic case. He had planned the procedure to take advantage of the endoscopic approach. During the operation, however, he became disoriented anatomically. Imaging showed that his orientation was not where he thought it was.

He stopped and converted to an open procedure.

“Until you face the real complication, you don’t really know,” he said. The experience reinforced something Dr. Park believes surgeons learn as their practices mature: A new technique can expand what is possible without becoming the right technique for everything.

He remains hesitant about endoscopic fusion in many cases and does not perform complex deformity surgery. Surgeons, he said, gradually learn “where to stop” based on their experience, knowledge and individual scope of practice.

That boundary is central to how he thinks about innovation. Rather than mastering one technique and extending it into every possible indication, Dr. Park sees value in having multiple ways to treat the same problem.

“If you only know how to do fusions, then you may offer fusion for every case,” he said. “The more technologies and experience you have, the more options you can consider and the better you can choose what’s right for the patient.”

What if the breakthrough is doing less?

That philosophy is pushing Dr. Park toward a different model of minimally invasive spine care: combining technologies so one operation does not have to accomplish everything.

Spinal tumors offer an example. For some patients with metastatic disease compressing the spinal cord, surgeons may perform separation surgery to create space between the tumor and spinal cord before delivering stereotactic radiation.

Dr. Park is exploring whether selected patients can undergo a more limited endoscopic decompression followed quickly by radiosurgery, avoiding a more extensive resection or fusion.

He described one recent case in which he performed a biportal endoscopic decompression through two small incisions without screws or plates. The patient proceeded to radiation the next day.

The significance, in Dr. Park’s view, goes beyond performing the same operation through smaller incisions. It is the possibility of breaking a major intervention into smaller, targeted components: surgery accomplishes what only surgery can accomplish, while another modality handles the rest.

“I think there’s a huge potential,” he said.

Beyond the smaller incision

Asked which large operations might surprise spine surgeons a decade from now, Dr. Park suggested the bigger change may be in what surgery looks like altogether.

He used robotics as an analogy. Early visions of robotic automation often imagined machines mimicking human actions. A robotic vacuum, however, did not ultimately look like a person pushing a vacuum cleaner. The task itself was redesigned.

Dr. Park believes surgery could undergo a similar shift. He considers technologies such as stereotactic radiosurgery another form of robotic intervention: Instead of a robot physically reproducing a surgeon’s movements, technology may accomplish some therapeutic goals without an incision at all.

Spine surgery will retain mechanical problems that require physical intervention, he said. Fusion, decompression and major reconstruction are not simply disappearing.

But Dr. Park expects surgeons to have more choices between doing nothing and performing a large operation. Some procedures may become still less invasive. Some patients may be treated by combining smaller interventions. Others may ultimately avoid an operation that surgeons today consider necessary.

That makes the future of minimally invasive spine surgery less about winning a race toward the smallest incision.

The more consequential question is whether surgeons can become better at deciding how much surgery a patient actually needs. And sometimes, Dr. Park believes, the answer will be less than surgeons once thought.

At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.

Spine surgery’s race to go smaller has limits

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