AANS Neurosurgeon | Volume 28, Number 4, 2019


Looking into the Future ... Spine Surgery in 2050

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Vision #1 from Dr. Steinen, Dr. Ho, Dr. Desai and Dr. Veeravagu

Spine surgery in the year 2050 is diverse. Decades of big-data collection combined with machine learning algorithms have provided us with robust tools to determine optimal surgical and non-surgical interventions to deliver maximum benefit for each individual patient. Generalized, evidence-based protocols are replaced by value-based treatment plans tailored to each patient’s specific needs. The patient has evolved into an informed customer, who no longer seeks “expert opinion” from “centers of excellence,” but receives advice via sophisticated online tools that combine individualized outcomes predictions with cost and value analysis. Excellent service is expected not only during the perioperative period, but also throughout the lifetime management of spinal disorders. Technology is advanced in industrialized countries; full-robotic spine surgery is available for those who can afford it. Here, surgeons employed in private and upscale academic hospitals have metamorphosized into pilots, navigating through 3-dimensional patient avatars when planning complex procedures that are ultimately executed by ultra-minimally invasive machines. The high value provided by these interventions, as evidenced by increased accuracy and decreased procedural complications results in a clientele that seek these surgeons with out-of-pocket payments internationally.

Competition in the healthcare sector has continued to increase and, for reasons of transparency, complications and outcomes of each health care provider and hospital are publically posted online. These are further bolstered by carefully curated social media presences. Every surgeon now fully embraces direct-to-consumer marketing as a critical part of practice building. There is zero-tolerance for complications and sub-optimal outcomes in the society, complicating traditional models of resident training. The trainee of 2050 completes virtual reality and simulator-based skills labs for pre-certification before actively participating in surgical procedures on humans.

In 2050, there is increased awareness of spine disorders. Preventative measures, including body mechanics, ergonomics, exercise programs and molecular and stem cell-based regeneration therapies are utilized in those individuals with a predicted relevant lifetime risk for degenerative disease of the spine. In general, patients are expected to be more proactive about preventative and post-operative care. Compliance with post-operative rehabilitation plans with high fidelity activity monitors and augmented/virtually reality in-home therapy is routinely monitored.

Spinal fusion is an outdated concept; the delayed complications of adjacent segment disease and proximal junctional kyphosis are no longer acceptable. With advances in pain management and molecular therapies, treatment strategies that preserve and restore physiological mobility of the spine replace the need for fusion. Accordingly, medical device companies have updated their portfolio, focusing on biotechnology as well as personalized, regenerative molecular and cellular therapies.

Another vision from Dr. Ratliff …  

Turmoil in the United States, resulting from Donald Trump’s unwillingness to stand down from the presidency in 2024 (after a second term) and a brief period of martial law before newly elected President Kamala Harris stepped into the oval office, led to the replacement of the U.S. dollar as the world’s reserve currency to the Chinese Yuan. While the U.S. dollar remained widely used, the Yuan grew substantially, as multi-national banks tired of the dramatic swings in U.S. foreign and fiscal policy.

Denomination of some government debt into a foreign currency placed significant fiscal strain on the Democratic promise to enact Medicare for all, making the program essentially unfundable during President Harris’s first term. With this failure, Mike Pence was able to successfully return to the White House with the Republican Party in 2028.  

It was, however, the primary platform issue when Vice President Ocasio-Cortez ran in 2032.  While she was unsuccessful in her first bid at the presidency, she triumphed over a leaden Donald Trump, Jr. in 2036. 

President Ocasio-Cortez enacted a broad increase in the breadth of Medicare within the first six months of her presidency, decreasing the age of eligibility initially to 50, and then to 45. Overwhelmed by the increased number of enrollees, the Centers for Medicare and Medicaid Services (CMS) developed an outsourcing plan to private entities that would provide health care services in the four CMS regions of the US. Mega-corporations that had developed means of controlling health care costs were awarded these contracts. In the West and Midwest, Amazon-Kaiser Permanente International won the contract to provide for the expanded Medicare rolls. The South was won by Walmart-HCA and the Northeast by Johnson, Johnson and Partners. Private insurers are allowed to continue, but enrollees decreased significantly. The AMA, riven with internal disagreements over the system, remained a sideline player and contributed little to the national discussion.

Spine care had faced a substantial challenge in the 2040s when widespread availability of intradiscal stem cell injections pioneered and popularized by the Laser Spine Stem Cell Institute chain led to a rash of chordomas, requiring surgery and proton beam radiotherapy.   The Laser Spine Stem Cell Institute chain was rapidly bankrupted by lawsuits; hospitals responded to the challenge by building more proton beam radiotherapy units. With just as rapid a decrease in chordoma prevalence as stem cell therapies were shunned, many hospitals faced bankruptcy as they attempted to pay off Yuan-denominated debt from building new radiotherapy platforms that now sit idle. These financial challenges led to more consolidation of the healthcare industry, as hospital systems combined to weather the financial storm. Other proton beam units explored other options to maintain financial viability, including proton beam treatment for facetogenic low back pain and for trigeminal neuralgia. These efforts were not met with success.

The increase in access to unrestricted healthcare, combined with longer life expectancy from highly effective immunotherapy for a variety of malignancies, drove substantial demand for spine surgery. The financial constraints of the new system, however, made standardization of surgical care a necessity. Patients were evaluated and their surgeries planned by machine learning algorithms trained upon prospective data captured in the 2010s. Surgical plans were executed by robots guided by similar protocols and based upon high-resolution intraoperative imaging. For an added fee, some patients chose to have their surgery overseen by a physician, as opposed to the more routine nurse practitioner. 

The University of Phoenix pioneered procedural APP programs, as hospitals realized that expensive surgeons were irrelevant when most procedures can be completed with image guidance and robotic planning tools. An 18-month remote learning course provided the training necessary to oversee execution of machine learning operative plans in a sizable majority of surgical cases. While this produced outrage by now under-employed surgeons, this was nowhere near as severe as the picket lines of pathologists and radiologists who saw their entire specialties rendered obsolete by AI software.

Spine surgeries are completed with an altogether acceptable rate of paralysis and with an extremely high patient-reported satisfaction rate. Allegations that patients who did not report good outcomes were dropped from the corporate-managed CMS rolls, and were hence relegated to a no-man’s-land of the uninsured and never proven in court, despite numerous lawsuits in a variety of jurisdictions.

Some wealthy patients, however, are cared for personally by senior and, sometimes, elderly surgeons who still maintain skills in the arcana of the physical exam and still actually touch their patients. These clinicians, similar to Swiss watchmakers of the early 2000s, charge an exorbitant premium for actually planning and executing an operative intervention with their hands, as opposed to operating via a robotic guidance system. Some of these elderly surgeons are also known to actually offer their wealthy patients choices, as opposed to best practice treatment plans based upon years of population data and outcomes. While these luddites were attractive to the wealthy few, it is anticipated that such inefficiencies will be lost to the system as these providers age into senescence.

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